A Reference Handbook OF THE MEDICAL SCIENCES EMBRACING THE ENTIRE RANGE OF SCIENTIFIC AND PRACTICAL MEDICINE AND ALLIED SCIENCE VARIOUS WRITERS ILLUSTRATED BY CHROMOLITHOGRAPHS AND FINE WOOD ENGRAVINGS Edited by ALBERT H. BUCK, M.D. New York City VOLUME VII. NEW YORK WILLIAM WOOD & COMPANY 56 & 58 Lafayette Place 1889. Copyright, 1889, By WILLIAM WOOD & COMPANY TROWS PRINTING AND BOOKBINDING COMPANT, NEW YORK. LIST OF CONTRIBUTORS TO VOLUME VII. SAMUEL W. ABBOTT, M.D Wakefield, Mass. Secretary of the State Board of Health of Massachu- setts. CHARLES W. ALLEN, M.D New York, N. Y. Visiting Physician, Charity Hospital.* T. JOHNSON ALLOWAY, M.D Montreal, Canada. Gynaecologist to the Montreal Dispensary ; Assistant Surgeon, Montreal General Hospital. GORHAM BACON, M.D New York, N. Y. Professor of Diseases of the Ear, New York Poly- clinic ; Aural Surgeon, New York Eye and Ear In- firmary. FRANK BAKER, M.D Washington, D. C. Professor of Anatomy, Medical Department of George- town University. HERMANN M. BIGGS, M.D New York, N. Y. Visiting Physician, Workhouse and Almshouse Hos- pitals, Blackwell's Island ; Demonstrator of An- atomy, Bellevue Hospital Medical College ; Instruc- tor in the Carnegie Laboratories. CLARENCE J. BLAKE, M.D Boston, Mass. Clinical Instructor in Otology, Harvard Medical School; Aural Surgeon, Massachusetts Charitable Eye and Ear Infirmary. ALBERT N. BLODGETT, M.D Boston, Mass. Professor of Pathology and Therapeutics, Boston Den- tal College. W. P. BOLLES, M.D Boston, Mass. Professor of Materia Medica and Botany, Emeritus, at the Massachusetts College of Pharmacy; Visiting Surgeon, Boston City Hospital. ELIZABETH STOW BROWN, M.D New York, N. Y. CHARLES STEDMAN BULL, M.D New York, N. Y. Professor of Diseases of the Eye, University Medical College, New York; Ophthalmic Surgeon, New York Eye and Ear Infirmary. CHARLES H. BURNETT, M.D.. .Philadelphia, Pa. Professor of Diseases of the Ear, Philadelphia Poly- clinic and College for Graduates in Medicine. SAMUEL C. CHEW, M.D Baltimore, Md. Professor of the Principles and Practice of Medicine and Hygiene, University of Maryland. A. W. CLEMENT, V.S Baltimore, Md. Bureau of Animal Industries, United States Govern- ment. P. S. CONNER, M.D Cincinnati, O. Professor of Surgery, Medical College of Ohio. W. T. COUNCILMAN, M.D Baltimore, M£>. Associate Professor of Pathological Anatomy, Johns Hopkins University. B. FARQUHAR CURTIS, M.D ... .New York, N. Y. Attending Surgeon, St. Luke's Hospital; Assistant Surgeon, New York Cancer Hospital. EDWARD CURTIS, M.D New York, N. Y. Professor Emeritus of Materia Medica and Therapeu- tics, College of Physicians and Surgeons, New York. LESTER CURTIS, M.D Chicago, III. Professor of Histology, Chicago Medical College ; Visiting Physician, Mercy Hospital. CHARLES LOOMIS 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, Bellevue Hospital. D. BRYSON DELAVAN, M.D New York, N. Y. Professor of Laryngology and Rhinology, New York Polyclinic ; Chief of Clinic, Department of Diseases of the Throat, Collegei of Physicians and Surgeons, New York. J. W. ELLIOT, M.D Boston, Mass. Clinical Instructor in Gynaecology, Harvard Medical School; Physician in the Department of Diseases of Women, Boston Dispensary; Surgeon to Out-Pa- tients, Massachusetts General Hospital. J. HAVEN EMERSON, M.D New York, N. Y. Physician to the Out-Patient Department of the New York Hospital, Class of Diseases of Women. GEORGE JACKSON FISHER, M.D.Sing Sing, N. Y. F. FORCHHEIMER, M.D Cincinnati, O. Professor of Physiology and of Diseases of Children, Medical College of Ohio. GEORGE B. FOWLER, M.D New York, N. Y. Professor of Medical Chemistry and Clinical Medicine, New York Post-Graduate Medical School and Hos- pital ; Visiting Physician, Bellevue Hospital, and the New York Infant Asylum. JAMES M. FRENCH, M.D Cincinnati, O. Lecturer on Morbid Anatomy and Demonstrator of Pathology, Medical College of Ohio; Attending Physician, St. Mary's Hospital. ALBERT L. GIHON, M.D Brooklyn, N. Y. Medical Director, United States Navy. JAMES R. GOFFE, M.D New York, N. Y. Instructor in Gynaecology, New York Polyclinic; Visiting Physician, Episcopal Orphan Asylum. S. A. GOLDSCHMIDT, Ph.D New York, N. Y. Inspector of Offensive Trades, Board of Health, New York. H. GRADLE, M.D Chicago, III. Professor of Physiology, Chicago Medical College; Eye and Ear Surgeon to the Michael Reese Hospital, Chicago. NATHANIEL GREENE, M.D Boston, Mass. III LIST OF CONTRIBUTORS TO VOLUME VII. CHARLES E. HACKLEY, M.D...New York, N. Y. Visiting Physician, New York Hospital. WILLIAM B. HILLS, M.D Boston, Mass. Assistant Professor of Chemistry, Harvard Medical School. WILLIAM. H. KINGSTON, M.D Montreal, Canada. Surgeon-in-Chief, Hotel Dieu ; Professor of Clinical Surgery, Montreal School of Medicine. JOSEPH W. HOWE, M.D New York, N. Y. Consulting Surgeon, Charity Hospital, New York ; Visiting Surgeon, St. Vincent's Hospital. F. W. JOHNSON, M.D Boston, Mass. GEORGE WOODRUFF JOHNSTON, M.D...Wash- ington, D. C. Professor of Gynaecology, National Medical College ; Gynaecologist to the Central Dispensary. WYATT G. JOHNSTON, M.D. .Montreal, Canada. Demonstrator of Pathology, McGill University. D. S. LAMB, M.D Washington, D. C. Acting Assistant Surgeon, U. S. Army; Professor of Anatomy, Howard University. CHARLES McK. LEOSER New York, N. Y. MORRIS LONGSTRETH, M.D. .Philadelphia, Pa. Physician to the Pennsylvania Hospital, Philadelphia. R. L. MACDONNELL, M.D Montreal, Canada. Demonstrator of Anatomy and Lecturer on Hygiene, McGill University. WALTER MENDELSON, M.D... .New York, N. Y. HENRY CHILDS MERWIN, LL.B... .Boston, Mass. Attorney and Counsellor-at-Law. T. WESLEY MILLS, M.D Montreal, Canada. Professor of Physiology, McGill University. CHARLES SEDGWICK MINOT, S.D.. .Boston, Mass. Assistant Professor of Histology and Embryology, Harvard Medical School. ROBERT B. MORISON, M.D Baltimore, Md. Professor of Dermatology and Syphilis, Baltimore Polyclinic and Post-Graduate Medical School. HENRY LEE MORSE, M.D Boston, Mass. Aural Surgeon to the Boston Dispensary ; Aural Ex- terne to the Massachusetts Charitable Eye and Ear Infirmary, Boston. SAMUEL NICKLES, M.D Cincinnati, O. Professor of Materia Medica, Medical College of Ohio. OSCAR OLDBERG, Phar.D Chicago, III. Professor of Pharmacy and Director of the Pharma- ceutical Laboratories in the Illinois College of Phar- macy, Northwestern University, Chicago ; Member of the Committee of Revision and Publication of the Pharmacopoeia of the United States of America. WILLIAM OLDRIGHT, M.D ...Toronto, Canada. Lecturer on Sanitary Science, Toronto School of Medi- cine ; Chairman, Provincial Board of Health. 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. GRACE PECKHAM, M.D New York, N. Y. Assistant Attending Physician, New York Infirmary. JOHN C. PETERS, M.D New York, N. Y. JAMES E. PILCHER, M.D Governor's Island, N. Y. Assistant Surgeon, United States Army. LEWIS S. PILCHER, M.D Brooklyn, N. Y. Adjunct Professor of Anatomy, Long Island College Hospital Medical School. ABNER POST, M.D Boston, Mass. Clinical Instructor in Syphilis, Harvard Medical School ; Surgeon to Out-Patients, Boston City Hos- pital. MORTON PRINCE, M.D Boston, Mass. B. ALEXANDER RANDALL, M.D. ..Philadelphia, Pa. Ophthalmic and Aural Surgeon to the Episcopal and Children's Hospitals. EDWARD REYNOLDS, M.D Boston, Mass. Assistant in Obstetrics, Harvard Medical School. HUNTINGTON RICHARDS, M.D New York, N. Y. Aural Surgeon, New York Eye and Ear Infirmary ; Chief of Clinic, Department of the Ear, College of Physicians and Surgeons, New York. IRVING C. ROSSE, M.D Washington, D.C. R. F. RUTTAN, M.D Montreal, Canada. Lecturer in Chemistry, McGill University ; Examiner in Chemistry for the University of Toronto. B. SACHS, M.D New York, N. Y. Instructor in Mental and Nervous Diseases, New York Polyclinic. W. W. SEELY, M.D Cincinnati, O. Professor of Ophthalmology and Otology, Medical College of Ohio. FRANCIS J. SHEPHERD, M.D Montreal, Canada. Professor of Anatomy, McGill University ; Surgeon to the Montreal General Hospital. CHARLES SMART, M.D Washington, D. C. Surgeon, United States Army. THOMAS L. STEDMAN, M.D... .New York, N. Y. Late Attending Surgeon, New York Orthopaedic Dis- pensary and Hospital. HENRY W. STELWAGON, M.D Philadelphia, Pa. Physician to the Philadelphia Dispensary for Skin Diseases ; Chief of the Skin Dispensary of the Hos- pital and Instructor in Dermatology, University of Pennsylvania. JAMES STEWART, M.D Montreal, Canada. Professor of Materia Medica and Therapeutics, McGill University. CHARLES P. STRONG, M.D Boston, Mass. Physician to Out-Patients, Massachusetts General Hos- pital ; Assistant Surgeon, Free Hospital for Women ; Assistant in Gynaecology, Harvard Medical School. MORSE K. TAYLOR, M.D San Antonio, Tex. Surgeon, United States Army. LOUIS McLANE TIFFANY, M.D. .Baltimore, Md. Professor of Surgery, University of Maryland. IV LIST OF CONTRIBUTORS TO VOLUME VIL CHARLES W. TOWNSEND, M.D... .Boston, Mass. Assistant to the Chair of Obstetrics, Harvard Medical School; Physician to Out-patients, Boston Lying-in Hospital; Assistant Physician to Out-patients, Bos- ton Children's Hospital. ARTHUR VAN HARLINGEN, M.D Philadel- phia, Pa. Professor of Diseases of the Skin, Philadelphia Poly- clinic and College for Graduates in Medicine ; Con- sulting Physician, Dispensary for Skin Diseases. SAMUEL B. WARD, M.D Albany, N. Y. Professor of Pathology, Practice, Clinical Medicine and Hygiene, Albany Medical College ; Attending Surgeon, Albany Hospital. CHARLES WARE, M.D New York, N. Y. Assistant Gynaecologist, Out-Door Department of Roosevelt Hospital. BENJAMIN F. WESTBROOK, M.D Brooklyn, N. Y. Attending Physician, Methodist Episcopal Hospital, Brooklyn, N. Y.; Consulting Physician, Brooklyn Hospital for Diseases of the Throat and Chest. JAMES T. WHITTAKER, M.D Cincinnati, O. Professor of the Theory and Practice of Medicine, Medical College of Ohio. V A REFERENCE HANDBOOK OF THE M E D I C A L S CIE N 0 E S. Teratology. Teratology. TERATOLOGY. General Considerations.-Tera- tology [derived from the Greek repas, reparos, equivalent to the Latin monstrum, "anything strange," and Kiyos, "discourse"] is a term for which we are indebted to Etienne Geoffroy Saint-Hilaire (1822). It is intended to embrace the entire subject of primitive and congenital malformations, including the history, literature, embry- ology, classification, and description of every deviation from the normal type of both plants and animals. Hence this department of science is divisible into Vegetable and Animal Teratology. The following brief essay is limited to elementary considerations relating to that portion of animal teratology which pertains to the human body. Teratology is but a branch of pathological anatomy, and is founded on abnormal embryology. Tcratological de- velopment can be understood only by a precise knowl- edge of normal embryology. The popular terms, monster and monstrosity, are some- what objectionable on account of superstitious associa- tions. Many also of the most expressive terms employed by the old writers on the subject, which are still to some extent retained by modern authors, were derived from the fabulous legends of Greek mythology. Of such are the terms Janus, Cyclops, and Siren. History.-From the earliest historical ages to the pres- ent time congenital malformations have attracted the at- tention of philosophical writers, as well as excited the wonder and superstitious awe of the illiterate. The works of most of the ancient naturalists and anatomists abound in frequent allusions to the subject. Hippocrates, Aris- totle, Pliny, and Galen may be cited as having not only observed their occurrence, but also as having attempted to furnish explanations of their causes and genesis. How- ever, all the ancient and much of the modern literature of the subject, including nearly everything that has been published as recently as the beginning of the eighteenth century, possesses very little scientific value ; consisting for the most part of a confused and perplexing mass of marvellous and apocryphal tales, brief and inaccurate de- scriptions, founded on fanciful resemblances to things which have no analogue or archetype in nature-being unlike all else in heaven above or on earth beneath : All prodigious things Abominable, unutterable, and worse Than fables yet have feign'd or fear conceiv'd, Gorgons, and hydras, and chimeras dire. To which are added absurd and superstitious notions re- garding the origin and portentous significance of the so- called monsters. Human teratology has only to do with congenital ano- malies, such as have developed during intra-uterine life, and excludes all acquired deformities, such as have orig- inated during or after the birth of the foetus. A comprehensive treatment of the subject would re- quire one or more considerable volumes and numerous illustrations. What is very much needed at this time is a compendious manual of teratology, in which the ele- ments of the science should be concisely and methodically presented. It would require figures of the typical forms of the several anomalies of organization, illustrative cases, and ample references to the literature of the subject. It should treat of embryology, and of the obstetrical, sur- gical, and the medico-legal bearings of the subject, to all of which should be added directions for the dissection of specimens, and proper methods of reporting cases, what to dissect, what to report, and where. Such a man- ual would be incomplete without an exhaustive glossary of the many terms and synonyms employed by old and recent authors, and a full bibliography of teratology. I am certain that no such work exists in the English lan- guage, and I am not aware of the existence of such a treatise in any foreign tongue. The subject is of suffi- cient importance to call for such a work. There is a rapidly increasing inquiry and demand for information relating to this branch of knowledge. The writer of this essay has been repeatedly solicited to prepare a manual of the kind above indicated. The material and literature are very abundant, though not readily accessible to the ordinary student. The bibliography embraces hundreds of volumes and pamphlets, mostly rare and very expen- sive ; including essays and treatises on special forms of malformation, many of them published in splendid folios, in the most sumptuous style ; while others are but typo- graphical abortions and bibliographic anomalies. Until quite recently, the appearance and causes of mal- formations belonged to the mystic and frightful domain of witchcraft and demonology. Most of the old writers of the sixteenth and seventeenth centuries, devoted lengthy chapters to the discussion of monsters believed to have been procreated by direct sexual intercourse of women with the devil. Some of the monsters, which were figured and described as partly human and partly animal, were accounted for by an assumed copulation of human beings with the lower animals, or the reverse. Ambroise Pare, the father of French surgery, in his great work on Surgery (1579), Book XXV., on monsters and prodigies, discourses on this subject in the following manner:1 "Therefore, in times past there have been some, who nothing fearing the Deity, neither Law nor themselves, that is their soule, have so abjected and pros- trated themselves, that they have thought themselves nothing different from beasts : wherefore Atheists, Sodo- mites, Outlawes, forgetfull of their own excellency and divinity, and transformed by filthy lust, have not doubted to have filthy and abhominable copulation with beasts. This so great, so horrid a crime, for whose expiation all the fires in the world are not sufficient, though they, too maliciously crafty, have concealed, and the conscious beasts could not utter, yet the generated mis-shapen issue hath abundantly spoken and declared, by the unspeak- able power of God, the revenger and punisher of such impious and horrible actions. For of this various and promiscuous confusion of seedesof different kinde, mon- sters have been generated and borne, who have beene partly men and partly beasts." Then follow "the ef- figies of a monster halfe man and halfe dogge," another man and goat, a third "figure of a pigge, with the head, 1 Teratology. Teratology. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. face, hands, and feet of a man," etc. Chaps, xiii. to xvi. are devoted to the discussion "of monsters occa- sioned by the craft and subtlety of the Devill." Pare, as well as Rueff, Schott, and others of that period, take the negative of this subject. Pare says, "It is much less credible that Divells can copulate with women, for they are of an absolute spirituous nature, but blood and flesh are necessary for the generation of man. What naturall reason can allow that the incorporeall Divells can love corporeall women ? And how can we thinke that they can generate, who want the instruments of generation ? How can they who neither eate nor drinke be said to swell with seed ? " Of this sort of discourse, in the old works, there is no end. While remarkable malformations among the lower animals were regarded as monsters portending dire ca- lamities, human monstrosities were considered as evi- dences of divine anger, or as the direct result of demoni- acal influence, and hence were viewed with apprehension and dread, being interpreted by the augurs of the times as prodigies entailed upon parents as punishments ; while in other cases they were to the general public wonders of bad omen. In a curious and rare old folio, printed at Basil, three and a third centuries ago (1557), the author, Conrad Lycosthenes, collected, with more industry than discrimination, all the prodigies which had been recorded, as he tells us, from the beginning of the world down to his own time. This curious book is profusely and very quaintly illustrated with wood engravings, affording good examples of the then-existing state of the art, as well as exhibiting the absurd popular notions of that day. Accompanying the picture of a malformation, human or animal, single or double, follows a representation of the special calamity of which it was believed to be the im- mediate precursor, be it an earthquake, flood, fire, pesti- lence, or war. After the narration of an instance of the birth of a monstrous child, lamb, or calf, in a certain province, there follows an account of its correlative event, represented by an engraving, such as the death of a bishop, or the destruction of a city by flames, by an earthquake, or by floods. The strong faith of even Mar- tin Luther accepted the popular idea that monsters are portents of evil; he speaks of the relations of a mon- strous calf and a catastrophe. The general belief that monsters had a Satanic origin gave rise to the'horrid practice of destroying them, either by drowning, stran- gling, or casting them into the flames, with the hope of thus diminishing the progeny of the devil. Notwith- standing that the greater part of the cases recorded in the old literature of teratology consisted of fabulous stories, concerning supernatural prodigies such as could have had no actual existence ; yet there are to be found, here and there, a few genuine cases quite accurately de- picted and described. Some of the cases which at first view would appear to be fabulous, are, when examined by the light of modern science, and compared with recent examples, found to be identical with recognized forms. Interesting as is the fabulous period of the history of teratology, space will not admit of further detail. The in- termediary or transitional period embraces the first half of the eighteenth century. During this short space of time the subject began to be regarded in the light of a science. It was cultivated by a considerable number of earnest and intelligent observers, who aimed to divest it of the mystery and superstition in which it had been so many years enveloped. This half century was marked by sub- stantial progress. It is no easy task to untrammel the mind from long and deeply-rooted superstition, prejudice, and authority. This, however, is the grand antecedent neces- sary to scientific discovery and permanent progress. To the members of the French Academy of Sciences, among whom Mery, Duverney, Winslow, Lemery, and Littre should be particularly mentioned, teratology is chiefly in- debted for its advancement during the transition period. In the works of these celebrated authors may be found a large number of interesting and valuable facts, which were correctly observed, accurately described, and reported with rational and judicious observations. The flimsy and supernatural explanations which had hitherto been enter- tained during the preceding period concerning the genesis of monstrosities, were in the present substituted by plausible hypotheses, and in some instances by scientific theories. Particular attention, as far as science had then advanced, was bestowed upon the causes and development of monstrosity. Notwithstanding that precise and phil- osophic thought began to be applied to the subject, most of what was said and written was of a polemic character. Almost endless controversies were carried on in the French Academy on the question, " whether monstrosity is original or acquired ? " Lemery and Winslow were the ablest and most prominent champions in the discussion. The former maintained that monstrosities are only vices of conformation, resulting in the course of abnormal de- velopment of the embryo ; while the latter contended that the original germs were already defective before develop- ment or growth began. This physiological discussion was continued with enthusiastic ardor for a score of years, ending only by the death of Lemery. The ques- tion of original or acquired monstrosity engaged the at- tention of all the principal European anatomists and phy- siologists of the age. Haller, and numerous authors of less celebrity, wrote more or less extensively on the sub- ject, and fairly exhausted every fact and argument which could be arrayed in the discussion of it. The third, or scientific, period of the history of tera- tology extends from the middle of the eighteenth century to the present time. It is characterized by an almost entire freedom from the fabulous and superstitious no- tions of the first, and the almost endless discussions of merely hypothetical and theoretical doctrines by enthu- siastic partisans of the second. This period is one of anatomical and embryological researches, by which method alone the relations of abnormal to normal devel- opment can be successfully pursued and clearly demon- strated. Morgagni, and the distinguished academicians above referred to, had by their combined labors already corrected many erroneous doctrines, and proposed more rational explanations respecting the nature and origin of abnormal development. The distinguished honor of elevating the subject to a science is due to the genius and labors of Albrecht von Haller, the immortal physiolo- gist. * Haller laid the foundation-stone of teratology in his celebrated work " De Monstris," in which he brought together all the facts relating to the subject which had been observed and recorded by his predecessors and con- temporaries, and subjected them to the scrutiny of his lucid and analytical mind. His deductions gave to the subject the character of a distinct branch of science, and established the basis of future progress. The followers of Haller were content to walk in the steps of their great master for many years, until that brilliant genius, Bichat, the creator of the science of histology, threw a radiance of illumination on the complex structures of the body, and reduced them to their elementary tissues. He insti- tuted the school of minute and laborious research, com- prehensive and elaborate experiment, by which the es- sence of organic forms, and the laws by which these forms are invariably directed, have thus far been, and will alone in future be, discovered and demonstrated. The various species of organized beings and their em- bryos were carefully compared with each other, and with that of man, whereby the general facts, plan, and unity of animal organization, including all the multiform gen- era and species of every epoch, were made manifest. On these comprehensive views a new theory of anomalies and monstrosities was founded, viz., that of arrest and retardation of development, which serves to explain many varieties of malformation-for example, cleft and fissure formations, absence and deficiencies of parts, etc. From the time of Bichat the science of teratology be- came identified with embryogenesis and embryology. By a careful study of the laws of development, the order in which the various organs are evolved in the embryo, it has been observed that monsters resulting from retarda- tion or complete arrest of development, are, to a certain degree, permanent embryos. The abnormal organs rep- resent early stages of formation in embryonic life. The 2 Teratology. Teratology. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. embryos of different species of animals resemble each other very strikingly when examined and compared at the earlier stages of their growth. " During almost the whole period of embryonic life," says Professor Agassiz, "the young fish and the young frog scarcely differ at all, and so it is also with the young snake compared with the embryo bird. The embryo of the crab, again, is scarcely to be distinguished from that of the insect; and if we go still farther back in the history of development, we come to a period when no appreciable difference whatever is to be discovered between the embryos of the various departments of the animal kingdom." In the course of this essay frequent reference to the embryonic evolution of parts and organs will be made in explanation of anomalies or vices of conformation. Classification and Nomenclature.-Teratology embraces the consideration of a multitude of objects and conditions, and has in the course of time acquired an ap- palling array of technical terms and synonyms, and has also been subjected to numerous systems of classification. The multiform varieties which are found in the entire series of abnormal development occurring in man and the lower orders of animals, would be bewildering to the student, were it not possible to classify them according to some rational method, based on distinctions of confor- mation and structural peculiarities. Some of the systems which have been proposed have been very complex and elaborate, while others have been extremely simple. There are many difficulties in the way of making a satis- factory and scientific classification. Vrolik, the eminent Dutch teratologist, ignored all attempts in this direction, and arranged malformations in general groups estab- lished on trivial distinctions. He believed it impractica- ble to construct a classification founded on distinctive structural characteristics. It is true that in an extended series of cases of malformation-from the simplest vices of conformation to the maximum of single and double monstrosity, the intermediate forms, to some extent, merge into each other by almost imperceptible degrees, and thus render it difficult, in some instances, to fix with precision the limit of a genus or species ; yet the same embarrassment is encountered in other departments of natural science, giving rise to a great diversity of opin- ions among authors, who erect new genera and species to suit their convenience, while to meet the minor distinc- tions they are obliged to create an indefinite number of sub-genera, sub-species, and varieties. There are certain well-marked forms, which may be regarded as types, that have occurred among the lower animals in common with man, without regard to species, nation, geographical lo- cation, or time, and which have been reproduced again and again, with modifications so trivial as to render it easy for the student to refer almost any form of malfor- mation to its appropriate order or genus. In treating of malformations in general, a distinct line of demarcation can be drawn between simple and compound; the former having one or more of the normal organs or parts defec- tive or wanting, the latter having some parts or organs more than belong to the normal organism of a single in- dividual. In the lower degrees of duplicity the excess of development is manifested in the multiplication of unim- portant parts-for example, an extra digit-thence on to the higher degrees of duplex formation, where the series ends in the production of two complete and symmetrical bodies which are homologously connected by a small bond of union, such as is seen in the case of the noted Siamese brothers, and in that of the Hungarian sisters. Of the single monsters we have a number of forms that can be referred to cleft malformation, or such as re- sult from non-closure of those parts of the body which are open in the early stages of normal embryonic devel- opment, but which at a later period become closed. Cleft and fissure abnormality may occur along either the dorsal or neural arches, or at any portion of the anterior or haemal arches. The opposite of cleft malformation also occurs, in which the closure of the neural and haemal canals is pre- mature-that is, before the parts and organs along the median line of the body are entirely evolved. Symphysis, or synthetic malformation includes all ab- normal fusion ; cyclopea, synotia, sympodia, syndactylus, atresias, etc., are all referable to this general class. Under the head of Monstra deficientia, many malfor- mations have been described. In an extended series of deficient, incomplete, retarded, or arrested development, cases will be found illustrating an entire absence of al- most every individual organ and member. Thus we find in one case the absence of one or more limbs ; in an- other the cranium and brain, the eyes, the face, the en- tire head, the heart, or the genital organs are wanting; and so on to the end of the chapter. The whole body may be absent, the head only being developed ; again, the head and trunk being entirely absent, the pelvic ex- tremities alone remain attached to the umbilical cord. Appropriate names have been given to all these abnor- malities by defect, which will be mentioned farther on. The abnormal position of organs, transposition of vis- cera, etc., have been included under the term situs mutatus. Malformations of the sexual organs are gen- erally treated under the rather indefinite caption of her- maphroditism. Remarks on the classification of duplex or compound monsters will be reserved until this inter- esting department of the subject is reached in course. Causes of Malformation.-This inquiry has given rise to much fruitless speculation ; and although a degree of obscurity still remains as to the essential cause of the several known vices of conformation, and more remark- able anomalies of organization which occur among all the divisions of the animal kingdom, in common with the human species ; yet we are gradually approaching to a clearer understanding of the genesis of all the varieties of malformation. The superstitious and absurd explana- tions of a former age, already mentioned, which to some extent are still held by a few persons from whom more rational views ought to be expected, though, for the most part, such as are in no way distinguished as tera- tologists, or even known to have bestowed any special attention upon the subject of embryogenesis, have nearly vanished before the light which recent embryological in- vestigations have shed upon the subject. Nothing would seem to be more irrational than an attempt to explain the anomalies of organization which occur in the human foetus by maternal mental emotions and impressions, when it is an undisputed fact that there is not a malfor- mation knowm which is peculiar to the human species; precisely corresponding malformations, in every respect identical in external configuration and in internal struct- ure, occur among the lower orders, both in the wild and in the domesticated state-viviparous and oviparous. They are not rare among birds, and are also found among rep- tiles and fishes, in crustaceans and insects. Indeed, wre may go still further, and find analogous malformations in the vegetable kingdom, -where single and double mon- sters abound-developments which result from arrests as well as from defective or excessive formative energy. The recognition of these facts alone ought to be enough to silence forever the antiquated and miserable super- stition that any form of malformation in the human foetus could possibly be due to the impressions and vagaries of the maternal mind. Such flimsy explanations would certainly fail to account for the fact that deep- seated organs, the vefy existence of which is unknown to the pregnant woman, are quite as frequently mal- formed as are the external and visible parts of the body. The books are filled wuth examples of congenital anom- alies of the heart, kidneys, intestinal canal, the abnor- mal distribution of blood-vessels and nerves, more or less than the typical number of vertebrae, ribs, etc. Embry- ology demonstrates the period, manner, and succession of the evolution of the several parts and organs of the embryo ; and yet the scientific gentlemen who adhere to the affirmative of this question relate cases of the mal- formation or absence of parts which are evolved previ- ous to the time when the assumed metamorphosing men- tal impression was made. Space will not permit the full discussion of the subject in this place. It was long ago somewhat exhaustively, and thus far unanswerably, dis- cussed by the writer in an article to be found in the 3 Teratology. Teratology. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. American Journal of Insanity, January, 1870, Utica, N.Y., under the following heading: "Does Maternal Mental Influence have any Constructive or Destructive Power in the Production of Malformations or Monstrosi- ties at any Stage of Embryonic Development ? " * External mechanical influences, such as blows, falls, or severe shock of any kind may, by affecting the gen- eral health of the pregnant female, have power to arrest, retard, or otherwise disturb the normal development of the embryo, although the evidence that such has been the case still remains to be furnished. The explanation of most malformations is to be found in pathological influ- ences analogous to those which occasion morbid changes in the body after birth. These influences may be very manifold. It would seem unnecessary to ascribe all anomalies of organization to a single, or only a few causes. Embryology.-It will probably aid the reader's under- standing of the genesis of many of the malformations to be referred to hereafter, if I furnish a very brief outline of the normal development of the embryo. Malformations of the original germ have been regarded by some as an important explanation of the cause of abnormal develop- ment. This explanation is rendered nil by the fact that embryology teaches that there is no such thing as an original germ. The germinal vesicle which exists in the ovum before impregnation entirely disappears shortly after fecundation. This occurs before the formation of the vitelline nucleus, entirely different from the germinal vesicle, which appears from fifteen to thirty hours after fecundation, of -which it is the positive evidence. Next follows the segmentation of the vitellus, which results in the formation of the blastodermic cells, which become arranged in the form of a membrane (the blastodermic) which is further subdivided into layers, to be referred to later on. After the formation of'the single blasto- dermic membrane, at a certain point on its surface there is formed the embryonic spot; this spot becomes elon- gated and oval. It is then surrounded by a clear oval area, called the area pellucida. This elongated line with- in the area pellucida is known as the cicatricula, primitive trace, or primitive groove. It is here that the neural canal of the embryo is evolved. The blastodermic mem- brane becomes split into an external or serous, and an internal or mucous layer; the latter develops into the epithelial lining of the alimentary canal. The intermedi- ate layer is formed, by a genesis of cells, from the opposite surfaces of the two above-mentioned layers, from which third layer nearly all parts of the embryo are developed. The middle layer, which is the thickest and most im- portant, eventually splits into two layers, the outer of which forms the muscular layer of the trunk, while from the inner the viscera are evolved. It is not practicable to give all the details of embryonic development in this place. A few additional facts must suffice. At a very early stage both the neural and visceral canals yet remain open. The dorsal is the first to close ; failure to do this results in spina bifida; failure to close the ventral plates ex- plains the cleft malformations on the anterior median line of the trunk. About the beginning of the second month four papillary prominences, or embryonic buds, being the first traces of arms and legs, make their appearance. The rectum appears at the fourth month, at first terminat- ing below in a blind extremity ; an arrest of further de- velopment at this stage results in imperforate anus. The anterior portion of the pharynx presents, during the sixth week, a large opening bounded by the facial arches, which opening is afterward partially closed as the differ- ent parts of the face are formed. Arrest of this develop- ment produces the facial fissures, such as single and double hare-lip, cleft palate, etc. The growth of the diaphragm is from the periphery to the central portion, through which the oesophagus and large vascular trunks find passage. Failure to close produces congenital dia- phragmatic hernia. The external genital organs begin to be developed about the fifth week. The heart, when first developed, is situated exactly in the median line and gives off two arches which curve to either side and unite into a single central trunk at the spinal column below. These are the two aortse ; the single trunk below becomes the abdominal aorta. Only one of these aortic arches, usually the left, is permanent. In some cases the right becomes the permanent one, as in birds, and on this de- pends the anomaly of transposition of viscera. From the brief abstract of the elements of embryology above presented, it will be easily understood that " most malformations represent certain stages of the develop- ment of the embryo and its organs, at which stages for- mation has stopped short, or from which ulterior devel- opment has ceased to follow the normal type." This theory, which was elaborated by Wolff, Tiedemann, and J. F. Meckel, is probably the most rational and scientific that has thus far been proposed or entertained upon this subject. Certain malformations not infrequently met with, which do not precisely represent the exact form at which the foetal development was arrested, are due to the important modifications which must result from the con- tinued growth of the normal parts in the progressive nu- trition of the foetus. It has been observed by eminent embryologists that the transient forms of the human em- bryo, in its several stages of evolution, bear a striking resemblance to the persistent types of the lower orders of animals; hence the human malformations which result from arrested development often acquire the appearance of brutes, while those occurring in animals, for the most part, have the forms of beings still lower in the scale. * The civilized world has made one long and progressive step in remov- ing the origin and cause of physical malformation from the malign sphere of devils, or of angry and unappeased gods, to the more controllable and less frightful metamorphosing power of the unfortunate mother's mind, disturbed by ardent longings for innocent fruits, or by the sight, sound, or touch, or even the dream of objects of disgust or affright. It is to be hoped that the enlightened world will soon make another progressive stride, by relegating to the realm of pathological histology, and to em- bryogenesis, the explanation of anomalies of organization. Why should the anxious and sensitive mother be any more responsible for deviations from the normal foetal development than the unreasoning brute, the cold- blooded reptile, or the nerveless plant, all of which produce monsters identical in kind,in degree, and in variety? Fig. 3821.-Adhesion of Placenta to Head. (Rudolph.) 2 The deviations from the normal type of a species are never so great as to destroy all semblance to it. There is a limit beyond which abnormalities never pass. In no case has a monstrosity been known in which there has been developed a part or organ not belonging to the species of animal which was the subject of the malformation ; 4 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Teratology. Teratology. such as partly human and partly animal, beast and bird, bird and reptile, etc. It is an interesting fact that all malformations are rare in comparison with the entire number of normal births, the average being one to three or four thousand births in the human subject, and in yet smaller proportion in the lower animals. Some of the types in teratology do not occur more than once in several millions of births. If maternal mental impressions could tioned that the germ at first is developed as a manifold membranous expansion, the free margins of which in- clined toward each other, anteriorly and posteriorly, and that they eventually meet and unite to form two cavities or cylinders. In case this contiguity and union of the plates should fail to take place, or should take place im- perfectly, or not along the whole extent of the line of normal fusion ; or, if union which had already occurred should undergo a solution of continuity through some inflammatory or other agency, with serous effusion and consequent distention, there would result, either anteri- Fig. 3823.-Acrania. (Vrolik.)4 orly or posteriorly, and commonly at the median line, sometimes elsewhere, a- cleft or gap, attended by pro- lapse or ectopia, or even by destruction of the implicated viscera. Non-closure of the Anterior Parts of the Body. -This results in a considerable variety of malforma- tions which can be little more than enumerated in an es- say so limited as this necessarily must be. Beginning from above we have a, cleft cranium, to which belongs acrania, hemicephalus, etc.; b, cleft face, or facial fissure ; c, cleft cheek ; d, cleft palate and uvula ; e, cleft upper lip-central, unilateral, or bilateral, commonly called hare-lip ; f, cleft tongue ; g, cleft lower jaw or chin ; h, Fig. 3822.-Acrania. (Vrolik.)3 occasion monsters, the proportions would soon be re- versed. The reader's attention will how be directed to the con- sideration of some of the varieties of monstrosities which occur in the single body, reserving the compound or double monsters for special treatment later on. The cases of improperly called spontaneous amputation in utero, due to constriction of a limb by coils of the umbilical cord, are not properly malformations, they are accidental deformities. So, also, those cases of adhesion of the placenta to the head of the foetus, an example of which is seen in Fig. 3821, are to be referred to intra- uterine disease, probably, as J. Y. Simpson has sug- gested, to a placentitis, of which he has described an acute and chronic form. Placental adhesions to the head are generally associated with some malformation of the foetus, such as ectopia cordis, eventration, or other cleft deficiency. It should not be understood that they are related as cause and effect, since such adhesions take place without concurrent malforma- tion, and, conversely, identical abnormalities are found without placental adhesion. It is not possible to entirely separate malformations from the results of diseases of the ovum and of the foetus. The late Profes- sor Simpson, of Edinburgh, wrote several elaborate es- says upon intra-uterine pathology {Edinburgh Medical and Surgical Journal, April, 1836, October, 1838, July, 1839); as did also Professor Montgomery {Dublin Journal of Medical Sciences, 1832, in his work qn "Pregnancy," and in the article on "Foetus," in the "Cyclopiedia of Anatomy and Physiology"); the late Dr. William C. Roberts, of New York City (" Diseases of the Foetus," etc., American Journal of the Medical Sciences, August, 1840, October, 1841); Vrolik, Otto, and many others, who have greatly enlarged our knowledge of this inter- esting subject. Cleft formations, or such abnormalities as result from non-closure of those parts of the body which are open or separated in the embryo in the early stage of its normal development, but which at a later period should become united, furnish a scientific explanation of many forms of fcetal anomaly. In the brief summary of facts pertaining to embryo- genesis which has already been furnished, it was men- Fig. 3824.- Acrania (Exencephalocele). (E. Geoff. Saint-Hilaire.) 6 cleft sternum, or fissure of the sternum ; i, cleft dia- phragm (resulting in diaphragmatic hernia) ; j, cleft ab- dominal walls ; k, cleft pelvis ; I, cleft urinary bladder, called inversio vesicae and ectopia vesicae ; m, cleft dor- sum penis, or epispadiasis. The last three are gener- ally concurrent. Several minor clefts would be men- tioned in an exhaustive treatise. Restricted space will not admit of descriptive details, illustrative cases, or reference to the literature of each of the above fourteen 5 Teratolojjy. Teratology. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. varieties of anterior-fissure abnormalities. Fig. 3822 rep- resents a typical case of acrania, or hemicephalus as some prefer to call it. Fig. 3823 shows the deficiency of the cranial parietes ; the brain is either entirely absent or very imperfectly developed. The cases are by no means rare. The body and limbs are usually well 3826 is a correct representation of Dr. Groux's sternum. Cleft abdominal walls, resulting in ectopia viscerum, are not extremely rare. Congenital umbilical hernia is to be referred to the lesser degrees of this defect, while in its extreme degrees the entire contents of the abdomen are uncovered and unsupported. The writer of this chapter has met with an instance in his practice where the foe- tus, born at full term, the abdominal parietes being entirely wanting, the viscera were merely covered with the thin, transparent peritoneum, which soon took on congestion and inflammation from exposure to the air, became opaque, and gave way on the third day after birth, allowing the intestines, liver, etc., to hang out of the child's abdomen, in which condi- tion it survived to the end of the fifth day. Fig. 3830 is a good illustration of this anomaly. Cleft pelvis, or fissure at the pubic symphysis, is rare. It is for the most part associated with ectopia vesica? and epispadia. Non-closure of the neural arch gives rise to spina bi- fida, which may be limited to a very few of the ver- tebrae, or extend to the entire vertebral column. In the highest degree of fissure even the bodies of the vertebrae are involved. This anomaly is due to an arrest of development, resulting probably from hy- drorhachis. It is quite frequently associated with congenital hydrocephalus and acrania. In some cases there is an entire absence of the spinal cord, in others the medulla is bifid ; which is occasioned by an arrest of development at that period of its evolution in which the two bilateral halves, of which it is origin- ally formed, are as yet separate. Hydrorhachis may occur without fissure of the vertebral column. Fig. 3827 illustrates spina bifida. Clejt pelvis in the sac- ral region is another example of fissure of the back part of the body. The sacrum may be absent or merely cleft, as seen in Fig. 3827, in which case it is no more than a Fig. 3825.-Fissure of Face. (Ahlfeld.) 6 formed, large, and fat. The foetuses commonly reach full term, and, though mostly still-born, sometimes live for several hours after birth. In some types of acrania the brain is entirely displaced from the base of the cra- nium, and lies or hangs in a sort of sack on the neck, ex- tending, in some instances, a distance down the back. These are cases of encephalocele, a very good example of which is shown in Fig. 3824. In lesser degrees it is called hernia cerebri. Facial cleft presents itself in various degrees. In ex- treme degrees of cleavage, such as is seen in Fig. 3825, it becomes a vice of conformation that can only be ex- pressed by the term monster in its most hideous and frightful sense. The fissures of the face, cheek, palate, and the several forms of hare-lip, all belong to the same order of anomaly of organization. The milder types are not rare, they are met with single or double ; the com- plex cases defying the surgeon's art. In order properly to understand the various forms of fissure of the face, the several changes which occur during the development of the head must, be briefly stated. Originally, there is a common oral and nasal cavity. The place of the nose is occupied by two fissures, winch extend from the inter- nal angles of the eyes to the upper margin of the cavity of the mouth. There is at this period not the least indi- cation of a palate, so that the mouth and the nose form one cavity. Arrest of development at these different stages results in the production of the various forms of facial fissure and cleft palate. Fissures of the sternum and thorax also occur in various degrees. In some cases of ectopia cordis the heart, deprived of the pericardium, protrudes through the cleft. In the well-known case of Dr. Groux, who visited the medical colleges and medical societies of all Europe and America, the sternum was cleft to such an extent that the cardiac movements and sounds could be studied in a very curious and satisfac- tory manner. The observations made in his case were extensively published, and are familiar to many. Fig. Fig. 3826.-Fissure of Sternum. (Jewett.) 7 part of total spina bifida. Cleft scrotum and urethra are known as hypospadias. Synthetic abnormalities are such as result from pre- mature fusion. Symphysis, in teratology, embraces a class of vices of conformation which are the opposite of 6 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES Teratology. Teratology. cleft malformation. The closure and fusion have oc- curred before the parts and organs that should lie along the median line of the body are fully evolved. The re- sulting malformations are aprosopa-no face ; micro- in the neck, either in juxtaposition or actually fused (sy- notia). Figs. 3828, 3829, and 3830 illustrate these condi- tions. Fig. 3828 shows cyclopia with absence of the inferior maxilla, and one degree of synotia. Fig. 3829 exhibits the large orbit which contained the compound globe. Fig. 3830 is a museum of teratology-acrania. Fig. 382!).-Cyclopia. Compound orbit. (Knape.) 10 nasal proboscis, cyclopia, aprosopa, agenya, synotia, and abdominal eventration. Sympodia, which litersilly signifies foot-joined, in tera- tology, is made to include all cases of coalescence of the lower extremities, even those in which the feet or con- siderable portions of the lower limbs are absent. In some instances a portion only of one limb is developed, which is united by fusion with its more nearly perfect fellow, the sympodic limb being terminated by a single foot; this is an example of monopodia. Bilateral symmetry is usually observed in sympodia. Figs. 3831 and 3832 exhibit the Fig. 3827.-Spina Bifida Involving Sacrum.8 prosopa-small face ; anophthalma-no eyes ; cyclopia- one eye ; synotia-united ears ; agenya-no chin ; micro- gcnya-small chin ; sympodia-united feet; syndactylus -united digits; atresia-closure of natural openings; and other abnormal congenital fusions. It is not prac- ticable in this place to enter into minute particulars con- cerning all of the above forms of symphysis. Cyclopia is that form of fusion malformation in which the original ru- diments of the eyes, whether evolved as a sin- gle vesicle or from two vesi- cular bulbs, ultimately re- sult in a more or less single globe, suggest- ing tlie fabled Cyclops,or one- eyed monster. Thiscompound globe occupies the median fa- cial axis. Most of the cases are associated with other defects of the face. Frequently the nose is represented by a tubu- lar prolongation, or pro- boscis, suspended or pro- jected above the eye. In the old literature of tera- tology the illustrators did not hesitate to make the head of an elephant on such foetuses, to harmonize with the suggestive trunk. In other cases the lower portions of the face are most de- ficient. The lower jaw is absent (agenya); the ears are Fig. 3830.-Cyclopia (with Synotus and Eventration). (Vrolik.) 11 Fig. 3828.-Cyclopia. (Knape.) * external configuration and osteology of a case of sym- podia in the human subject, which is remarkably sugges- tive of the structure of the seal. In such cases the fusion is so complete as to entirely obliterate all traces of the genitals, as well as the anal opening. This variety be- longs to the class of monsters which teratologists desig- 7 Teratology. Teratology. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. nate by the terms siren, symmeles, and sympodia sireni- formis. In the lower degrees of sympodia neither of the feet is developed. The fused limb ter- minates as a stump. Figs. 3833 and 3834 represent the form and the bones of such a case, which has been described under the term si- renomelia. Syndactylus in- cludes every degree of fusion of the fingers and toes. sia oris, atresia palpebrarum. There is a series of anomalies which is the oppo- site of atresiae, viz., the persistence of certain communicat- i n g apertures be- tween parts which, at a later period, ought to remain separate, as also the abiding pat- ency of certain canals which are normally closed either before, or immediately after, the birth of the fcetus. Of these the following may be mentioned : Permanent patency of the foramen ovale, of the ductus arteri- osus, and of the ductus veno- sus Arantii; also patency of the processus vaginalis peri- tonaei, and of the urachus. In the last anomaly urine flows out at the umbilicus. The next class of deficiencies which will be noticed is that known in teratology as perome- lia, which term signifies defi- cient limbs, and is intended to embrace every fault of the ex- tremities, from minor defects to their entire absence. Apoda, no foot; ascela, no leg ; amelia, no limb ; achira, no hand ; abracha, no arm. The prefix pero, or peros, to any of Fig. 3833. - Sympodia. (Otto.) 14 Examples occur in which all of the digits of the hand, or of the foot, are completely fused throughout their entire length. In such cases the nails Fig. 3834.-Sympodia. (Otto.) 16 the names of parts would imply deficiency of the same. Amelia, or want of all the extremities, is quite rare (Fig. 3838). Instances of entire absence of both up- per or of both lower limbs are less rare, though not common. The first rudi- ments of limbs appear in the embryo about the beginning of the second month, being merely slight emi- nences or embryonic buds. An arrest of de- velopment at this stage of evolution would pro- duce the anomalies un- derconsideration. Adult examples of absence of one or more limbs are among the stock won- ders of "side-shows" and " dime museums." The malformation known as phocomelia, or seal-limbs, results from arrested or much retarded development of the bones of the limbs, which are left so short, curved, and rudimentary that they are concealed with- in the shoulders and hips. The hands and feet are gen- erally in these cases full Fig. 3831.-Sympodia. (Langsdorff.)12 are so united as to be continuous. Webbed fingers and toes are also included in this category. Some of the examples of this anomaly are very suggestive of retrocessive evo- lution ; the coalescence of digits points to the web-footed aquatic ani- mals, and to the solipedes that walk the earth. " It is in her monstrosi- ties that Nature reveals her laws," is an observation made by the phy- sician-poet Goethe, who evidently saw in the malformations of one species that which is normal in an- other. Figs. 3835, 3836, and 3837 are illustrations from Otto's great work on Monsters. Atresia is an abiding closure of tubes and cavities, which are orig- inally evolved with caecal termina- tions. Details cannot be given ; the following are the principal atresiae : Atresia ani, atresia vulvae, atresia vaginae, atresia uteri, atresia urethrae, atresia auris externae, atresia nasi, atre- Fig. 3839.-Sympodia. (Langsdorff.) 13 Fig. 3835.-Syndactylus. (Otto.) 16 8 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Teratology. Teratology. sized and well formed. Fig. 3839, from Vrolik, repre- sents a good specimen of this type. Awphali, or foetuses with the head entirely absent. This term should not be confounded with acrania, in which there is an absence of the cra- nial walls, with more only of one leg ; in other cases, merely of the two lower limbs (Figs. 3840 and 3841). In the fourth type there is still no thorax ; the trunk is more developed ; the lumbar vertebra?, the pelvis, the spinal marrow and its nerves are present. The lower limbs are quite complete, there is no heart (acardia). The fifth type has the body still more de- veloped, an imperfect thorax, dorsal vertebra?, and ribs; no upper limbs, no heart, the feet are generally defective or less defective development of the brain, which in ex- treme cases is entirely wanting. In this monstrosity there is no head. The body and limbs are very defec- tive, as are also the internal organs. Previous to the end of the third week of human gesta- tion the head of the embryo is not discernible, nor yet clearly distinct from the body ; after this period, during the fourth week, it develops so rapidly as to be equal in bulk to the trunk. Acephalus would therefore result from an arrest of development at any period before the fourth week. Tiedemann and the two Vroliks have divided the sev- eral degrees of this genus of anomalies into nine classes or types, which will be found useful in the designa- tion and description of cases. First Type: Acephali in the form of a rounded mass, without any indication of extremities. (Amorphusglo- bulus, of Gurlt.) The mass is covered with skin, and generally con- tains a fold of intes- Fig. 3836.-Syndactylus. (Otto.) ,T (Figs. 3842 and 3843). In the sixth type the chest is more nearly perfect; the upper extremities are present, but there is no visible head, no heart or lungs. The seventh type, acephali in which some cranial bones are found. Fig. 3838.-Amelia. (Hastings.) 19 tine and other confused foetal rudiments; it is attached to the placenta by the umbilical cord. A number of cases are on record. The second type differs from the first by being a more irregular rounded mass, with indications of feet. All the cases have an umbilical cord, imperfect genitals, an anal opening, and contain a portion of the colon, the kidneys, the lower portion of the vertebral column, imperfect pelvis, and the bones of one lower extremity. The third type of acephali has the trunk somewhat developed, no upper extremities, im- perfect lower ones. In a case observed by Ruysch, there was no body (acormus), the acephalus consisting Fig. 3837.-Syndactylus. (Otto.)ll! Fig. 3839.-Phocomelia. (Vrolik.) 20 An amorphous head with an indication of eyes and nose, no mouth or ears (Fig. 3844). Eighth type, body and all the extremities well formed, and having a neck, which is 9 Teratology. Teratology. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. wanting in all of the above types. The neck is sur- mounted and terminated by the ears, -which are fused at developed alone, they are delivered at the same time with from one to four well-formed foetuses. Only in the ninth type has a heart been observed. Owing to the fact that in the acephali the heart is almost always absent, some teratologists have preferred to call the entire class Acar- their bases. Beneath these ears is an im- perfect cranium. This form has only thus far been ob- served in the lower animals. In the ninth type there is only a trunk without a head, or any indication of upper or lower ex- tremities. Only one human case has been reported. The trunk contained a large heart, imperfect lungs, a malformed liver, a stomach, and an alimentary canal. In nearly all cases the acephali are produced by women Fig. 3840.-Acormus (Asomia). (Vrolik.) 21 Fig. 3842.-Acephahis. (Poppel.) 23 diet. This class of anomalies is interesting, as affording proof of the development of large systems of nerves and blood-vessels, quite independently of the brain and heart. The parts of the acephali which are developed indicate ample nutrition and an abundant circulation of blood. It is perhaps hardly necessary to state that life terminates in these monsters with their birth. There is an extraordinary malformation by defect yet to be mentioned. It is where neither body nor extremities Fig. 3843.-Internal Structure of Acephalus shown in Fig. 3843. (1'op pel.)'1 are formed, the head being the only portion of the foetus that is developed. This is in the fullest sense an acormuJ. It is the opposite of the third type of acephali, already described, in which all that is developed of the foetus is a pair of legs, and in some cases a single lower extremity. Lycosthenes, Rudolph, and a few others have related the who had previously given birth to many children. These headless and very imperfect foetuses are seldom or never Fig. 3841.-Acephalus (Acardia). (HerholdtJ " 10 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Teratology. Teratology. occurrence of cases in which the head "was the only part of the foetus formed. This was attached to the placenta of a well-formed twin by a few blood-vessels, by which the nutrition of the head was accomplished to such an extent that it was fairly well developed. Fig. 3845 il- lustrates this remarkable anomaly. II. Compound or Composite Monsters.-As the term simple malformations was employed, in the first part of this essay on teratology, to include all congenital ab- normalities which occur in a single body ; being malfor- mations from defect, deficiency, or absence of parts, ranging from the slightest to the most extreme degrees ; so, in the second part, the term compound, or composite, malformations and monsters, is intended to embrace all cases in which is to be found any supernumerary part, or organ, or other evidence of duplex development, in a series ranging from the mere addition of an insignificant member, to the complete duplication of the entire body, as is seen in the union of two well-formed foetuses. The expressions in teratology are employed interchangeably to avoid a wearisome tautology. In my treatise on ' ' Du- plex Development and Compound Human Monsters," I have prefixed the word diplo to the accepted term tera- tology, and thus inflicted on my readers the lengthy term diploteratology, which is made to comprise the history, literature, classification, embryology, and de- scription of double and triple formation ; including par- asitic monsters, foetus in foetu, and supernumerary devel- opment. Before entering upon the study of double monsters, properly so called, a brief abstract of the facts pertaining to hermaphroditism and to supernumerary development will be given. Hermaphroditism.-It is hardly necessary to state to the intelligent reader the fact that no human being ever existed possessed of complete sets of the generative organs of both the male and female sex. A bisexual hu- man being is an anatomical and a physiological impossi- Fig. 3844.-Acephalus (Acardia). (Herholdt.)25 Fig. 3845.-Acormns. (Tiedemann.) 20 word monster should not be used in speaking of the lesser degrees of duplex development, such as a mere increase of the natural number of digits, vertebra:, ribs, or mam- mae. It is only applicable to the higher and graver de- grees of organic duplicity. There is no sharply defined line to be drawn between what may be termed a malfor- mation and a monstrosity. An abnormality may consist of a slight vice of conformation, or it may amount to a repulsive and hideous deviation from the normal type. On the other hand, examples of double development of the greater part of the body may occur without present- ing an unpleasant object to behold. Some are rather pleasing than loathsome or horrible, as the term mon- ster implies to most persons. In order, therefore, to avoid any misapprehension, all deviations from the nor- mal type of the single body are included in the class sim- ple; and all additions to the normal type of a single body are embraced in the class compound abnormalities. Many bility. It is, however, a remarkable fact that a consid- erable number of well-authenticated examples of human individuals possessed of coexisting generative organs, more or less perfect, some of which are male organs and others female, have been observed, dissected, described, and recorded in the voluminous literature of the subject. It is also true that a very large number of spurious cases are contained in the books and journals. It is an easy mat- ter to be mistaken in the diagnosis of cases of apparent hermaphroditism. An hypertrophied clitoris resembles a penis ; an hypospadic and atrophied penis resembles a clitoris ; retention of the testes in the abdomen gives to the scrotum the appearance of the labia majora ; descent of the ovaries into the labia makes them look like a scro- tum with testicles. These and other indications have given rise to nice medico-legal questions as to the deter- mination of sex in doubtful cases. " From a developmental point of view, we may distin- 11 Teratology. Teratology. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. guish in the genital organs three segments. The first includes the external organs, and primitively these are neutral. As growth proceeds, the genital tubercle and folds are differentiated either into clitoris and labia, or else into penis and scrotum ; the second segment includes the vagina, uterus, and tubes in the female, and the epi- didymus, the vasa deferentia, the seminal vesicles, and the ejaculatory ducts in man. The development of this segment differs from that of the preceding in that it does not result from the transformation of a single blastema into male or female organs. Sexual differentiation oc- curs by the continuous evolution of either Muller's ducts or Wolff's ducts. If the former develop and the latter atrophy a female is formed, and vice versa. At the out- set, then, the embryo is bisexual. The third segment is formed by the ovaries in woman, the testicles in man. These organs are formed at the expense of the sexual em- inence. The tissue from which the latter is formed con- tains at the outset both male and female elements. The atrophy of one or another element results in sexual differ- entiation." 21 True hermaphroditism is an anomaly in which two glands of opposite sexes are developed in one foetus. Thus, in the third segment, there may be on one side a testicle and on the other an ovary. In other cases an ovary and a testicle are found on the same side. In the second segment, on one side organs formed by Muller's ducts may be developed, while those formed by Wolff's are evolved on the other side ; or on the same side both the ducts and the bodies may be coincidently developed. In the first segment, in like manner, there may exist cli- toris and scrotum, or penis and labia. Hence there are several varieties of hermaphroditism, which have been carefully studied by Saint-Hilaire and Sir James Y. Simp- son, the latter making three classes, viz.: lateral, trans- verse, vertical or double. The essay of Dr. Simpson in the " Cyclopaedia of Anatomy and Physiology," reprinted in his " Obstetric Memoirs and Contributions," is an elab- orate one, consisting of one hundred and twenty-five octavo pages, and two full pages of bibliography. To this article, now somewhat antiquated, the reader is re- ferred for interesting details. True hermaphroditism in the human being is so re- markable an anomaly, that, were it not proven by numer- ous reliable observations, it would stagger rational belief. It should be remembered, however, that hermaphrodit- ism is the normal condition of many species of plants, and also of many species of worms and mollusks. Why it should occur in the higher orders of the animal king- dom, even as an anomaly, has thus far remained unex- plained. In no instance has the male been able to im- pregnate, or the female to become pregnant. With double sets of organs-bisexual, though imperfect and atrophied-it has been aptly said of them, "there exists apparent anatomical wealth by the side of physiological poverty." Supernumerary Development.-Life and evolution are manifested by uniform laws, subject to more or less vari- ation by surrounding conditions. While in general the plant and animal species hold tenaciously to their pecu- liar types, yet it is well known that under cultivation and domestication they have been made to undergo very marked modifications. It is more than probable that in time past, climate, soil, altitude, food, and many sur- rounding influences, have wrought important changes in many species of plants and animals. In one species of animals the normal number of certain organs and un- important parts differs from that in others. Thus we find the vertebrae and ribs differ extensively in number in the whole range of vertebrates, as is shown by the vast number of vertebrae in serpents and saurians as com- pared with those in the mammalians, and also by the difference in those of one mammal from those in an- other. Supernumerary vertebrae and ribs are found not infrequently in man. The same may be said of the mammae. In the human female, the sheep, goats, horses, etc., there are two; in the cow four and often six ; in the dog fourteen. They are placed with bilateral symmetry on each side of the anterior median line of the body. In the elephant the upper or anterior pair only are devel- oped ; they are axillary. In man the pectoral pair ; in horses and sheep the inguinal or hypogastric pair ; in swine and dogs the whole series is developed. There are hundreds of cases on record of supernumerary nip- ples and breasts in the human subject. In some instances, there are three, four, and even five. They have been found well developed and functional in the axilla, and also in the groin of the human female. Here is, appar- ently, in this anomaly a retrocessive evolution ; a return to the normal series of the lower mammals. This organ is present, though imperfectly developed, in the males of most mammals. Polydactylism.-There is much difference in the speci- fic number of digits, in the whole range of the animal kingdom. The African ostrich has two toes ; the rhea, the cassowary, and the emeu each have three. Most of the birds have four. Nearly all of the animals that have claws are possessed of five, and this is the normal num- ber of digits in man. There are hundreds of cases of ex- tra digits of the feet and of the hands, in the human subject. Six, seven, eight, and in three instances, nine toes on one foot have been observed (see Fig. 3846). Extra fingers are not extremely rare ; extra toes are quite common. In some families they have been h ered i tary through sev- er a 1 genera- tions. In the Dorking fowl double toes or double thumbs are universal and characteristic. There is a spe- cies of goat in which every male has four horns. Space will not permit the mention of all the varieties of super- numerary development in the animal body. These are anomalies of embryonic dichotomy, fissuration, or loba- tion. They belong to the same category to which we must refer the extra leaflets of a four-, five-, or seven- leaved clover. I once cultivated a clover root that bore scores of extra leaflets-mostly four-leaved. An ex- planation of the extra leaflets would serve to explain the development of extra digits. Polymelia, or extra limbs, will be reserved for consideration further on. Foetus in Foetu.-This very interesting subject must be treated quite superficially in this place. There are a number of perfectly trustworthy cases on record of the inclusion of one foetus within the body of another, and also of adherence of a more or less complete foetus to the exterior parts of another. Teratologists have included some of these cases under the name of parasitic monsters. In one case, we are told on the authority of Fattow, in a foetus of seven months, two rudiments of foetuses were found in its abdomen. Several other authorities can be cited. The foetal rudiments are generally very imper- fect, though unmistakable, and are enclosed in a cyst. In some of the cases the foetus is nearly perfect. Dr. Robert P. Harris, of Philadelphia, has made a valuable report on congenital ventral gestation (" Trans. Coll, of Phys., Phila.," vol. iv., pp. 231-248, 1879), in which he has collected from the literature, eight authentic cases. Dr. Atlee's case, reported by Dr. Harris, is that of "a girl six years of age, who recovered after the discharge of the foetal mass from her abdomen, and lived seven- teen years." Dr. Harris gives a figure of the skeleton of the included foetus. The second case is that of a boy, Amedee Bisseu, who died at Rouen, France, at the age of fourteen. In his abdomen was found a sac containing a skeleton-skull, spine, pelvis, and rudimentary ex- tremities, and other foetal elements. The third case is reported in the Med.-Chir. Trans., vol. i., p. 234, 1809, Fig. 3846.-Polydactylus Pedis. (Johnson.) 28 12 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Teratology. Teratology. by George William Young, Esq. This also was a boy, who died aged a little over nine months. The autopsy revealed a cyst containing a male acephalous foetus. The fourth case, reported by Dr Gaither, of Kentucky (N. Y. Med. Repository, vol. i., p. 1, 1810), was that of a girl two years and nine months of age ; in its abdomen was found a female foetus, weighing one pound and fourteen ounces. Imperfect head, body seven inches long, lower limbs six inches. I will only add that of Mr. Highmore, of England. He reports, in an illustrated quarto pamphlet, the case of Thomas Lane, who died at fifteen years of age, in 1814. A sac or tumor, weighing four and a half pounds, was found in his abdomen; it contained an acephalous foetus with imperfect extremities. It was at- tached to the interior of the sac by a short, thick funis ; sex, female. Foetal rudiments have also been discovered in scrotal tumors. Velpeau, in 1840, met with a case. Mr. Fatti, of Austria, in 1826, reported a case of scrotal tumor which contained the ribs, vertebral column, two lower extremities as far as the knees, and the two orbits of a foetus. The Bulletin des Sciences Medicales, in 1829, again contained a similar report from Professor Wendt, of Breslau, of an operation by him on a boy seven years of age. In this category should be placed what have been improperly called dermoid cysts. These are gen- erally found to contain foetal elements, hair, teeth, osse- ous nuclei, etc. They are to the ovaries what the above- mentioned scrotal tumors are to the testicles. I will not mention in detail the cases of so-called foetus in fcetu which are found in the literature of the subject, where foetal elements, more or less developed, have been discovered in the anterior mediastinum, at the palate, at- tached to the cheek, the neck, the epigastric and umbil- ical region, and to the sacral and perineal region. In some of the above-mentioned cases, it is reasonable to entertain the belief that they are genuine examples of foetus by inclusion ; that, at an early stage of embryogenesis, before the closure of the ventral plates, a fecundated ovum may have found its way into the hsemal canal and thus became enclosed in its twin brother or sister, as we sometimes see one egg enclosed within the shell of an- other. I incline, however, to the opinion of the late Professor William Vrolik, who observes : "If we take a survey of all the cases which are designated fcetus in fcetu, and of the large number of theories on the origin of this monstrosity which have been criticised by Himly, it is certain that none of them can be maintained. It is most probable that the 'foetus in fcetu' is an incomplete effort to form a double monster." Double Monsters.-Before attempting to describe the numerous varieties of double foetuses which have been observed, and are to be seen in the pathological museums of this country, and in still larger numbers and variety in those of Europe, I will present a brief abstract of the theories which have been advanced to explain their ori- gin, and also state the laws by which their development is governed. Several theories have been suggested to ex- plain the production of double monsters: 1. The notion which attributes them to the assumed influence of mater- nal mental impressions has already been considered and dismissed as untenable, alike in double or single anom- alies of organization. I will simply allude here to a case of double-faced fcetus (Diprosopus tetrophthalmus, "Dip- loteratology," case 118, Fig. 71) delivered at the seventh month. It is a case identical with a considerable number of others to be found in the books. Three months pre- vious to the mother's pregnancy, that is, ten months be- fore the birth of this fcetus, the mother viewed the bodies of two children that were placed, side by side, in one coffin, so that when the coffin was opened the two faces only were visible. The sight of these two little heads, lying so closely together, made a profound impression on the mind of the lady, who became pregnant three months subsequently, and was eventually delivered of this two- faced foetus. Here we have one of the strongest cases in support of the popular belief-that the mother's mind can produce grave malformations of the foetus in utero. And yet this is a form of double malformation which is quite common among kittens, fowls, and reptiles. What can be more absurd than such a flimsy superstitious explana- tion as this ? yet it carries more force with the credulous than reason and science combined. 2. The hypothesis that double monsters result from the fecundation of double eggs, i.e., of eggs with two distinct yolks, enclosed in one capsule, has been proved by repeated experiments to be incorrect. The late Pro- fessor Panum, of Kiel, incubated eighty double eggs of the domestic fowl, with the result of producing separate twins; in some both male, in others both female, and, in others again, one of each sex. In one case, one of the yolks developed a single chick, the other yolk evolved a double-monster chick. In three instances in the human subject, a woman has given birth to a single foetus, and at the same time to a double-monster foetus. 3. A more plausible hypothesis, still entertained by some medical gentlemen who are badly informed on the subject, is that all adherent or engrafted foetuses, as they style them, were originally twin conceptions. That the membranes which usually separate the ova being absent, through imperfection or absorption of the contiguous sur- faces, the two germs were brought into contact, and coa- lesced by reason of some exudative inflammatory action, or of "the strong formative power existing at the early period of uterine life." The late Professor C. D. Meigs, of Philadelphia, strongly entertained this theory to the time of his death, and during the present autumn I con- versed with another Philadelphia professor of obstetrics who teaches this doctrine to his classes at every session. The advocates of this theory undertake to explain the symmetrical union of parts by a very ingenious, but purely mental invention, viz., that the two foetuses are attracted to each other, and are thus united at the same points by "an elective affinity ! " It will not be found profitable to follow this fanciful and visionary embry- ology any further in this place. 4. The mode in which double monstrosities are evolved is no longer a matter of speculative philosophy. It has been demonstrated by direct observation, and under as favorable conditions as those by which our knowledge of the normal evolution of the single embryo has been stud- ied. Allen Thompson (" Remarks upon the Early Con- dition and Probable Origin of Double Monsters," London and Edinburgh Monthly Journal of the Medical Sciences, vol. iv., p. 481, 1844) had the good fortune to meet with a double embryo in the egg of a goose, which had been incubated five days. Here he had a demonstration of the fact that a double primitive trace is actually formed on a single blastodermic membrane proceeding from a single egg, possessed of a single vitellus and vitelline membrane. Wolff, Von Baer, Reichert, and Panum, have each had the same experience in the eggs of birds, and have fur- nished corroborative evidence of the doubleness of the primitive germ. Lereboullet enjoyed extraordinary fa- cilities for the study of the early stages of duplex devel- opment in the transparent eggs of the perch, among which he found a considerable number that produced various degrees of dichotomy of the primitive trace. He was enabled, from day to day, to watch through the microscope the development and growth of the double embryos. The recent researches of Camille Dareste, embracing more than nine thousand experiments in the artificial production of monstrosities, are extremely in- teresting, and have shed much light on teratological em- bryogeny. By the labors of the above teratologists, and other worthy names deserving of mention, we have learned that compound monsters proceed from single germs, which have subsequently undergone different de- grees of dichotomy, and that they are governed in their development by certain fixed and invariable laws, among which are unity of sex, homologous fusion, and bilateral symmetry. The Law of Unity of Sex.-For the past quarter of a century the writer has taken great pains in carefully ex- amining several hundreds of specimens of human double monsters, and even larger numbers among the lower animals, which are to be found in the pathological mu- seums in the principal large cities of the United States, and he is able to state that he has never seen an excep- 13 Teratology. Teratology. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tion to this law. The literature of teratology contains reports of, and references to, not less than five hundred cases of double human monsters, and also great numbers belonging to the beasts and birds, and there is not a single modern instance in which the male and female organs are found to coexist. In every case there is single sexuality. In a few instances the writers of the old wonder-books mention united hermaphroditic twins. When the absurd inaccuracies of these old treatises, such as those of Licetus, Lycosthenes, and Aldrovandus, are taken into account, they cease to have any weight as authorities. It is safe to say that duality of sex will never be seen in a double monster. The Imu of Homologous Union.-The union of the parts of a double embryo obeys this law' with as much constancy as is observed in the fusion of the two lateral halves of a single embryo in normal embryogenesis. Bone meets bone, a muscle on the right of the median axis meets and fuses with its exact corresponding muscle of the opposite side, and so with blood-vessels, nerves, and entire organs, such as the livers, hearts, and brains; and thus we see that the homologous union proceeds until all the parts which lie adjacent to each other are fused on the median line. There are many instances among the cases of non-symmetrical double monsters where, at first sight, it would appear that this law is not sustained. On a more careful examination it will be found that it has not been violated. In the so-called parasitic monsters the fusion was homologous in the early embryonic peri- ods, but in consequence of the arrest or retardation of growth of one foetus and the continued development of the other, the blighted or atrophied element becomes overlapped and more or less included by its better nour- ished fellow. The cases in which a head or a pair of thoracic or of pelvic extremities are found attached at the epigastrium, are not exceptions to this law. The presence of these parts at this, or at any other point, is explained by the original symmetrical fusion of corre- sponding parts and eventual failure to evolve and de- velop the missing parts ; the non-symmetry being the same in relation to dual development, as is the case of asymmetry in a single foetus, due to arrest of one side of the body or extremities. The Law of Right and Left Symmetry.-The operation of the law of bilateral symmetry in the two sections of a compound monster has been frequently observed. The development of a double germ or double foetus is gov- erned by the same germinal or embryonic law that pre- sides over the evolution and growth of a single organism. Hence we find a bilateral balancing of parts. This in- volves a transposition of certain viscera ; for example, one liver will occupy the right side of one of the compo- nent fcetuses, and the other liver the left side of the other foetus. The livers will also be fused on the median axis of the compound body. The two stomachs will be right and left. So, also, the apices of two distinct hearts, a right and left one, will be found to converge, and both hearts be enclosed in one pericardium. In other cases the two hearts are fused in such a manner as to make one composite organ. The universality of this law is less positively proven than the two previously stated. To establish the requisite proof requires much more thorough and painstaking reports than we find in the journals and other media through which the cases of compound monsters are given to the public. This is probably as good a place as any for the purpose of mak- ing a practical suggestion to physicians and other natu- ralists. In a recent conversation with Dr. John S. Billings, librarian of the United States Surgeon General's Office, I was informed that a physiological and pathological laboratory was in course of construction, in connection with the Army Medical Museum and the Army Medical Library. Dr. Billings stated that he would be pleased to have any specimens of monstrosity, single or double, carefully dissected by experts under his direction. The specimens would be preserved in the pathological museum, and proper reports made of the dissections. It is labor wasted for the ordinary obstetrician and common naturalist to keep, as a dried or an alcoholic specimen, an interesting case of single or double monster. It soon deteriorates, ceases to be a wonder, and if dissected at all, it is done in a very superficial and imperfect manner, and thus teratology is perchance deprived of a valuable contribution. It is to be hoped that in future any speci- men of monstrosity will be at once sent to Washington, D. C., as above indicated. There is great necessity for more precise information concerning the internal struct- ure of most of the species of compound monsters. What Determines the Form and the Degree of Fusion in Diplogenesis.-The various forms or species of duplex development are determined by the extent to which the primitive trace is cleft, and also by the limitation of the dichotomy to the cephalic, or to the caudal extremity of the neural axis. Either extremity may become bifid, or both may be cleft at the same time. Should the ce- phalic extremity alone develop dichotomy, the resulting foetus would be more or less double above and single below. The reverse will hold if the cleavage exists at the caudal pole of the neural axis. In case the dichot- omy exists coincidently at both poles, there will result'a double foetus with junction at the middle portions of the body, as was seen in the case of the Siamese twins. The degree of duplicity and the extent of fusion depend upon the proximity or remoteness of the two segments of the primitive traces, and the relative inclination of their axes. The five rude diagrams here presented (Fig. 3847) will serve to illustrate the relative positions of the two seg- ments of the germ. The several forms of double mon- sters, hereafter to be described, are here indicated-su- perior and inferior dichotomy, cauda to cauda, cephalic poles in axial apposition, and lateral parallelism of the segments. In the last instance the completeness of the two component individuals of the double monster will depend on the extent of separation or of the nearness of the segments. If in close proximity, the fusion will ex- tend through the whole length of the bodies; if remote, there will be space enough for the evolution of all parts of both bodies, the union being reduced to its minimum, as in the case of the Siamese twins. Parasitic Monsters and the Heteradelphs of Geoffroy Saint-Hilaire.-Under these names most teratologists have included all the double monsters in which one of the foetuses is more or less perfect and the other merely an appendix to it, and dependent upon the more perfect one for its nutrition and growth as well as for its vitality. These terms I entirely ignore, and regard such classifi- cation and nomenclature as erroneous and very mislead- ing. The so-called parasitic and heteradelphic monster is the minus proportional, the lesser or imperfectly devel- oped half of a double monster. When the two indi- viduals of a compound monster are fully developed, being equal and symmetrical, they represent the plus quantity. The classification which I have adopted in my monograph (" Diploteratology," 1865-68), selects the maximum or plus development of each order, genus, and species of compound monster as the type. This is fol- lowed, in the description of cases, by the lower degrees, or minus proportionals, of the class under consideration, arranging the departures from the classical type in a descending series or scale. By this method, which I am not aware of any teratologist having employed previous to the publication of my essay, the true relations and analogies of apparently dissimilar forms must be more readily recognized and comprehended. Ou the other hand, it widely separates apparently analogous varieties, which, in previous classifications, have been made to stand in close but unscientific relation to each other. Fig. 3847. 14 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Teratology. Teratology. Classification of Duplex Development.-The reader will be prepared, by the remarks which have already been made, to understand that, by an attentive observation of the modes of original cleavage, fission, or dichotomy of the primitive neural axis, and the subsequent fusion of adjacent homologous elements, a demonstration is fur- nished of the practicability and propriety of a threefold division, corresponding- with duplicity and more or less separation existing ; first, at the superior; secondly, at the inferior extremity (anterior and posterior in animals) of the cerebro-spinal axis ; and, thirdly, with duplicity and more or less separation existing coincidently'at both extremities of the vertebral axis. This division of com- pound monsters into three primary groups, or orders, co- incides with the earliest development of double embryos, according to the observations of all who have been so fortunate as to have opportunities of making researches at early embryonic periods. The following terms have been proposed for the three cardinal groups above indicated : Order I, Terata Catadidyma.-(Derived from repas, reparos, "a monster," and Kara, "down," and SlSvp.os, " a twin.") Definition : Duplicity, with more or less separation of the cerebro-spinal axis from above downward. Order II. Terata Anadtdyma.-(From avd, " up" or " above," and SlSupios, " a twin.") Definition: Dichot- omy from below upward, or from the caudal toward the cephalic pole of the neural axis. Order III. Terata Anacatadidyma.-(From " above," " down," and " a twin," as in the above-given Greek derivatives.) Definition: Coincident dichotomy at both extremities of the cerebro-spinal axis. Each of the above orders embraces several well-marked forms, ■which are sufficiently characterized to be placed in the relation of genera, which genera will admit of further subdivision into well-defined specific groups. As before remarked, in defining ea,ch order, genus, and species of double monster, the maximum, or plus develop- ment, is taken as the type. This type is followed, in the history and description of cases, by the lower degrees, or minus proportionals, of the group under consideration, arranged in a descending scale. The typical forms consist, in most cases, of two indi- viduals symmetrically developed, and united by obvious homologous fusion. In the non-symmetrical forms, one of the component individuals is well developed ; the other, in consequence of arrest or retardation of the formative process, is more or less defective in size, or deficient by the absence of parts. All such cases have heretofore been denominated heteradelphic and parasitic monsters. In some of the so-called parasitic monsters, the law of ho- mologous union is apparently violated ; for example, where a head, or a pair of extremities, with or without some portion of the trunk, is found attached to the epi- gastrium of a well-developed individual. This, however, is not a contradiction of this law ; the union was sym- metrical and homologous at an early stage of embryonic development ; subsequently, the formative process on one side became retarded or arrested, while it continued active on the other, thus resulting in non-symmetry. When arrest in evolution and growth occurs in one por- tion of a double embryo, at a period prior to the budding of the extremities, or the complete closure of the ventral plates, while the other portion of the duplex embryo continues its normal development, the arrested rudiments may be so far enveloped by the well-formed individual that they will appear as an amorphous mass, or a sort of- tumor, which on examination will be found to contain more or less of the foetal rudiments. These are the so- called cases of foetus in foetu, "foetus by inclusion," etc. Examples of this kind have been found at the mouth and cheek, at the sacrum, and at other points. There are a number of instances of adult human beings bearing about with them such foetal cysts. In the classification adopted in this essay, all cases of this kind are referred to the type to which they obviously correspond, being identical in kind, and differing only in quantity. This view of the relation of parasitic monsters, and foetus in foetu, to the higher degrees of duplex formation, receives strong support from the fact that the cases of asymmetry make a transition to the symmetrical types. In some of the gen- era there are extended series of intermediate gradations. Supernumerary formations are included among duplex developments, and yet they are not classed with double monsters. A supernumerary part is not an essential or- gan, or a complete apparatus, but merely a portion of one. It is generally no more than a numerical augmenta- tion of elements which have multiple homologies in the normal type, and which are observed to -be most liable to undergo variations in number in the series of lower ani- mals. The following are very pertinent remarks by Allen Thompson (op. cit.), on the distinctive characteristics of double monsters : " It seems to me more consistent with the observed facts to consider as the double malformations only those instances in which the parts of two cerebro-spinal axes, or of two vertebral columns, are present; for I am in- clined to think that there is no well-authenticated in- stance upon record of the existence of the double condi- tion of any important organ, in which there is not reason to believe that some degree of duplicity, it maybe slight, has also existed in the cerebro-spinal system. In proof of this, I may cite the example of one of the lowest de- grees of double malformation of the face, described as occurring in a lamb, by Gurlt, in wThich there existed a double tongue, an approach to a double lower jaw, and a cleft palate, as the most obvious malformations. No duplicity of the cerebro-spinal axis was visible externally, but a careful dissection showed internally a commencing double condition of the bones at the base of the skull, an additional pair of corpora quadrigemina, double pineal gland, pituitary body, etc. But for the careful dissec- tion made by Gurlt, this case might have been described as an example merely of double tongue and jaw." Having premised the general principles upon which a plan of classification can be founded, I will now proceed to give a few additional details concerning the subdivi- sions of the three cardinal orders above designated. Order I. Terata Catadidyma. - This order, in which the cerebro-spinal axis exhibits more or less du- plicity and separation at the cephalic pole, embraces four groups, which are so distinctive and peculiar, that they naturally stand in the relation of genera. Taking them in the descending scale, or from the higher to the lower degrees, we have: Genus I. Pygopagus. (Fom iruy^, "the nates," and ?rc£yce, "I fasten.")-Definition: Two individuals more or less complete, separated as low as the pelvis, by the lateral or posterior portions of which they are united. Genitals double. In the higher degrees there are two umbilical cords, which are normally attached, one to each abdomen. Vital organs independent in the type. Genus II. Ischiopagus. (From " I arrest," or l<rx- tov, " the'haunch," and Tidyw, "I fasten.")-Definition: Two more or less complete individuals, with pelves united so as to form a common basin or ring (Fig. 3851); the right pubic bone of one subject unites with the left of the other, and vice versa on the opposite side; the axis of the symphysis pubis is at right angles to the common vertebral axis of the two subjects. The cephalic poles are at the distal ends of the neural axis. Single funis and umbilicus. Two sets of genitals-right and left. Four pectoral and four pelvic extremities. Abdomen common to both. One bladder. Genus III. Dicephalus. (From Si, Sis, "double," or "twice," and Ketiaxf "head.")-Definition: Two bodies more or less perfect, with two distinct and separate heads ; the vertebral axes more or less parallel, or con- verging from above downward. Genitals single ; one funis and one umbilicus. The degree of coalition of the two bodies, the number of extremities, and the condition of the viscera, vary in the several specific groups. Genus IV. Diprosopus. (From Si,Sis, "double," or "twice," and updawTrov, "face," or "countenance.")- Definition: An apparently single body, two heads more or less fused, the compound head having two faces,.the axes of which vary in their relation to each other in the 15 Teratology. Teratology. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. different species, which species are founded oh the num- ber of eyes and ears that are developed. Order II. Terata Anadidyma. - This order, in which the cerebro-spinal axis is more or less duplicated and separated from the caudal toward the cephalic pole, is divisible into three generic groups, viz.: Genus I. Cephalopagus. (From Ke^, "head," and Wyco, " I fasten.") Definition : Two more or less com- plete bodies, conjoined by some portion of their heads. The bodies and extremities are otherwise distinct and free. Genus II. Syncephalus. (Fromaw, " with," " together," and "head.") Definition: In the typical form of this genus, all the parts of two bodies are developed. The anterior portions of the bodies do not stand in their normal relative positions. The junction is as if two well- formed foetuses had been completely cleft and separated from the umbilicus, through the abdomen, chest, neck, and head ; and then as if these split bodies had been placed together and had coalesced. This would result in two.late- ral faces, Janus-like, each composed of halves from the opposite foetus. The same with the thorax, which forms one great cylinder, or cavity, surrounded by two opposite vertebral columns, two opposite lateral sternums, and forty-eight ribs. The right half of the sternum and the accompanying twelve ribs of one body, unite at the lateral median line with the same parts from the left of the other body, which arrangement also exists on the op- posite side of the compound thorax. A glance at Figs. 3864 and 3865 will make the description easily understood. The unsymmetrical species will be mentioned farther on. Genus III. Dipygus. (From "double," and wy^, "nates.") Definition: The dichotomy is confined chiefly to the caudal extremity of the neural axis and the adja- cent parts. The vertebral column may, however, be duplicated throughout the greater portion of its length, or, in the lesser degrees, it may exhibit mere traces of duality in its sacral or coccygeal extremity. Order III. Terata Anacatadidyma.-This order, in which the duplicity and separation occur coincidently at both poles of the cerebro-spinal axis, is divided into two generic groups. Genus I. Omphalopagus. (From 6g</>aAJs, " the navel," and 7rdya>, "I fasten.") Definition: In the maximum degree, or typical form of this genus, two symmetrical and well-developed individuals are connected by a very small band arising from the middle and anterior region of the bodies. In the middle of the under surface of this bond of union a single funis was attached in foetal life, and the umbilical depression will there be found in adult life. (The Siamese brothers furnish one of the best known examples of this type. Fig. 3869.) In the less dis- tinct forms of double dichotomy in this genus, the extent of the coalescence varies in the several species, from the small band above mentioned, to a fusion of the whole anterior portions of the two bodies from the abdomens to the mouths; in the latter case making a transition and near approach to the genus syncephalus. The difference being that separation, to some extent, of the cephalic pole always exists in every case of omphalopagus. Genus II. Rachipagus. (From faxes, " the spine," and Wyw, "I fasten.") Definition: Two bodies, more or less developed, united back to back, with separation above and below the limits of fusion. The cases which belong to this genus are extremely rare. The genus pygopagus makes a transition to rachipagus. The old literature contains numerous cases of foetuses and children joined back to back. The lower degrees are chiefly met with among animals, as cases of extra limbs attached to the back of a fully developed subject. Having given an outline of the nomenclature, the derivations, and definitions of the primary groups into which the several forms of duplex development naturally subdivide, I will proceed to consider more in detail the genera and species, pointing out their distinctive charac- teristics, and illustrating them by reference to a few actual cases. Order I. Catadidyma. Genus I. Pygopagus.-This, in common with all the genera of compound monsters, presents symmetrical and asymmetrical forms. The latter are the atrophied or incomplete varieties, which result from arrested or retarded development and growth of one of the component individuals. The typical form is repre- sented by two well-formed bodies, united at the sacra, the ilia, or, less intimately, through the medium of the adja- cent soft parts. The vital organs are distinct in each, and each body is nourished in the foetal state by an independ- ent funis. The rectums unite in making a single tube which terminates in one anus. In females the bladder, urethra, and uterus are normal in each. In males the scrota are fused and contain four testes. In some cases the kidneys are double, each of them having two ureters. The symmetrical pygopagus is extremely rare in the human subject, and still more so in animals. The pygo- pagus asymmetros is much less rare, its lower degrees being not infrequently seen in domestic fowls. The pygopagi possess a high degree of viability, both in their maximum and minimum varieties. The capability of sustaining life, and attaining adult age, is due to non- fusion and independence of the vital organs. It has been observed that either individual may have local dis- eases without affecting the other, while a systemic disease affects both parties. Death occurs in both at the same time. Two very famous cases in the human subject have attained adult age. Both were female. A brief account of each will be given. Pygopagus symmetros. (Torkos : Philosophical Trans., London, vol. 1., p. 311. Pl. xii.) The "Hungarian Sis- ters," Helen and Judith, were born in Hungary, October 26, 1701. They died February 8, 1723. Both expired at the same instant. Each had measles and also small-pox at the same time, but other maladies independently. Judith had convulsions, while Helen was unaffected. Menstruation in one began nearly a week before that in the other. They were very intelligent, and were well educated. They were fine singers, and spoke several languages with facility. They were both very handsome. For seven years they were publicly exhibited in most of the countries of Europe, where they attracted the atten- tion and investigation of the most distinguished natural- ists, physiologists, and psychologists. Accounts of their structure and endowments were published in various works. They were also celebrated in song by several poets. They were buried in the convent of the nuns of St. Ursula, at Presburg, in which convent they spent the last twelve years of their life. Their union was such that they could not walk side by side ; when one went forward the other was obliged to go backward. When one stooped, she raised her sister quite from the ground, an act which Helen often per- formed, being stronger and more active than her sister. They had no sensibility in common, except in the im- mediate vicinity of the line of coalition. The spinal columns were intimately fused from the second verte- bral element of the sacrum to the end of the coccyx. The vulva was common to both. The vagina began single, but soon divided into two distinct canals. In like manner, there were two intestinal canals terminating in one rectum. The desire to defecate was simultaneous, not so with micturition. The two aorta; anastomosed at the point where the iliacs are given off ; the venae cavae were united correspondingly, thus establishing a large and direct communication between the two hearts. Pygopagus symmetros. (Ramsbotham : Med. Times and Gazette, London, September 29, 1855, p. 313. Miller: Southern Med. and Surg. Jour., February, 1854. Fisher : Diploteratology, Trans. Med. Soc. State of N. Y., 1866, p. 227. Pancoast : Photographic Rev. of Med. and Surg., Philadelphia, June, 1871). In a little more than a cen- tury and a half after the birth of the above-described case, America produced, of African slave parents, an almost exact duplicate of the " Hungarian Sisters." The " Carolina Twins " were born in Columbus Co., N. C., July 11, 1851. They are still living and in perfect health, being in the thirty-seventh year of their age. They are well known to the public, as they have been exhibited in Europe and America ever since they were small chil- dren. In the year 1866 I made a careful examination of 16 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Teratology. Teratology. this interesting pygopagus. They are almost identical in all respects with the "Hungarian Sisters." The fol- lowing is a very brief summary of the case. "Millie and Christina," as at first called, now Millie and Crissie walk by their outer limbs alone. One can readily lift the other by the act of stooping. While they are united squarely, back to back, they have, by effort and habit, so twisted themselves as to incline the bodies laterally to- ward each other. Fig. $848, is from a photograph taken in Philadelphia in 1871. I)r. Wm. H. Pancoast made a very careful examination of the junction and of the genitalia in this case, and reports that the labia majora are continuous from one to the other, as seen in Fig. 3849, which is from the Photographic Review of Medicine and Surgery above cited. Dr. Pancoast writes : " I found only one vagina, and no bifurcation of it; only one womb, with an unusually long neck." He assures us that two distinct bladders exist. The rectum is single; the anus may be seen in Fig. 3849 directly below the compound vulva. The parts are enlarged in the diagram, Fig. 3850. Fig. 3850.-The Same. In the centre is the vaginal opening, at the right and left are the urethral outlets, and the nymphae. The star indicates the anus. In exploring the rectum no bifur- cation was reached. The apex of the united coccyges was distinctly felt, being thicker and stronger than natural. They defecate and urinate at the same time. Their menstruation, which is regular and natural, also occurs simultaneously. Space forbids any further par- ticulars. Pygopagus symmetros. (Treyling : Acta Acad. Nat. Curiosorum, Tom. v., p. 445, Obs. 133.) United females, born in Carinola, in Italy, a.d. 1700. The coalition simi- lar, though less extensive than that of the two cases above described. The osseous junction was confined to the coccyges, yet the connection was so intimate and organic that only one rectum and one anus existed. When they were four months of age, a surgeon, more bold than judicious, sep- arated them by an operation which proved fatal to both of the children. This should serve as a warning in future cases. Three other cases of human symmetrical pygopagus are recorded. In one case death occurred in three weeks, in another in nine months. Of the six cases the sex is given in five, all being female. Pygopagus asymmetros. The non-symmetrical forms of the pygopagus may be divided into two specific groups, viz.: P. disjunctus and P. conjunc- tus. The former includes the cases in which the imperfectly developed, or parasitic, portion of the compound body is more or less free or distinct from the principal body. The P. conjunctus embraces cases in which the minus proportional is so intimately blended with the well-developed body as to appear in the form of a tumor in the sacral region. Pygopagus disjunctus. General characters : In cases Fig. 3848.-Pygopagus Symmetros. (Pancoast.) 29 Smith, are well formed, and resemble each other closely ; complexion that of a fair mulatto ; features and expres- sion as well as manners pleasing ; cheerful, amiable, and intelligent; fond of reading, sing sweetly, and converse modestly and fluently ; dance and walk gracefully, and can run with remarkable celerity. In running or walk- ing they advance their inner limbs together, then bring forward the outer limbs, which touch the floor as one. The union extends from the top of the sacra, across from ilium to ilium. This bond of union is very firm and measures twenty-six inches in circumference. They can Fig. 3849.-Pygopagus Symmetros. (Pancoast.) 30 17 Teratology. Teratology. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. belonging to this group in the human subject, there will be found, in the sacral region of a well-formed body, a tumor of variable size and form, commonly an irregular mass terminating in rudimentary extremities, mostly pel- vic, less frequently thoracic ; sometimes loops of intestine are found in the mass. In one case the so-called parasite consisted solely of a head and neck, by which it was at- tached to the sacrum of the main body. The face was turned downward. Several human cases are reported in which imperfectly developed limbs have been found at- tached to the sacrum as above mentioned. The presence of foetal elements, and the relative position of the ex- tremities, prove conclusively that they are imperfectly developed cases of pygopagus. The cases are not rare in fowls and other birds. It has also been observed in the toad. In the Anatomical Museum of the University of London is "a small toad having an additional and well-developed long posterior extremity, attached to the right side of the pelvis near the median line. This extra limb is composed of the elements of two, as it has seven toes, five being the normal number " (J. B. S. Jackson's MS. notes). Pygopagus conjunctus. Cases belonging to this group are more common than those of the last mentioned. It is, in fact, the most frequent form in which the parasitic monsters, or foetus in fcetu, occur. It consists of a non- pedunculated tumor in the vicinity of the sacrum of a ■well-formed body. The tumor contains unmistakable foetal rudiments, in some cases a more or less imperfectly developed foetus. In other sacral tumors the foetal ele- ments are not certainly present. It is quite probable that most, if not all, of the congenital tumors in the region of the sacrum and coccyx, belong to the arrested, the non- symmetrical, or amorphous species of the pygopagus, and represent its minus proportional or minimum devel- opment-being unlike not in kind, but simply in quan- tity. Limited space forbids the citation of cases and literature, which are both very abundant and very inter- esting. Genus II. Ischiopagus. General Characters.-The dis- tinctive characteristics of this form of double malforma- tion, as observed in its maximum development, consist •in the union of two sym- metrical and well-formed bodies on a common verte- bral axis, by fusion at the pelves and lower portion of the abdomens. The vi- tal organs are independent. The pelvic extremities pass off on either side, in pairs, at right angles to the com- mon axis of the trunks. The two limbs of each lat- eral pair are so perfectly symmetrical, in form and size, that they apparently occupy a normal relation to each other ; while in fact they consist of a right limb of one individual, and a left one of the other. The same is true of the genitals. In the case of a male, each lateral penis and its urethra is a copart- nership organ, one half being furnished by each body. This is also true of the scrotum, testes, etc. The same plan of arrangement exists in the case of females. In the ischiopagi there is but one umbilicus and one funis, which is situated in the centre of the united abdomen. The vertebral columns are contiguous or conjoined. The right os innominatum of one body joins the left of the other, forming a lateral symphysis pubis, and vice versa on the opposite side. By this arrangement the pel- vic bones form a single great ring, or basin, as seen in Fig. 3851. To separate the two bodies of a symmetrical ischiopa- gus and give each its own parts, an incision should be made on a transverse line, through the central umbilicus and abdomen, bisecting the external and internal genitals, the symphyses of the pubes, the rectums, and the bladder, which is common to both. In a perfectly symmetrical and completely developed ischiopagus, there is neither re- dundancy nor deficiency in the structure of any portion of the two component bodies. The non-symmetrical forms are divided into arbitrary species according to the number of pelvic extremities, their fusion, etc., viz.: I. tetrapus, four; I. tripus, three ; I. dipus, two limbs. In a series of cases of ischiopagi we meet with many of the malformations found in single bodies, as acrania, hare-lip, atresia of ureters, urethra, and rectum ; sympodia, etc. It is chiefly owing to these defects that they so rarely live any considerable length of time. Most of them are born prematurely, and nearly all of them die before the end of the first week. The delivery in most cases is natural and unattended by dan- ger to mother or offspring. They are comparatively rare, only about twenty human cases are on record. As far as ascertained, they are chiefly females. It is an ex- tremely rare monstrosity among animals. Ischiopagus symmetros. (Palfyn : "Descript, anatom, de deux Enfants," etc. Vide Licetus, "De Monstris," Appendix, Leide, 1708. Fisher : Diploteratology, " Trans- actions of the Medical Society of the State of New York," 1866, p, 243, Fig. 15, Case 26.) Fig. 3852 represents a Fig. 3852.-Ischiopagus Symmetroa. (Palfyn.) 3a monster of this genus, born in Ghent, Flanders, April 28,1703, The labor was natural. Each head was-sepa- rately baptized. One child lived twenty-seven hours, the stronger one two hours longer. Females, one vulva com- plete, the other rudimentary. One perfect and one im- perforate anus. In the non-symmetricgl forms of ischiopagus, one or both of the component bodies are more or less imperfect. In most instances there is an unequal balancing of parts in relation to the median line of fusion. The genus is divided into four species. 1. Ischiopagus tetrapus. Two bodies, one or both of which are more or less imperfectly developed, united at the pelves, having a common vertebral axis, four pelvic extremities, arranged in lateral pairs, with correspond- ing genitals, etc. 2. Ischiopagus tripus. Differing from above by having three pelvic extremities, one lateral pair, with genitals and anus ; and a single or fused pelvic extremity on the opposite side and at right angles with the common ver- tebral axis; no genitals nor anus. This form is illus- trated in Fig. 3853. In some instances the fusion of the sympodial extremity is very superficial, and principally tegumentary. Ischiopagus tripus. The case represented in Fig. 3853, was born in Cadiz, Spain, May 30, 1818. Each child, sex female, received baptism the day of birth at the Ca- thedral of Cadiz. They lived five days and ten hours. Fig. 3851.-Ischiopagus (Pelvis). (Palfyn.) 18 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Teratology. Teratology. and died at almost the same moment. The case is fully reported in my " Diploteratology " (Transactions of the Medical Society of New York, 1866, p. 253, Fig. 35, case 36), as are also four other cases of I. tripus. 3. Ischiopagus dipus. Same as the last, excepting that only two pelvic extremities exist, both of which are on one side of the common axis. One set of genitals, one anus. This is a very rare form. Two cases only are re- ported. One is recorded by G. Blasius, in his Appendix of recent cases of monstrosity to the third edition of Li- cetus (" De Monstris," 1665). This was born in England, October 26, 1664. A second case was born, one hundred and seventy-seven years later, in Ceylon, 1841. The first was a female and lived two days ; the second, male, lived two months. The Ceylon case is reported by Pereira in the Edinburgh Med. and Surg. Jr., vol. Ixi., p. 58, Pl. I., Fig. 2, 1844. 4. Ischiopagus dipygus. E single, well-formed indiv- idual, with one sympodic, or with two distinct supernu- was but six months of age. The extra limb was then large and tieshy. and hung from the pubis between the normal limbs, in a reversed position, that is, with the knee and toes backward and the heel toward the front of the child. In adult life it has been twisted as seen in FlG. 3851.-Ischiopagus Asymmetros. (Handyside.) 34 Fig. 3854, for the purpose of placing it most comfortably in the large trousers which he now wears. The prob- able mode of junction at the symphysis is represented in the diagram, Fig. 3855. There are two large penes. In urinating, the streams are equal and coincident from both. The bladder is presumed to be single. He will not permit catheters or bougies to be passed in order to settle this question. He is said to be very amorous, and to possess remarkable virile power. On the outer side of each penis there is a nor- mal scrotum and one testi- cle. Between them hangs a shrunken scrotum, which contained two testes until he was ten years of age, when, as he says, they ascended into the abdomen. For a full history and descrip- tion of the case the reader must consult the several authors above cited. Case VII. Ischiopa- gus dipygus. (Gurlt : " Handbuch der Path. Anatom, der Haus- Saugethiere," Berlin, 1832, Atlas, Tab. XIII., Fig. 2. Fisher: op. cit., Case 42, Fig. 44.) This is the case of an adult dog, with a supernum- erary sympodial posterior extremity, occupying the same relative position as the extra limb of the Gypsy above de- scribed, being in every respect its congener. The toes and proper anterior surface of the compound limb are placed in the direction opposite to that of the normal hind legs. Fig. 3853.-Ischiopagus Tripus. (Laso.) 33 merary lower extremities, attached or engrafted at the symphysis pubis of the principal body, by more or fewer pelvic elements. Two lateral sets of genitals. This is an extremely rare form of double malformation, either in man or in the lower animals. It represents the lowest degree of ischiopagus. Its relation to the genus cannot be questioned. It is readily distinguished from the lower degrees of pygopagus, not merely by its attachment to the pubic, instead of the sacral or coccygeal, region, but by the anterior surface, the knees, toes, etc., of the su- pernumerary limb facing the corresponding surfaces of the limbs of the complete body, and by the additional characteristic development of two lateral sets of genitals. Ischiopagus dipygus. The case of John Baptist Dos Santos, a native of Portugal, now forty-two years of age, is one of the most interesting on record. (It was re- ported, when six months of age, in the "Med. Chir. Trans.," London, 1846, vol. xxix., p. 102, Pl. IV., Figs. 1 and 2. Lancet, London, vol. ii., p. 124, Figs. 1 to 4, 1865. Handyside : Edinburgh (pamphlet), 1866.) Fig. 3854 is from Handyside's report. The case is given in detail in my " Diploteratology," Case 41, Figs. 39-43. The true position of the pubic fused extremity is best seen in the figure published by Mr. Acton in 1846, when Dos Santos Fig. 3855.-Intrapubic Attachment of the Extra Compound Limb. (Handy- Bide.) 19 Teratology. Teratology. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. If the dog were made to stand upright upon its hind feet, this extra limb would hang in the same manner as that of the Portuguese man. Genus III. - Dicephalus. The genus Dicephalus is characterized by the existence of two distinct and separ- ate heads, equal or unequal, associated with various de- grees of duplicity and separation in the vertebral column. In the higher degrees, two distinct spinal columns are developed, while in the lower degrees, the cervical and dorsal portions are merely bifurcated. In all cases the spines are placed side by side, either parallel, or at an angle, converging from above downward. The compo- nent bodies are laterally conjoined ; both of the faces look anteriorly, and commonly in the same direction. The maximum degrees of dicephalus approach the genus ischiopagus, the lower forms make an easy transition to the genus diprosopus. The number and condition of the pectoral extremities depend on the proximity and relative positions of the vertebral axes. If the spinal columns are in juxtaposition throughout their entire ex- tent, as seen in Fig. 3859, two upper and two lower limbs only will be developed. If the spinal columns are parallel and somewhat remote from each other, a median fused thoracic, and a median fused pelvic, extremity will be the result. In proportion as the vertebral axes di- verge at the cephalic poles, the duality of the intermedi- ate parts of the two bodies, their viscera, and limbs will become more complete. As the dichotomy at the cere- bral poles advances, we first observe a fused pectoral ru- diment on the median line ; next, a more complete com- pound limb, terminating in two hands; then two separate limbs, as in the famous Ritta-Christina; and finally, a compound median posterior pelvic extremity. The in- ternal structure corresponds with the external configura- tion, as a rule ; the deviations in the viscera of two ap- parently similar cases are slight and unimportant. In the non-symmetrical forms, almost every degree of un- equal development of the component individuals is to be found. This want of bilateral symmetry in duplex for- mations is referable to the same disturbing influences which occasion unequal development in the two halves of a single body, as so often seen in atrophy, or absence of organs or limbs on one side only. Right and left symmetry in the viscera of all double monsters is the rule, which, at least in the dicephalus, may be said to be a law. The hearts, livers, spleens, stomachs, etc., are as much right and left as are the hands or feet of a single individual. The same thing is sometimes observed in the external parts. . The late Pro- fessor Wyman informed me that he dissected a dicephal- ous calf, in which "each head was completely formed, but the two were as much right and left as a pair of hands or eyes." The facial axes were both curved in opposite directions, downward and inward, bringing the two muzzles nearly in apposition. In this genus there is only one funis and one umbilicus. The dicephali in- clude the commonest forms of double monsters which occur in man or the lower animals. About one-third of all double malformations belong to this genus. Nearly two-thirds of the cases are of the female sex. There are many examples of their viability, some having attained adult age. I have divided the genus into five specific groups. They are not very sharply defined, as they make a tran- sition from one to another, yet they are almost indispen- sable where so many varieties are to be described and studied. The nomenclature has a triplicate character ; it is, however, simple and expressive. The following are the names, and their literal meaning : 1. Dicephalus tetrabrachius tripus-two heads, four arms, three legs. 2. Dicephalus tetrabrachius dipus-two heads, four arms, two legs. 3. Dicephalus tribrachius tripus - two heads, three arms, three legs. 4. Dicephalus tribrachius dipus - two heads, three arms, two legs. 5. Dicephalus dibrachius dipus-two heads, two arms, two legs. The latter may be divided into two varieties, viz. : Variety a. Dicephalus diauchenos-two heads, two necks. Variety b. Dicephalus monauchenos-two heads, one neck. Limited space forbids entering into important detail concerning these several forms. In one case reported by Walter (" Observ. Anatom., etc.," Berolini, 1775, Tab. I.- IV.), there was delivered at the same birth, with a four- armed-tripod dicephalus, a single well-formed child of the same sex. This also occurred in a case reported by Blasius (in the Appendix to Licetus' " De Monstris," 3d edition, Amsterdam, 1665, p. 316, fine plate. See Fisher, op. cit., Cases 40 and 43). The late Professor Panum, of Kiel, in his researches on the incubation of double-yolked eggs, found in one case, a double embryo was evolved in one yolk, while the other failed to incubate. This cor- responds with the above cases. Dicephalus tetrabrachius dipus. (Serres: " Recherches d'Anat. Transcend, et Pathol." Paris, 1832, Atlas, Pl. I.- IX., and many other places. Fisher: " Diploter.," Case 50, Figs. 49-51.) This dicephalus was horn March 3, 1829, in Sardinia. It, or they, died at Paris, November 23, 1829, having lived eight months and eleven days. It is the well-known case of Ritta-Christina. The pericar- dium was single, but contained two hearts, which were right and left, touching or lapping at their apices. The stomachs, spleens, and conjoined livers were right and left. There were two gall-bladders, situated on the me- dian line of fusion. The intestinal canals united at the lower third of the ileum, from thence a single tube led to the anus. Fig. 3856 exhibits the external form of this variety of dicephalus. Fig. 3857 shows the bilateral symmetry of the muscles of the back and shoulders. Fig. 3858 shows two hearts, one being smaller than the other. Fig. 3859 is the skeleton in Horner's case, in which the spines are nearly parallel. Fig. 3856.-Dicephalus Dibrachius Dipus. (Gruber.)36 20 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Teratology. Teratology. than those of the upper arm. The muscles, nerves, and vessels are correspondingly modified. The hearts are generally separate, though con- tained in a single pericardium. The livers are always fused ; the stomachs and upper portions of the small intestines are separate. The viscera are arranged in right and left bilateral symmetry. As far as my researches have gone, I find twenty-eight human cases of this species reported. Nine male, seven female, twelve sex not men- tioned. Such carelessness in reporting cases of monsters is to be lamented. The fifth species of dicephalus has but two legs and two arms. It includes the double mon- sters which have twTo distinct and separate heads, with either tw'o necks or only one, an apparently single body, and four extremities. In the sub- species, Dicephalus diauchenos, each head rests upon its own separate neck. The duplicity of the vertebral columns generally extends through the entire length. In some cases the sacrums are alone fused, in others the dichotomy terminates at the middle or upper third of the dorsal series. Even in this near approach to singleness of body twro distinct hearts are sometimes found in one pericardium. In other examples the hearts are fused in such a manner that the numerous cavi- ties of the compound organ intercommunicate ; the arterial and venous trunks being developed and disposed in a very curious way. This form of dicephalus is comparatively common. Not less than eighty human cases are known. Sev- eral adult cases are referred to by authors. Fors- ter mentions the case of a Turkish archer, which he says was published, with an engraving, in a German newspaper, but neither title, date, nor locality is given. The skeleton shown in Fig. 3859 is that of a case published by W. E. Horner in 1831 (Ameri- can Journal of the Medical Sciences, O. S., vol. viii., p. 349. Fisher: "Diploteratology," Case 74, Fig. 61). The case is well reported and is worth a careful perusal. Case 76, in my work so often referred to, is one of the same kind, and is here merely mentioned in order to Fig. 3857.-Dicephalus. (Gruber.) 38 Buchanan, in his " History of Scotland," 1582, relates the case of an adult man who lived in Scotland in the latter part of the fifteenth century. " The body was double above the navel in all its members, both in ap- pearance and in reality. The king took diligent care of this being's education and training; and especially in music, in which he made wonderful progress. Besides, he also learned various languages; and the two bodies manifested discord between them from differing wills. Sometimes they would quarrel, and sometimes would please one another. Sometimes also they would consult together with each other." ... . " This monster lived twenty-eight years, and died while John the Regent was administering the affairs of Scotland." * Buchanan says: "We have written concerning this matter the more con- fidently, because there are very many honorable men liv- ing still who saw him." Dicephalus tribrachius tripus.-The three-armed, three- legged, double-head has the following general characters : The vertebral columns are parallel, or nearly so, and are complete and separate throughout their entire extent. They are necessarily not widely apart, otherwise the me- dian, thoracic, and pelvic limbs would not be fused, which is the distinctive characteristic of this species. The com- pound median upper and lower extremities are common- ly about equally developed. In a series of cases, how- ever, a great diversity in the extent of the duplicity will be found. Thus, from mere hump-like eminences, they pass through transitional forms to limbs of normal size and length, in which cases they are terminated by either fused or separate, well-formed hands and feet. The median scapulas are in most instances confluent in the higher forms; the extremity arising therefrom is exter- nally apparently single, but dissection reveals the ele- ments of two limbs, the bones being fused or distinct. The bones of the forearm are more frequently distinct * King James III. died in battle, June 1, 1488. This prodigy must have died within a few years subsequently, as John was the Regent of Scotland but a very short time. Fig. 3858.-Dicephalus. (Gruber.) 37 21 Teratology. Teratology. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. state that its occurrence in my practice was the' immedi- ate cause of whatever attention I have bestowed upon the subject of teratology during the time which has elapsed since the report of the case in 1857 -now over thirty years. At the time of the report the literature of teratology was almost entirely inac- cessible in this country. I am pleased to have observed a rapidly increasing interest in the subject, particularly during the past decade. Subspecies II., Dicephalus monau- chenos, represents an extremely rare form of this genus. Only two or three examples in the human subject are known. Its distinctive charac- ter is the existence of but one neck, on which two distinct heads are found. The neck, though exter- nally single, contains two more or less complete cervical ranges of ver- tebrae. One of the cases referred to is reported by White {Dublin Medical Press, 1839, vol. i., p. 212. Fisher: op. cit., Case 102, Fig. 63). The di- chotomy extended through the entire spine. Separation of the cervical vertebrae extended to the fourth or fifth block. There was but a single pair of lungs. The fused heart had two auricles and three ventricles. A right and a left stomach were united at the common pylorus, be- low which the intestinal canal was single. Two-headed monsters, with apparently single bodies, have been found among calves, colts, lambs, pigs, rabbits, cats, dogs, mice, chickens, tortoises, snakes, fish, and even in the earth-worm. Genus IV.-Diprosopus. In this, the last genus of the first order, the duplicity is apparently limited to the head, which is a compound of two. The term Diprosopus sig- nifies two faces, or a double face. The genus ranges from a series of cases in which two nearly complete heads are conjoined by their posterior and proximal lateral sur- faces (the two faces being distinct and separate), to a series in which the compound head is apparently single, only slight but positive traces of duplicity being discovered in some portions of the axis of fusion. In such a series of diprosopic monsters, ranging from the highest to the lowest recognized forms, the approach to singleness is so gradual, and finally so nearly complete, as to suggest the idea of a being whose bilateral halves may have been de- rived from two primi- tive embryonic traces, which had been devel- oped in a single vitel- lus, but, in conse- cpience of their close proximity and perfect parallelism,were fused on a median axis, so symmetrically as to result in a single body. The two faces are generally symmetrical in relation to each other. In some cases, however, the two faces do not exhibit bilateral symmetry in relation to the axis of fusion* one face being perfect, while the other is more or less defective {Heteroprosopus, of Gurlt). In some instances the facial axes are nearly or quite parallel; in other examples they are divergent at various angles above, as seen in Fig. 3860 ; while in a third class of cases they diverge at a more or less acute angle below, as seen in Fig. 3861. The angles of the antero-posterior planes also vary in their relations to each other in differ- ent cases of diprosopus. The relative positions of the organs of sense, as well as their number and degree of development, depend chiefly on the relation and proximity of the facial axes, and the axial planes. These angles of conver- gence or divergence furnish impor- tant guides in the recognition and description of the different forms of this interesting genus of duplex development. To facilitate the de- scription of the various forms em- braced in this genus, it is here divided into five specific groups, characterized by the existence or absence of certain organs of sense. This division commences with the highest degree of duplicity, and ends with the lowest, or with those cases in which the absence of the intermediate parts of the contiguous heads is so complete, and the fusion so extensive, as to reduce the compound head to a degree of singleness little short of the normal structure. The specific groups are des- ignated as follows : I. Diprosopus tetrotus.-Four-eared double face. II. Diprosopus triotus.-Three-eared double face. III. Diprosopus tetrophthalmus.-Four-eyed double face. IV. Diprosopus triophthalmus. - Three-eyed double face. V. Diprosopus diophthalmus.-Two-eyed double-face. This genus embraces some of the rarest forms of double monsters in the human subject. The forms with separate faces are much more common among the domestic ani- mals. The diprosopic monster has been found among several species of birds, fish, snakes, and even in the tape- worm. About forty human cases are known. In fully two-thirds of the cases the sex is female. Owing to the fusion of hearts and brains, as well as to the fact that most of the cases are acranial, the diprosopus is rarely viable. Order II.-Terata anadidyma.-This is character- ized by duplicity, with more or less separation, of the cerebro-spinal axis from below upward, or from the caudal toward the cephalic pole of the neural axis- monstra a inferiore sen posteriore duplicia. This order is divisible into three generic groups, which, in accordance with the plan of classification herein adopted, places first the highest or plus degrees of de- velopment attainable within its prescribed limits, and follows, in a descending scale, with the lesser degrees or minus proportionals of the same. The maximum devel- opment in this order is the reverse of the first-terata catadidyma-in which two nearly complete bodies are homologously united at the caudal poles of the vertebral axes, while in this the component bodies are conjoined at their cephalic poles. Genas I.-Cephalopagus. Its typical form is repre- sented by two well-developed individuals, united by the crowns of their heads, the bodies being distinct and free. The axis of the compound body forms a straight line. The vital organs are independent, the hemispheres of the brains are not in contact, though both are contained in a common cranial cavity. They are separated, by a trans- verse partition consisting of double layers of the menin- ges, into two cerebral chambers. Each body has an um- bilicus. In the non-symmetrical forms the defective or parasitic body, or part of a body, as the case may be, receives its nutrition through vascular communication with the prin- cipal or well-developed body. Retardation, or more or less complete arrest of devel- opment, in either of the component parts of a cephalo- pagus results in asymmetry-it may be from mere in- equality of size, all the parts existing ; or it may be from deficient quantity, some portions being entirely absent. In this genus the law of homologous union does not in- variably prevail. In a general way-as head to head- it is never violated, yet in detail it is not carried out. For example : the frontal bones of one skull may be joined by suture to the parietal, or even the occipital, bones of Fig. 3861.-Diprosopus tri- ophthalmus. (Vrolik.)40 Fig. 3859. - Dicephalus Dibrachius Dipus. (Horner.)38 Fig. 3860.-Diprosopus triotus. (Sommer- ing.) 33 22 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Teratology. Teratology. the other ; hence the head or face of one may be turned to the right, and the other to the left (as seen in Fig. 3862); or one may have the face turned upward, the other being to the side ; or, lastly, they may be joinecj so that the faces and anterior aspects of the bodies will look in opposite direc- tions. In most of the cases the bodies lie in a straight line, being joined vertex to vertex. In other cases the junction is by occiput to occiput, or os frontis to os frontis ; in the former the individuals pre- sent back to back, in the latter front to front. In consequence of the indepen- dence of the brains and other vital organs, there are no structural impediments to the maintenance of life after having escaped the dangers incident to delivery, which, it would appear, are not very much increased on account of this mode of conjunction. Even in the non-symmetrical cases the beings possess a consid- erable degree of viability. In the unequal Cephalopagus one of the component bodies is generally well and fully formed, while the defective portion stands in the relation of a tumor, or a mere parasitic mass. The genus is divisible into two specific groups, viz., Craniodidy- mus and Prosopodidymus. The former includes all cases in which the junction is by the crania ; the latter, those in which the coali- tion is by any portion of the faces. Space will not permit the men- tion of a great number of syno- nyms employed by different tera- tologists in their classifications and descriptions of forms which I have included under this genus. The omission of derivations, synonyms, literature, illustrative cases and figures, throughout this entire article, is a necessity much to be lamented ; the stu- dent must therefore seek the re- quired information in works which are incidentally referred to. The points of contact and fusion at the cephalic poles of double embryos, otherwise free and independent, ap- pear to be less under the influence of the law of strict homologous union than is the case with any other relative position in which two embryos are developed on a single vitellus. The origin of all double monsters being now known to result from the evolution of double primitive traces on the vitelline membrane of a single ovum, and all their forms to arise from the relative positions and the proximity or remoteness of the germinal grooves, it is easy to comprehend that the two germinal segments ap- proaching each other by their cephalic poles, would, in their fusion, be less under the force of the law of equal balancing of parts than in the case of a double embryo where the vertebral axes are either parallel or oblique. . The cephalopagus, or head-joined monster, is an ex- tremely rare form ; the literature of teratology furnishes but few human examples. If we divide them into three groups, we shall have : (a) Joined by the crowns of the heads ; eleven cases known, (i) Joined by the foreheads ; the two bodies facing each other; three cases, (c) Joined by the backs of the heads ; the bodies back to back ; three cases. In three cases of asymmetry the parasitic portion consisted of a head only, which was joined vertex to vertex, on the complete individual. A case of this kind is reported by Home (" Philosophical Transactions," vol. Ixxx., p. 296, Pl. 17. London, 1790. Ibid., vol. Ixxxix., p. 28, 1799. Fisher's Monograph, Case 158, Figs. 88, 91). When the child had attained the age of two years, it was killed by the bite of a cobra. The skull is preserved in the Hunterian Museum, in London. In this, as in other forms of double monsters, the sex is female in two-thirds of the cases. Of fifteen cases, nine were female and six male. The case of cephalopagus craniodidyrtius represented in Fig. 3862, was reported by Peter Sannie, of Haarlem. It was born dead, on November 14, 1752, at the full period of gestation. Several symmetrical cases of cephal- opagus are reported by reliable authorities to have lived for a number of years, in one instance to the age of elev- en years. In this case one of the females having died, while the other remained alive, a surgeon separated the heads. The operation proved a failure, since the living girl survived but a very short time. The cephalopagus is also quite rare among the lower animals. It has been seen in the common domestic fowl, and in the duck. Genus LI.-Syncephalus. The reader will remember that the general characters of this genus were briefly given in that portion of this article which relates to classifica- tion. As this is the proper place for a fuller considera- tion of the genus, I may repeat somewhat of the previous definition. The type in this genus is represented by two bodies equally developed, and not wanting in any of their limbs, organs, or parts, but united in a very abnormal manner. The dichotomy extends from the umbilicus below to the vertex above. The relative positions of the two component bodies, and their mode of junction, will best be understood by supposing that two foetuses be each cleft or split open on the anterior median line, from the vertex, through the nose, mouth, neck, sternum, and abdomen, to the navel; and that the halves be spread wddely apart, in such a manner that when the two cleft bodies should be applied to each other, the right margin of one body would be in homologous contact with the left margin of the other, and vice versa on the opposite side. This would result in two lateral faces, looking in opposite directions-Janus-like,-each face composed of halves from the opposite fcetus. The same with the ster- nums, which would be compound, and with the entire thorax, consisting of a great cylinder, or common cavity, surrounded by two opposite vertebral columns, two op- posite lateral sternums, and four sets of ribs, forty-eight in all. The common thoracic cavity is separated from the abdominal cavity, common to both bodies, by the great diaphragm that results from the union of two. The thorax contains four lungs, into which air enters by one trachea. The hearts may be separate, or so fused as to have their cavities communicate. The oesophagus is a single tube, entering a double stomach, on which is placed a right and left spleen. One pylorus and one duodenum ; the intestine bifurcates lower down. The pelvic organs are distinct and normal in each. Space will not permit a full description of the anatomical peculiarities that are found in the several forms of syn- cephalus. The syncephalus Janus, as above stated, has two more or less com- plete and equal lateral faces. In some cases they are perfect, in others they are both cyclopean. In a second species, one face is perfect, the other being undevel- oped, excepting, it may be, that two ears, separate or fused, may be found near the neck, as seen in Figs. 3864 and 3865, which rep- resent the opposite sides of a syn- cephalus monoprosopus. The third species of this genus, syncephalus aprosopus, is characterized by the absence of both faces. The head, if large, has two opposite occiputs, and two pairs of lateral right and left ears, no eyes, noses, or mouths. In a still lower degree the heads are represented by a small prominence at the top of the neck, terminating Fig. 3862. -Cephalopagus craniodidymus. (Sannie.)41 Fig. 3863. - Syncephalus Diprosopus (Janus). (Ser- res.) 42 23 Teratology. Teratology. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. in four ears. In all the species, excepting the typical Janus, one of the bodies may be very much smaller than the other, and this falling off may be traced, in a series of cases, until only a very imperfect mass of parasitic foetal rudiments is found, being the blighted products of ar- rested development in one of the component embryos of a syn- cephalus monster. The syncephali are not specially rare. The litera- ture contains not less than seventy human cases. I have been able to note over fifty cases in the hu- manbeing, eighty- five in mammals, and eighteen in birds-chiefly in chickens. Owing to the intimate and complicated modes of conjunc- tion of the brains, hearts, and other essential vital or- gans in the syncephali, they are, for the most part, non- viable. They have in rare instances been knowm to live a few hours, but in no case to attain maturity. Genus III. - Dipygus. In this genus the dichotomy with separation is at the caudal extremity of the neural axis. The vertebral column may be duplicated throughout a great portion of its length, or in so slight a degree as to exhibit mere traces of duality in the sa- cral or coccygeal portions. The funis is single. The head and all portions of the body above the funis are apparently single. The dipygus has been chiefly observed among the lower animals. I have notes and references to thirty cases. The calf, lamb,, pig, dog, and cat, have all furnished exam- ples. Fig. 3866 represents a case in the calf. There are one head and chest, two front legs, and double hind parts, four legs, and two tails. The double tails of lizards, duality in the back part of the body, and the presence of two tails in the king-crab (or horseshoe crab), belong also to this genus. I possess a specimen of this kind. The only cases that I have found in the human subject are in the works of Licetus, and other old authors of uncer- tain authority, though it is not improbable that cases of this kind have occurred, and may yet be seen in future. Order III.-Anacatadidyma.-In this order the duplicity with separation occurs, coincidently, at both extremities of the cerebro-spinal axis. This double polar dichotomy may occur, with more or less union of the two component bodies, at the anterior, or at the pos- terior or dorsal, aspect of the bodies. In the former case there is but one navel and funis, which is always at the lower point of fusion, while in the latter each body has its own funis. This distinction constitutes the foun- dation of the two genera into which the third order seems naturally to divide. Genual.-Omphalopagus. Derived from ofitpaKos, "the navel," and irayw, " I fasten." In the maximum degree, or typical form, of this genus, two symmetrical and wrell-developed individuals are connected by a small band arising from the anterior region of the bodies; be- ing composed of the cartilaginous extremities of the xiphoids, a delicate isthmus of the united livers, and a tubular communication between the peritoneal cavities ; the whole being covered by integument. The umbilicus is found in the middle of the lower part of this bond of union, which in the fcetal condition received the funis, through which both bodies were supplied with blood. The Siamese twins furnished the most perfect example of this type. In the less distinct forms of this genus, the extent of the coalescence varies to such a degree as to furnish a basis for the several species hereafter to be mentioned. Thus we find a series ranging from the simple small band above described to a fusion of the whole an- terior portions of the component bodies-from the ab- domen to the mouths. In the latter instance they make a transition to the genus syncephalus. The genus omphalopagus is, for the sake of accuracy and ready recognition, divided into several species dis- tinguished by the character and extent of the fusion. In the highest degree, in which the ex- tremities of the xiphoid cartilages are contiguous, and form the . principal substance of the bond of union, the term 0. xiphodidy- mus is employed. For the second specific group, in which the ster- nums are more or less involved, we have 0. sternodidymus. A third species is founded on a union of the entire thoracic parietes- 0. thoracodidymus. When the union extends as high as the face, a fourth species is made under the designation 0. prosopodidy- mus. In the fifth and last group cases are included ih which the abdomens of the component bod- ies are largely involved in the coalition ; here the term 0. gas- trodidymus is employed. If a reporter of cases desires to be more explicit, and to make the name more descriptive, he can use the prefix gastro-for exam- ple, 0. gastro - thoraco - didymus, etc. For brevity's sake the generic term may be entirely omitted, or the abbreviation 0. made use of, as xiphodidy- mus or xiphopagus, sternodidymus, or sternopagus, and so on. The genus omphalopagus embraces a large proportion of all human cases of double monsters. My researches for the materials of teratology are still quite incomplete, and yet I have notes of one hundred and twenty human cases, also of thirty among animals and birds. These in- clude both the symmetrical and the parasitic forms. The non-symmetrical forms embrace a graded series ranging from a slight difference in size of the two component parts, to cases of absence of parts-here a headless body, and there a bodyless head ; or a pair of thoracic, or a pair of pelvic, extremities, attached to the xiphoid or sternal re- gion. In some instances the attachment is almost as high as the neck. There have been a number of celebrated char- acters, who have attained adult age, that have exhibited themselves on account of carrying their atrophied and Fig. 3864. - Syncephalus Monoprosopus. (Fisher.) 43 Fig. 3865.-Opposite side of Fig. 3864. (Fisher.) 44 Fig. 3867.-Omphalopagus Xiphodidymus. (Bruck- mann.) 46 Fig. 3866.-Dipygus Tetrapus. (Gurlt.)45 24 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Teratology. Teratology. parasitic brothers attached to their epigastric regions. The famous case of Jeane Baptiste, reported and beautifully figured by Thomas Bartholine, and so frequently copied ; Ake, of whom models are found in many pathological museums; and Bruckman's case, represented in Fig. 3867, are all examples of non-symmetrical xiphodymus, or xiphopagi. Fig. 3868, from Wirtensohn, is still an- other case of the kind. The world-renowned case of the Siamese twins is by far the best illustration of the typi- cal form of the O. xiphodidymus that the literature of well shown in the diagram marked Fig. 3871. The im- portant anatomical structures which enter into the com- position of the band by which these human beings were united for a period of nearly three-score years, prove the wisdom of the conservatism which prevailed among sur- geons who were consulted with reference to separation, of the brothers by the knife or by any other means. Fig. 3869.-Omphalopagus Ziphodidymus. (Pancoast.) 4H Fig. 3868.-Omphalopagus Sternodidymus. (Wirtensohn.) 47 teratology can furnish. It is to be regretted that space will not admit of a detailed account of it; however, as it is so recent, and the accounts are so full, accurate, and accessible, we must be content with calling the attention of the reader to our excellent figure of the bodies, after the autopsy by Professor Pancoast, from a photograph taken by his direction (Fig. 3869). The intercommunication of the abdomens, and the curious arrangement of the peri- toneal pouches, are illustrated in the diagram, Fig. 3870. The hepatic isthmus connecting the two livers is also • Fig. .3870.-Peritoneal Pouches, etc., in the Connecting Band of Chang and Eng. Diagrammatic representation of the band. A, Upper or hepatic pouch of Chang ; E, E (dotted line), union of the ensiform cartilages; D, D, D, connecting liver band, or the ''tract of portal continuity: " C, the lower peritoneal pouch of Chang; E, E, lower border of the band. Genus II.-Rachipagus. Derived from "the spine," and irayco, "I fasten." Definition.-Two indi- viduals, more or less equally developed, united by some portion of their vertebral columns, with separation above 25 Teratology. Testicle. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. and below the limit of coalition. This is probably one of the rarest forms of double monsters. I have notes and references to only six cases in the human subject, and none among animals. All the references are from fined to the female sex. My notes cover many hundreds of cases. In the American Journal of the Medical Sci- ences, October, 1878, p. 534, one hundred and five cases are referred to. Dr. Handy side mentions two adult brothers, each having quadruple mammae. As many as seven nipples have been found on one person. Su- pernumerary mammae, secreting milk, have been found in the axilla and also in the inguinal region. In the lower animals the number and position of the mammae vary much in the different species. The elephant has two, which are axillary ; the mare two, inguinal: the cow four, inguinal; and in from ten to twenty per cent, of domestic cows a pair of extra teats will be found be- hind the normal ones. The frequent development of extra nipples and mammae, and their distribution from axilla to groin, in man, is very suggestive pf an antece- dent evolution, and of retrograde metamorphosis. Uterus bicornis, double uterus, and double vagina do not properly belong to diplogenesis. It is not a case of dichotomy. It is the result of arrested development. In early foetal life the uterus is formed from the Wolffian bodies. The canal of Muller unites with its fellow of the opposite side to form the uterus and Fallopian tubes, and subsequently the double central partition disappears. If, however, the progress of development be in any way checked, this partition will remain, the result being either complete double uterus, or uterus bicornis, with double vagina. Bifid uterus is the normal condition of the organ in most mammals. Cases are known of bifid and even double penis in man. I can barely mention the occur- rence of extra ribs, vertebra, cranial bones ; double kid- neys ; single kid- ney with tw'o ure- ters ; extra ears, more or less devel- oped ; extra horns in goats, cattle, etc.; bifid tails in fish and reptiles, etc. Polymelia, poly- celia, polypedia, polybrachia, poly- mania, and poly- dactylus, are a series of terato- logical terms that are applied to cases of many limbs, many legs, many feet, many arms, many hands, and many digits, whether fingers or toes. The litera- ture contains nu- merous illustrative examples of each of these forms. A recent and ex- tremely interesting case of polybrachia is shown in Fig. 3872, which is cop- ied from Charpen- tier's " Treatise on Obstetrics," vol. iii., p. 327, of Wood's Cyclopae- dia of Obstetrics and Gynecology, New York, 1887. The case is inserted by the editor. Dr. Grandin, from an account given of it by Dr. Burnett, of Long Island City, in whose practice the child was born. Child, a female, Fig. 3871.-The Hepatic Isthmus across the Connecting Band of Chang and Eng. the old literature : Obsequens, Rueff, Schenck, Lycos- thenes, and Pare. There are no anatomical grounds for questioning the possibility of such cases. It is a mere extension of the same kind of dorsal union which is seen in the pygopagus-Helen and Judith, and the Caro- lina colored twins. The question could be reasonably raised, Wherein does the rachipagus differ from the py- gopagus ? Why should the former genus be recognized in a scientific classification ? All classification is more or less artificial, and is invented for convenience and utility in description, and facility of identification ; it is little more than grouping and setting limits to groups. Rachipagus begins where pygopagus ends. I have had one case reported to me, in which two human fcetuses were united back to back, from the necks to the pelves. The mother had aborted at the fourth month, and the foetuses were preserved for a time in alcohol; but subse- quently, by neglect, they were permitted to decay from evaporation of the alcohol. Class II.-Triple Monsters.-This heading is in- troduced merely to permit the statement that it is a fact that two or three cases of triple monsters have occurred, and that there are no embryological objections that can be brought forward to prove that they cannot be evolved as well as double formations. The same terms can be used in describing them by the substitution of the prefix Tri, e.g., Tricephalus, Triprosopus, etc. Under the next division a case of triple arm and hand will be described. Supernumerary Formation.-This embraces the consideration of all cases of extra organs, members, or parts which are found in bodies not otherwise double, particularly in single bodies in which no duplicity can be discovered in any portion of the cere bro-spin al axis. The term Polymeria-from iroKvs, "many," and pepos, ' ' a part "-covers the whole subject. Polymelia, (" many " and "a limb") embraces an account of duplicate extrem- ities, and may be subdivided into three species, viz. : 1. Polyscelia ("many" and "a leg"). 2. Polybrachia ("many" and "the arm"). 3. Polydactylus ("many" and " a finger "). Polymeria.-It is not possible, within our restricted space, to give an account of all the organs and parts that have exhibited more or less doubleness, or that have been evolved in numbers beyond what belongs to the normal type of the species in 'which the malformation is found. Polymastia, polymasthus, polymazia, pleiomazia, pleo- mazia, and multimammes, are terms employed by differ- ent teratologists to express that form of hypergenesis which results in the development of more than the nor- mal number of mammary glands. This is not a very rare malformation in the human subject, and is not con- Fig. 3872. - Polymelia (Polybrachia). (Bur- nett.) « 26 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Teratology. Testicle. aged thirteen months, well formed, excepting the right upper extremity. " There are two humeri, each articu- lating with a radius and ulna. In the forearm are three radii and three ulnae, the central possibly articulating with the inner humerus. There are three hands ; each can be moved separately. The inner hand has four fin- gers and one thumb, the latter always flexed in the hand from absence of the extensor muscle, and on its ulnar surface two rudimentary fingers ; the middle hand has four fingers, always contracted, and no thumb ; the outer hand has five perfect fingers. Thus then : Two humeri, three radii, three ulnae, sixteen fingers, two rudimentary." Here we have an instance of triple development, which is in no essential respect different from what has been alleged to have occurred in the production of a three- headed human feetus. Several authentic cases of double legs, arms, and hands are on record. I have examined an adult horse with an extra foot and hoof on bach of his four legs. Two or three other cases are found in the books. Extra digits are not rare. There are families in which most of the persons have extra toes, and this hy- pergenesis has been known to be hereditary through sev- eral generations. I have known a father and son, each to have an extra thumb on the right hand. I also have knowledge of several generations of cats that produced double front feet in the greater part of their offspring. There are not less than three cases, given by good au- thorities, of as many aS nine digits on a single human foot. Fig. 3846 exhibits one of the most recent exam- ples of extreme polydactylism in the human subject. I am disposed to regard all degrees of duplex develop- ment-from the mere addition of a digit to the complete duplication or triplication of the entire body-as belong- ing to the same category, viz., as more or less complete examples of dichotomy, cleavage, fissuration, budding, or lobation of the whole or of a part of the original germ, or of the evolving embryo. This excludes the idea of a fusion of two or three originally separate germs. Pre- cisely the same thing is observed in the lower forms of animal life, and also in the vegetable kingdom. To at- tempt to explain why, or through what agency the dichot- omy or trichotomy takes place, is, in the present state of our knowledge, utterly futile. It is a well-known fact that the so-called laws of nature are not absolute. It is as easy to explain an extreme case of diplogenesis as it is to account for the slightest addition, even an extra cell, to the standard and normal growth of any simple structure in plants or animals. This brief essay on teratology is intended for the gen- eral scientific reader. To those who already possess a considerable knowledge of the subject, or to persons who desire to pursue it more exhaustively, it may prove un- satisfactory. The latter may study the works contained in the extended bibliographical lists of teratological trea- tises which are contained in the works of Isidore Geof- froy Saint-Hilaire, Ernest Martin, W. Vrolik, Ahlfeld, Tarufti, and also in my own monograph, to which I have so often referred. The various headings relating to this subject, which are to be found in the several volumes of the Index Catalogue of the Library of the Surgeon-Gen- eral's Office, United States Army, will prove very use- ful. In fact, almost every teratological monograph, even reports of single cases, often contain a wealth of refer- ences. It is not difficult to get speedily entangled in the intricacies and absorbing interests of the subject. George Jackson Fisher. 1 8 Vrolik (from Otto): Tabula?, Tab. Ixxxii., f. 7. 17 Ibid., Tab. Ixxxii., f. 3. 18 Ibid., Tab. Ixxxii., f. 6. 19 Hastings: Trans. Med.-Clin. Soc. Edin., vol. it, p. 39. Pl. i., f. 2. Edin., 1826. 20 Op. cit., Tab. Ixxvii., f. 1. 31 Tabulae, Tab. xvi., Fig. 7. 32 Herholdt: Beschreib. sechs Menschlicher Missgeburten, Tab. iv. Kopenhagen, 1830. 38 Poppcl: Ueber Herzlose Missgeburten. Fig. i. Munchen, 1862. 34 Op. cit., Fig. 2. 35 Op. cit., Tab. vii. 38 Tiedemann: Ueber Pseudacormus, Fig. 1. Breslau, 1854. 37 Charpentier: Obstetrics, vol. iii., p. 284. New York, 1887. 38 Johnson: Trans. Pathol. Soc., Loud., vol. ix., p. 427, 1858, Lfgn. 14. 39 Pancoast: Photographic Rev. of Med. and Surg., vol. i., No. 5. Phila.. 1871. 30 Ibid., p. 47. 81 Ibid., Fig. 22. 33 Fisher: Transactions of the Medical Society of the State of New York, 1866, p. 243, Case 26, Fig. 15. 33 Fisher: Op. cit., p. 253, Case 36. Fig. 35. 34 Handyside: Obs. in the Arrested Twin Development of Jean Battista Dos Santos. Edinburgh, 1866. 36 W. Gruber: Anat. Monstr. Bicorp.. Tab. i. Prag. 1844. 36 Gruber : Anat. Monstr. Bicorp., Tab. iii. Prag, 1844. 37 Op. cit., Tab. vi.. Fig. 2. 38 Fisher: Transactions of the Medical Society of the State of New York, 1866, p. 286, Case 74, Fig. 61. 39 Fisher: Transactions of the Medical Society of the State of New York. 1867, p. 403, Case 3, Fig. 67. 40 Fisher (from Vrolik): Transactions of the Medical Society of the State of New York, 1867. p. 418, Case 136, Fig. 73. 41 Fisher: Op. cit., 1868, p. 128, Case 154, Fig. 85. 43 Fisher (from Serres) : Op. cit., 1868, Fig. 97. 43 Fisher: Op. cit., 1868, Fig. 109. 44 Fisher: Ibid., Fig. 110. 45 Fisher: Op. cit., Fig. 118. 48 Charpentier (from Bruckmann): Obst. and Gynec., vol. iii., p. 323, Fig. 235 (Wood's Cyclop.). New York, 1887. 47 J. Wirtensohn: Duorum Monstro. Duplic. Humanorum, Tab. i. Berolini, 1825. 48 Photograph of Siamese Twins. 49 Charpentier: Wood's Cyclopaedia of Obstetrics and Gynecology, vol. iii., p. 327, Fig. 240. TEREBENE. Terebene, Ci0Hi8, is a liquid hydrocar- bon, obtainable by the action of strong sulphuric acid on oil of turpentine. It is a colorless, mobile fluid, of a pleasant pine-wood odor and taste, free from the acridity of oil of turpentine. It is insoluble in water, but dis- solves slightly in alcohol. Terebene seems to affect the human system like a mild oil of turpentine. It has been taken in so large quanti- ties as a teaspoonful every four hours, continued for a week, without untoward effects. Under the influence of the medicine the urine acquires an odor as of violets, and may slightly increase in quantity, but no case of undue ir- ritation of the kidneys has been reported. Medicinally, terebene has been found of service for the alleviation of cough and dyspnoea from respiratory disease, and of dyspepsia with flatulence and acidity. The drug is commonly given in doses of ten drops, or thereabouts, dropped upon sugar, or made into an emulsion. In re- spiratory affections the vapor of terebene may be ordered to be inhaled in addition to the internal administration. Edward Curtis. TERPIN HYDRATE. When a mixture of turpentine- oil and water is permitted to stand, crystals of terpin hydrate, C10Hi8(OH)2 + OII2, often deposit. For arti- ficial preparation of the crystals in quantity, a mixture is made of oil of turpentine, nitric acid, and alcohol, which, after frequent shaking for a few days, is set aside in shal- low vessels for crystallization to occur. Terpin hydrate is in the form of colorless, rhombic crystals, insoluble in water or alcohol, and practically devoid of odor and taste. The drug is claimed to possess the medicinal "expecto- rant " virtues of the terebinthinates, while free from the deranging influence of the class. It may be admin- istered in doses ranging from 0.20 Gm. to 0.65 Gm. (from three to ten grains), given a number of times daily. Edward Curtis. TESTICLE AND CORD, MINUTE ANATOMY OF. The testicles are ellipsoidal organs suspended in the scro- tum by the spermatic cord. They are usually uniform in size, each being from 4 to 5 ctm. (1| to 2 inches) in length ; 2.5 to 3.5 ctm. (1 to 1| inch) in antero-posterior measurement, and 2 to 3 ctm. (| to 1| inch) in width. The weight is from 4 to 6| drachms, and the volume 0.7 to 1.5 cubic inch (Henle). The two testicles frequently differ in size, the left in that case being usually heavier, and their size often varies, also in the same individual at different times. 1 Johnson's Translation, B. XXV., chap, xii., p. 982. London, 1634. 3 Rudolph : Monstroruin trium pneter naturam cum secundinis coalito- rum disquisitio, Tab. I. Berolini, 1829. 3 Tabulae, etc., Tab. xli., f. 2. Amsterdam. 1849. 4 Tab. xlii., f. 4. 6 Etienne Geoff. Saint-Hilaire: Essai de classification des Monstres ac4phales. (Pl. 14), Pl. iv., Fig. 3. Paris, 1821. 6 Ahlfeld (from Meckel's Archiv, 1828, p. 156): Die Missbildungen des Menschen. Atlas. Taf. xxiv., Fig. 6. Leipzig, 1882. 7 Report upon the Case of the late Dr. E. A. Groux. Brooklyn, 1878. 6 Vrolik : Tab. xxxiv., f. 15. 9 Monstri Huinani Max. Notab., Tab. ii., f. 1. Berolini. 1823. 10 Op. cit., Tab. ii., f. 2. 11 Tabulae, Tab. xxvi. 13 De Sympodia, Tab. i. Heidelberg®, 1846. 13 Ibid., Tab. iii., f. 2. 14 Otto: Monstr. sex human, anatom, et physiolog. disquis. Franco- furti, 1811. 15 Ibid., Fig. iii. 27 Testicle. Testicle. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The testicle has two coverings ; the outer of these, the tunica vaginalis, is a closed sac of serous membrane which forms a bursa that rests upon the whole of the anterior and lateral walls. Underneath the tunica vaginalis lies the tunica albu- ginea, the proper capsule of the testicle. This structure is about 0.6 mm. (/0 inch) in thickness. It is composed of white fibrous tissue, with a small number of elastic fibres. These fibres form net-works whose general direc- run in a transverse direction. These bundles are occa- sionally 1 mm. inch) in thickness, sometimes scarcely perceptible " (Henle). They are prolonged upon the sep- tulae. Within the conical spaces, and extending between the albuginea and septulae, is a network of connective tissue which is peculiar to the testicle; it is made up of fibrous tissue arranged in plates. The plates are covered and partly formed by epithelial-like cells. They form the partitions of cavities which are connected with one an- other by cleft-like openings. These cavities appear to be lymphatic spaces. If they are injected by puncture, the fluid finds its way into the lymphatics of the cord, and also into the outer portions of the walls of the sem- inal tubules. Between the lamellae of the connective tissue are often found groups of epithelial-like cells somewhat resem- bling the cortical cells of the suprarenal capsules. Their origin and function are unknown (Fig. 3874). Each one of the conical spaces formed by the septulae is filled by a convoluted mass of tubules, bound together Fig. 3873.-Cross Section of Testicle. 1, Albuginea ; 2. peripheral zone ; 3, lobules ; 4, straight tubes ; 5, rete testis. In the albuginea are seen the sections of the venous trunks. (Thiersch.) tion is lengthwise of the organ. The net-works lie in layers which alternate with the fibrous tissue, and give the albuginea a stratified appearance. The portion of the albuginea which lies under the tunica vaginalis is cov- ered with pavement epithelium which forms the visceral layer of the tunica vaginalis. At the posterior portion of the testicle, underneath the epididymis, the tunica albuginea becomes very much thickened and projects into the interior of the organ, forming the antrum Highmori, or mediastinum testis. The mediastinum occupies about one-third of the trans- verse, and one-fourth of the longitudinal, diameter of the testicle. It is slightly nearer to the median line than to the external border of the organ. Partitions of connective tissue radiate from the medi- astinum in all directions to meet the tunica albuginea. Fig. 3875.-Passage of Convoluted Seminal Tubules into Straight Tu- bules, and of these into the Rete Testis, a. Seminiferous tubules: b, fibrous stroma, continued from mediastinum testis ; c, rete testis. (Mi- halkovicks.) by the connective tissue described above. The tubes form the secreting portion of the organ. Seen in transverse section, a lobule of the testicle can be divided into an outer or peripheral, and an inner zone. In the peripheral zone the convolutions are much closer than in the inner zone. Each lobule consists of two or more tubes, which, closely convoluted and massed together, converge tow- ard the mediastinum. The tubules may, with some dif- ficulty, be unravelled, except, perhaps, in the peripheral zone. They are then seen to divide frequently and anas- tomose at acute angles. They end in loops or by uniting with some other tube, but do not terminate in blind ends, except, perhaps, rarely, in the peripheral zone. They anastomose sparingly with the tubules of neigh- boring lobules, especially in the peripheral zone, where the septulae are incomplete. As the tubes pass toward the mediastinum they unite with one another, become fewer in number, and finally all unite into one tube, which becomes less and less convoluted, the last three or four Fig. 3874.-Section of Testicle of the Cat, showing (1, 2, 3) sections of the tubes in various planes; 4, the interstitial cells in the connective tissue. (Henle.) These partitions, or septuhe, divide the testicle into conical spaces, in which lie the secreting tubules. The number of these spaces is estimated by Krause, quoted by Curl- ing, at between four hundred and five hundred. Henle says, from one hundred to two hundred. The number probably varies considerably in different persons. At the posterior portion of the testicle, " at the place where the vessels of the spermatic cord enter the testicle, are found collections of organic muscular fibres which 28 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Testicle. Testicle. millimetres (£ to | inch) of its course being nearly straight (Fig. 3875). The calibre of the tubes varies with the degree of dis- tention. Even when uniformly distended, they are not of the same diameter in different parts. Small bulgings, which are more numerous toward the peripheral zone, fre- quently occur. The average diameter of the tubules in a vigorous young man is from 1 to 2 mm. (/^ to inch). Larger tubules, however, are often seen. The length of each tubule is estimated at about two feet, and the num- ber of tubes at between eight hundred and nine hundred. The length of the tubules collectively has been variously estimated at from eight hundred and fifty to one thou- sand seven hundred and fifty feet, and the secreting sur- face at one hundred and seventy-seven square feet. The outer layer of the tube is a membrana propria, which va- ries in thickness from 0.010 to 0.016 mm. to inch). In transverse section the tubes appear concentrically striated ; in longitudinal section they are longitudinally striated ; in both' positions rod-like nuclei are seen. Spread out and examined o n the flat surface, these nuclei ap- pear as disks, having adiame- ter the same as the length of the rods, 0.01 mm. ( ? inch). (Henle.) The walls, then, are com- posed of layers o f 11 at ten ed cells with discoid nu- clei. The outer portions of the walls are loose- 1 y connected, and only the inner layer is complete. Within the tubes are found several layers of cells somewhat irregularly disposed ; the layer, however, which lies next the membrana propria is most nearly complete (outer or lining cells) (Fig. 3876.) These cells are somewhat flattened and measure from 0.011 to 0.014 mm. to inch) in transverse section. The nuclei of some of these outer cells usually present some indication of division. The outer layers of cells present great differences, according to the degree of development of the spermatozoa. In tubes in which the spermatozoa are fully developed there are two or three layers of cells, within which is a granular mass which cannot be divided into separate cells. Within this mass is a large number of small round bodies resembling nu- clei, and lastly, in the centre of the tube, a mass of sper- matozoa. In other places the spermatozoa may be seen in various stages of development, but, when young, with the head always in contact with the outer layer, if not actually embedded in it. How early in life spermatozoa are found in the tubules it is impossible to say. They are certainly found earlier than is commonly supposed. The writer has specimens in his possession from a new-born child, with the tubules full of perfect spermatozoa. The method of development, which is still not quite settled, will be described in another place. The tubules retain their peculiar characteristics until they have arrived nearly at the mediastinum, when they taper into short straight tubes (tubuli recti) of smaller di- ameter. The membrana propria is continued to the me- diastinum, where it is lost; the epithelium loses all but the outermost or lining layer. The straight tubes pass into a net-work of passages without proper walls, which are channelled out in the mediastinum (rete testis). They are lined by flattened epithelium. The meshes of this net-work are irregular in size and the passages vary greatly in calibre, but usu- ally they are larger than the seminal tubules. The pas- sages of the upper and posterior portions of the mediasti- num are larger. The channels of the upper part of the rete gradually collect into a series of tubes which pene- trate the tunica albuginea and pass off from the testicle to unite with the epididymis. These are the efferent tu- bules, or vasa efferentia. The arteries of the testicle are derived from the sper- matic artery. Fine arterial branches pass through the albuginea, they are especially frequent at the mediasti- num. The arteries, attended by the muscular fibres be- fore mentioned, enter here at the point of exit of the sper- matic vessels. These vessels accompany the septulse and are distributed to the plates of connective tissue, and form a close plexus around the tubuli. The vessels make a considerable proportion of the parenchyma of the tes- ticle. The plexus is not specially close, but noticeable by ' ' the thickness of its walls, and by its remarkably tor- tuous, coil - like, twisted course " (Fig. 3877). The veins in the albuginea have in the main a longi- tudinal direction, so that in a trans- verse section their apertures may be seen in a row (see Fig. 3873), each surrounded by a border of connec- tive tissue. They are especially fre- quent in the pos- terior portion of the testicle. The lymphatics have their origin in the connective tissue before men- tioned ; the walls of the seminal tubules also appear to belong to the lymphatic system ; the vessels follow the course of the spermatic vessels and terminate in the lum- bar lymphatic glands. The ultimate distribution of the nenes is unknown. The epididymis is composed of the convolutions of the excretory duct of the testicle. It rests upon the posterior portion of the testicle, projecting above nearly to the mid- dle of the upper extremity. Its upper portion is club- shaped (head, or globus major). The lower extremity ends a short distance below the testicle and is pointed (tail, or globus minor). Between these lies the connecting portion, or body, triangular in shape. From the lower extremity of the epididymis the sper- matic cord passes upward through the abdominal ring and over the posterior portion of the bladder, to enter the prostatic urethra. The epididymis has its own fibrous covering or albuginea, similar to that of the testicle, but so thin (0.04 mm.,^ inch) that the substance of the epi- didymis can be seen through it. The sharp edge of the epididymis is composed of connective tissue and vessels, the connective tissue being much richer in elastic fibres than the testicle itself. The vasa efferentia form the connection between the testicle and epididymis, and belong properly to the latter. These tubes are uncertain in number, " varying from nine to thirty. As a rule they are from twelve to four- teen " (Henle). They perforate the tunica albuginea im- mediately under the head of the epididymis. At first they are nearly or quite straight, but become more and more convoluted until they reach the epididymis. They form a series of cones (coni vasculosi). The length of each cone is at most about 8 mm. (| inch). Unravelled, the tube will average 20 ctm. (8 inches). The diameter of the unravelled canal at its exit from the Fig. 3877.-Section of Injected Testicle, show- ing Blood-vessels surrounding the Tubules. (Henle.) Fig. 3876.-Section of Parts of Three Seminiferous Tubules of the Cat. a. With the spermatozoa least advanced in development; b, more ad- vanced : c, containing fully developed spermato- zoa. (Schafer.) 29 Testicle. Testicle. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. testicle is about 0.6 mm. (-/o inch), and it narrows to about 0.4 mm. (^ inch) at the epididymis (Fig. 3878). The walls of the rasa efferentia are provided with a con- siderable quantity of smooth muscular tissue, and they but of smaller calibre. It varies from 4 to 36 ctm. (U to 15 inches) in length ; its usual length being from 5 to 8 ctm. (2 to 3 inches). It is often absent. As many as four have been reported in the same subject. Less constant is a conical lobule at the upper end of the epididymis, which resembles a vas efferens that has failed to make connection with the testicle. The organ of Giraldos is situated at the posterior por- tion of the epididymis, between the head and the vas deferens, and surrounded by blood-vessels and the strands of the seminal cord. It is recognized with difficulty, unless the surrounding tissue has been rendered trans- parent by reagents. It consists of a variable number of Hat, white bodies, of about 5 or 6 mm. (| inch) in di- ameter, each of which consists of a collection of tubes blind at each end, from 0.1 to 0.2 mm. (^io to T|T inch) in diameter. The tube is swollen at each end to a round or lobulated bladder. Saccular swellings occur here and there, especially near the ends. The tubes are lined with columnar, ciliated epithelium. The cavity, about half that of the tube, is tilled with a clear fluid.' Henle calls this body the paraepididymis (Fig. 3880). The hydatid of Morgagni is a firm, pyriform vesicle, at- tached by a thin pedicle to the front surface of the upper part of the epididymis. The length of the stem and size of the vesicle are variable. The stem is from 1| to 9 mm. (-^ to | inch) long; the vesicle about 14 mm. (-^ inch) wide. The vesicle is lined with cili- ated cells, "and contains a clear fluid with cells and nu- clei " (Henle). The stem is composed of connective tissue and is solid. It runs down under the serous covering of the epididymis, and disappears between the vessels and nerves of the spermatic cord. The vesicle is said to be occasion- ally solid. It is occasionally lacking. In such cases a small vesicle, with a stem which can be followed some distance, has been found under the covering of the epi- didymis. The hydatid is supposed to be the remains of Muller's duct. Another appendage has been described, which rests upon that part of the under surface of the head of the epididymis which is turned toward the testicle, or in the furrow between this and the testicle, or more often upon the testicle itself, close to the epididymis. It is conical, with the base outward, but not properly pedunculated. It may be simple or divided into two or three lobes. Its length varies from 1 to 8 mm. (^ to 4 inch). Two of unequal size are sometimes found. Sometimes the sac contains semen with spermatozoa. In that case it is in connection with the canal of the epi- didymis. In other cases it is closed by firm connective tissue, and the enclosed fluid contains only round ele- ments and molecules. At its lower end, the epididymis becomes less and less convoluted, until it turns upward and passes into the vas deferens. At the beginning the vas deferens is somewhat tortu- ous, but soon becomes straight. Its length is from 16 to 20 ctm. (6 to 8 inches). Straightened out, it is nearly twice as long (Henle). Its diameter is about 3 mm. (f inch). The calibre is quite small in comparison with the thickness of the walls. It consists of an external layer of connective tissue, a muscular layer, and a mucous membrane. The muscular coat is about 1 mm. inch) in thick- ness, and consists of three layers: an external longitu- dinal, a middle circular, and an internal longitudinal layer. The internal layer is most marked near the be- Fig. 3878.-Diagrammatic Representation of the Course of the Canals in the Testicle and Epididymis, together with the Passage of the Canal into the Vas Deferens. T, Testicle; Rt, rete testis: E, epididymis; PE, organ of Giraides ; Vd, vas deferens ; ♦, vasa efferentia ; *♦, vas aberrans. (Lauth.) are lined with short conoidal epithelium crowned with short and very thick cilia. The vasa efferentia all empty into one tube, the canal of the epididymis. This tube is at first very much con- voluted, the convolutions being held in place by fine areolar tissue, which is much richer in elastic fibres than the tissues of the testicle. Numerous partitions of fibrous tissue divide the organ into lobes. When unrolled the vas deferens is said to be about twenty feet in length. The diameter of the tube is tolerably uniform, but gradually diminishes from the head downward toward the tail, when it again increases ; the average diameter in the middle portion, when the tube is moderately filled, is about 0.44 mm. inch). The walls are composed of smooth muscular fibres, whose direction is for the most part circular. The nuclei of the muscular fibres seen in sections of the canal parallel with the muscle, appear as small rods; intransver.se sections of the muscle as bright points. The epithelium is from 0.04 to 0.05 mm. (koo to yiir inch) in thickness. It consists of two layers, an external layer, next the muscular fibres, of round cells with nuclei of about 0.005 mm. inch), and an internal layer of conoidal ciliated epithelial cells. These cells, unlike the cells of the vasa efferentia, are crowned with very long and slender cilia 0.02 to 0.03 mm. (t/oit to inch) in length. Their movement is di- rected toward the outlet of the epididymis. Toward the lower portion of the epididymis the cells lose their cilia and the walls increase in thickness to about 0.12 mm. inch) (Fig. 3879). At the lower end of the epididymis passes off a blind appendix, the ms aberrans. This is a convoluted tube with a blind end, similar in structure to the epididymis, Fig. 3880.-Canal of a Lobule of the Organ of Giraldos. (Henle.) Fig. 3879.-Longitudinal Section of the Wall of the Canal of the Epididymis, from the Head. 1, Cilia ; 2, cylindrical cells which carry the cilia : 3, layer of round cells; 4, muscular layer, fibres cut transversely ; 5. cross cut of a ves- sel ; 6, connective tissue. (Henle.) 30 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Testicle. Testicle. ginning of the tube. Sometimes it is said to be lacking altogether, or it may be masked by the elastic tissue in the basement layer of the mucous membrane (Fig. 3881). The circular layer is usually the thickest. The adven- titia contains bundlesof mus- cular fibres. T h e epithe- 1 i u m consists of cylindrical cells of about 0.05 mm. inch) in height. A layer of round cells, similar to those of the epidid- ymis, is de- scribed bysome observers as ly- ing underneath the cylindrical cells. Outside of the cells is a basement mem- brane c o m - posed of a net- work of con- nective tissue with anet-work of elastic fibres on the outside. The membrane has two or more ruga? which run in a longitudi- nal direction. Very soon after the vas deferens becomes attached to the base of the bladder it begins to enlarge, especially in its transverse diameter, and soon reaches more than double its original size. It diminishes again toward the junc- tion with the seminal vesicles, forming a spindle-shaped structure called the ampulla. With this increase in size the course becomes slightly tortuous, the flexures being fastened to the adventitia by tense longitudinal muscular bundles. The calibre changes more slowly than the size of the tube, but the wall is made relatively thinner than that of other parts by diverticles from the main canal. These diverticles pass off at an acute angle, run upward next the canal for a space, and terminate in a blind extremity. This is best seen by comparison of a series of sections from the lower end of the vas deferens. At first there is one opening, then come sections with two, and finally with three, openings. A longitudinal series of side open- ings may correspond with one long diverticle, or with several short ones-the diverticles in one case springing from the blind end, in the other from the stem. There cons membrane undergoes many modifications. It be- comes thicker, more homogeneous, and often wrinkled, while the strong elastic layer of the basement membrane is lost. In the narrow parts the membrane is very much convoluted. These convolutions may be obliterated by dilatation. Besides these convolutions, the membrane is beset with small furrows, visible to the naked eye. In places these furrows form bulgings of the wall with wide openings, bound- ed by plexiform folds or trabeculae of the mucous membrane. The furrows may be subdivided by sec- o n d a r y furrows. The coarser furrows average 1 mm. (^y inch) in diameter, thefinerO.l mm. inch) and less. Injected and freed from the outer struct- ures, the mucous mem- brane is nodular, the fur- rows of the outer surface corresponding with the folds of the inner. Some of the furrow's are so deep, and the folds of mucous membrane project so far, that upon cross section they appear to be enclosed by a net-work of fine trabeculae (Fig. 3883). The epithelium which lines the various parts of the ampulla is in general the same bright cylindrical epithe- lium as that of the rest of the vas deferens, only shorter, being not more than 0.02 mm. (-/jo inch) in height. The most characteristic distinction between the ampulla and the rest of the vas deferens is the presence of pecu- liar glands. These glands penetrate the whole thickness of the basement membrane, and oc- casionally extend into the muscular layer (Fig. 3884). They are present everywhere except in the narrowest diverticles and the thin duplicatures of mucous membrane. They are tubular, with bulbous ends. Their length is about 0.3 mm. (-^ inch), their diameter at the bulbous end about 0.05 mm. (^^ inch). In form they resemble, in many places, Lieberkuhn's glands of the small intestine. Sometimes several unite in a com- mon outlet; some resemble racemose glands. They have a small lumen bordered by round and an- gular cells. In and among these cells are scattered nu- merous molecules of a yellowish- brown pigment, which gives them their characteristic color, visible to the naked eye, and tinges the mucous membrane of the ampulla yellow'. The glands are to be dis- tinguished by this epithelium from the smallest bulgings of the mu- cous membrane, which resemble them in size. The regular arrangement of the muscular layer is disturbed by the diverticula and the various bulg- ings of the mucous membrane. The larger diverticula, when they pass into the circular layer, frequently retain their own internal longitudinal layer. Still larger diverticula have a complete muscular layer of their own, similar to that of the main trunk. The interspaces between the djverticles and the main trunk are filled with connective tissue. The widest Fig. 3883.-Longitudinal Section of the Urethra and Prostate, with the Lower End of the Ampulla opened from the Median Side. 1. Prostate ; 2, urethra ; 3, ejaculatory duct; 4, entrance of the seminal vesicle ; 5, posterior wall of the latter. (Henle.) Fig. 3881.-Section across the Beginning of the Vas Deferens, a, Epithelium ; b, mucous membrane ; c, d, e, inner, middle, and outer layers of muscular coat. (Klein.) Fig. 3884.-Section of the Mucous Membrane of the Ampulla, showing Glands. (Henle.) Fig. 3882.-Cross Sections of Vas Deferens. A, Just above the ampulla ; B, C, through the ampulla ; *, blind upper end of diverticle; **, cross section of a diverticle which has penetrated the septum. (Henle.) may also be spaces in which there are no diverticles. Usually just before the junction with the seminal vesicle, the last diverticles, together with the main trunk, form a mere bladder-like receptacle from which the ejaculatory duct passes out like a stile (Figs. 3882). There are, however, many variations. With these changes the mu- 31 Testicle. Tetanus. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. canals have thinner muscular walls than the smaller ones. The muscular coat of the first part of the ampulla runs smoothly over the bulgings and diverticles without indi- cating their presence except, perhaps, by an occasional slight irregularity. But at the lower end of the ampulla the diverticles push out the muscular coat. Sometimes they equal in diameter the ampulla itself. These projec- tions are connected to the ampulla by connective tissue, sometimes also by longitudinal bundles of muscular fibres. The last projections open into the ampulla by openings of greater or less width ; sometimes the mucous mem- brane projects considerably and forms a sort of valve. The Seminal vesicles are appendages of the ampulla similar to the last-mentioned diverticles, but larger and more developed. Seen from without, they appear like slender, flattened sacs, which bound the fundus of the bladder on its two sides. The length of the seminal vesicles varies between 4 and 8.5 ctm. (If and inches). Its transverse diameter is from 0.6 to 2.7 ctm. (J to 1 inch). Frequently they are asymmetrical and of unequal size. The upper end of the seminal vesicle is not its termi- nation, but only the bending place of the tube, which turns downward and ends in a blind extremity near the point of origin of the vesicle. It may, therefore, be separated into two divisions, one passing upward and the other downward. Each has nu- merous diverticles, which may themselves also have sec- ondary diverticles. A cross section resembles that of the ampulla, except that it is larger and more complex. The two divisions and the diverticles are held together partly by connective tissue, partly by bundles of the ex- ternal longitudinal muscular layer, which extends over the intervening space. The descending branch is usually wider and has.thin- ner walls than the ascending. The calibre is variable, but, on the whole, wider than that of the ampulla. The ejaculatory ducts arise near the upper wall of the prostate, from the junction of the vas deferens and the seminal vesicle, occasionally from a saccule which, in- stead of ending in the vas deferens or the ampulla, opens into the angle between them Usually the vas deferens and the ampulla have an equal share in the formation of the structure. Sometimes one or the other has more to do with it. Occasionally the vas deferens opens by a very fine opening into the duct. Sometimes, when the union seems complete from the outside, a partition of mucous membrane is seen to separate the two canals for a considerable distance. When the walls of the vas def- erens and the seminal vesicles join the ejaculatory duct, they become rapidly thinner, passing from 2 to 3 mm. Ch to | inch) in thickness, to about 0.4 mm. inch). The duct is at its origin about 3 mm. (| inch) in diam- eter, its calibre is about 1 mm. (-2l6- inch), and it is about 15 to 20 mm. (| to | inch) in length. At its outlet it is barely 0.5 mm. inch) in diameter. At their outlet the two ducts often approach so closely that their median walls coalesce. In the wider part of the canal the mucous membrane of the ejaculatory duct still has the same folds, the same glands lined by a granular epithelium, and therefore the same yellow color as the seminal vesicle. Gradually, in place of the glands, shallow depressions occur, and in the last part of its course the mucous membrane is smooth and without glands. The muscular layer of the ejaculatory duct assumes, within the prostate, the character of a cavernous tissue ; the muscular fibres are almost completely crowded away by thick elastic fibres, and between the net-like, anasto- mosing bundles, appear narrow communicating spaces filled with blood. These spaces resemble the spaces of the cavernous tissue of the urethra. Within the firm tissue of the prostate this cavernous layer forms a yielding sheath around the ejaculatory duct. Its volume may be diminished by pressing out the blood when the ejaculatory duct is distended. After the duct collapses, the blood may return again and fill the vacant space. Lester Curtis. TETANUS. (From tCivw and Ttraivu ; Lat., spasmus; Ger., Starrkrampf, Mundsperre; Fr., tetanos; Eng., lockjaw.) Tetanus consists in a painful tonic contraction which appears usually in the muscles of the lower jaw, pro- gresses successively to those of the neck, the trunk, and the limbs, and is complicated by general violent convul- sions of the whole frame, which recur with greater or less frequency. In its pathological anatomy it presents the appearances of an acute central myelitis of the supe- rior region of the spinal cord, with exaggeration of the reflexes (F. Poncet). The disease in question has been recognized since the days of Hippocrates, and no doubt was well known be- fore that time. The writings of this celebrated man upon tetanus are among the most valuable, even in our day. The progress of the disease in any of its forms, the duration of the malady, the fatal result, and all other es- sential characteristics of its course have not been materi- ally modified since the period during which this re- nowned observer lived, and the description given by him is almost literally the same as is obtained from the study of the disease in our own time. Hippocrates says, for example, "Those who are attacked with tetanus die within four days. If they survive this period they re- cover." Further on, he says : " The patient dies on the third, the fifth, the seventh, or the fourteenth day. If he passes this time he will recover." The additions to our knowledge, for which we are in- debted to Larrey, Rodney, Cremor, and others, have made the prominent features of the malady known to later readers ; while Dupuytren, Sauvage, and others have made extensive and valuable researches into the patho- logical anatomy and the gross pathological appearances of this dreaded disease. To these appearances belong the redness of the nerve-trunks, the congestion of the nervous centres, the rupture of muscular tissue, or even entire muscles, which are observed in the autopsy of these cases. In England, where the disease is proportionately much more frequent than in many other parts of the world, a large number of valuable observations have been made upon tetanus, and to Taylor, Poland, Yandell, and Colles we owe much of value in regard to the character of this disease in the valley of the Thames and in the vicinity of London. Since their time, and particularly within the last thirty years, the investigations in relation to tetanus have been innumerable, and often of great value ; but no just enumeration of these inestimable contributions can here be attempted. Varieties.-The older authors divided tetanus into several forms, according to the character of the contrac- tions in the individual case. Thus we have " trismus," in which the muscles of the jaw are particularly affected ; "opisthotonos," in which the contractions are chiefly confined to the great body of muscles lying on either side of the spine ; " emprosthotonos," in which the spasm is observed in the muscles of the anterior portion of the trunk; and later was added the appellation " pleuros- thotonos," in which the contractions were limited to, or at least chiefly affected, one of the lateral halves of the body. The progress of the disease has made justifiable two grand classes of cases: acute and chronic tetanus. The first is almost universally and rapidly fatal; while the second follows a more moderate course in point of the se- verity of the immediate symptoms and extent of muscu- lar invasion, and may at times end in recovery from the disease. Tetanus is often classed or distinguished according to its mode of origin. Thus we have traumatic tetanus, in which the disease follows some external injury to the body, and is most frequently of such a character as to bruise or crush the tissues which are the seat of the le- sion ; and in this way may be induced extensive destruc- tion of the nervous elements of the part. At times the disease is observed to appear after the wound has long been cicatrized, and is sometimes then called rheumatic tetanus. Spontaneous tetanus has also been recognized, 32 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Testicle. Tetanus. as well as that arising from exposure to cold (tetanus a frigore). This variety forms a part at least of the cases of tetanus observed in India and other tropical countries. Tetanus is generally milder, both in its essential feat- ures as well as in the mode of termination, in adults than in children. The variety of tetanus in the new-born (te- tanus neonatorum sen nascentium) is usually very severe, and almost uniformly fatal. This affection, called also infantile trismus, forms one of the greatest perils of in- fantile life in many of the warmer latitudes, and it ap- pears at times in parts of Europe and America which lie well to the north. The occurrence of tetanus after parturition is now a recognized fact, and this constitutes one of the dangers accompanying the puerperal condition. Acute Traumatic Tetanus.-Notwithstanding the rapidity of development of this most violent disease, it is possible to distinguish several periods in the progress of the malady. Thus we may often designate a period of invasion, a period of extreme development, and a period of termination, which latter is generally fatal. The oc- currence of tetanus in a wounded person is sometimes, or at least may be, preceded by a peculiar condition of the wound and its immediate vicinity. The discharge from the wound, if it be still suppurating, is of a peculiar and unhealthy character, and there is more or less irritation of the surrounding tissues. The disease may, however, appear in cases in which there is no such appreciable cause, and even when the utmost precautions in the way of antiseptic treatment have been scrupulously carried out. At times there is, preceding the advent of tetanus, a circumscribed redness of the part, which is not due to lymphangitis, to erysipelas, nor to any of the other recognized septic or inflammatory affections of recent wounds. The redness gradually extends toward the body, if the seat of the wound be upon an extremity ; or in an irregular manner around the point of origin, if the wound be located upon the trunk. In a certain number of cases tetanus occurs after compound fractures, partic- ularly if there be comminution of the bones of the part, or extensive laceration of the soft tissues. Rarely it is observed to follow simple, uncomplicated fracture of a long bone without external injury, as occurred in a recent case within the knowledge of the writer, in which tetanus was developed in a case of simple fracture of the radius, without laceration of the external tissues. The tetanic symptoms appeared about eighty-two hours after the accident, when all danger from the injury was believed to have disappeared and the patient was perfectly com- fortable, and the disease resulted fatally in ten hours. The primary symptoms of tetanus are often so mild in character that they are not noticed by the patient, or his attendants, until the disease is well advanced. The first indications noticed are generally pain, located indefinitely in front of the ear, and distress and inability in the move- ments of the lower jaw. There is not often any appre- ciable degree of fever during the invasion of tetanus, and the pulse-rate is about 70 per minute, but, nevertheless, the commencing cramp of the temporo-maxillary muscle is the beginning of the tetanic disease, which then often advances with alarming rapidity. The muscles of the face soon become affected, and their contraction occasions contortion of the features, and pro- duces the " risus sardonicus" of the older authors. All the muscles of the face and neck soon become rigid, the skin of the forehead is thrown into folds, the alm of the nose are elevated, the angles of the mouth retracted, the lips are thinned, the eyes are sunken, and the lids par- tially closed by the contraction of the orbicular muscle. The appearance of the patient is now frightful in the ex- treme, and the countenance bears no resemblance to the ordinary facial expression of the individual. When the rigidity of the muscles of the neck has become fully de- veloped, the other phenomena of tetanus rapidly super- vene. These consist most frequently in general convul- sions, arising in the vicinity of the original injury, and extending over the entire body. There is now observed a considerable febrile action, the temperature of the body is elevated to 39° or even 40° C. (102° to 104° F.), and there is constipation and retention of urine. The skin is bathed with perspiration, the face becomes livid, the eyes are glistening, the pulse is accelerated, weak, and easily compressible. In proportion as the paroxysms increase in frequency, the spasm extends to other groups of mus- cles. Those of the trunk are first affected, then those of the neck, when the danger to the patient may be consid- ered to be imminent. Deglutition becomes more and more difficult, the trismus retains the jaws in close appo- sition, so as to prevent the introduction of food or medi- caments ; there is a constant flow of saliva from the lips, and the continual pain forces the patient to groan aloud, even when his cries are arrested by the severity of the spasm of the muscles of respiration. There is great op- pression in the region of the chest from a sense of con- striction of the body at the waist, and there is frequently marked epigastric uneasiness. Even in a condition of so great gravity, there is no interference with the mental condition of the patient. The mind remains clear, the sensorium is free from any impairment. There may even be developed an inordinate susceptibility to pain, or other impressions, on the part of the patient. There is constant distress from the persistent spasm, which does not relax, although the twitchings, which are one of the chief sources of the acute pain, may be of intermittent character, and thus allow the patient short periods of comparative quiet, in which sleep may be obtained in short naps, interrupted by terrifying and recurrent night- mare, and followed on waking by a reappearance of the agonizing jactitation which constitutes the essential feat- ure of this distressing malady. In this state the patient passes a period of thirty-six to sixty hours, which leads up to, and is succeeded by, the period of extreme develop- ment of the* disease. The pulse now becomes even more rapid, often reaching 130 to 160, or even 180 per minute, and becomes thready and very weak. The respiration is accelerated, often reaching 38 to 40 per minute ; the tem- perature is elevated, sometimes registering 104° to 105.5° F. (40° to 40.8° C.), and all the symptoms of the case are greatly augmented in severity. The progress of the disease is now rapidly in the direc- tion of a fatal issue, and death most frequently occurs during a convulsion, from asphyxia, or arrest of the heart's action from sheer exhaustion. Tire temperature often continues to rise even after the death of the patient, and may reach the astonishing ele- vation of 42° to 43° C. (107.6° to 109.5° F.). The course of tetanus usually occupies, from the first invasion of the disease, or, at least, from the first appear- ance of definite symptoms, from three to five days, though the entire course of the malady, ending with the death of the patient, may be comprised within a few hours; but these more rapid forms of tetanus are frequent only in the warmer latitudes, or arc observed chiefly in children. Although the greater number of cases of tetanus which occur are uniformly and inevitably fatal, and belong to the acute form of the disease, yet there is undoubtedly a certain number of cases of chronic tetanus in which the progress of the disease and its termination may not follow the same course. After a period of about fifteen days following an injury of greater or less severity, the patient is sensible of light chills, he experiences, as in the acute form of the disease, certain dull aches or rapid and lan- cinating pains, which extend toward the trunk from the extremity. The jaw becomes fixed, swallowing gradu- ally becomes more painful, and already there are evi- dences of rigidity of the thoracic walls. The pulse stands at 80, the temperature at 37.5° C. (99.5° F.). Except as to severity of symptoms, the period of invasion of the chronic form of tetanus presents no variation from that of the acute form, either in the manner of its advent or in the period of incubation. After the disease has thus appeared, there is noticed a less degree of severity than in the acute form. There are considerable intervals in which the convulsive twitchings may be entirely absent, and the patient may obtain a cer- tain amount of refreshing sleep, turn himself in bed, or even sit up, with comparative comfort. The urine and 33 Tetanus. Tetanus, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. faeces may be at times naturally voided, and the patient may even enjoy periods of complete freedom from distress. The pulse may, however, reach 120, the temperature may be elevated to 38.5° C. (101.4° F.), and the respiration in- creased to 28 in the minute. In this condition the disease may persist for days, with relaxation of the more distressing symptoms, during which the patient may take aliment, and may even feel no distress in respiration. The attacks gradually become milder in character, and recur at longer intervals. The convulsions resemble in character and in the manner of their excitation those which are observed in cases of strychnia-poisoning, and are produced by the same or similar exciting causes, such as sudden movements, changes of temperature, etc., but are followed by longer and longer intervals of quiet, although the muscular groups may be in a state of moderate tonic contraction. The tetanic cramp then gradually disappears, either by cessation of the spasm or, as is more common, by the gradual lessening of the degree of muscular contraction, and by the diminution of the number of muscular groups which are affected ; with the subsequent disappearance of all indications of spasm of any kind, when the re- covery may be regarded as complete. There are often relapses of an alarming character, during the process of subsidence of tetanus, which may threaten the life of the patient by their severity, even when recovery is well ad- vanced. When death occurs in the course of chronic tetanus, it is due to the sudden change in the nature of the disease, to that of acute tetanus, to intercurrent diseases, or to other complicating conditions. Recovery from chronic tetanus is sometimes followed by tempo- rary or permanent consequences of more or less serious character ; such as distortion of the features, melancholia, abortion, haemorrhages of purpuric character, etc. Death from tetanus is usually by one of three forms : By asphyxia, by exhaustion, or by hyperpyrexia. Death from asphyxia may be brought about in one of two ways : Either by complications in the pulmonary tis- sues, or by mechanical closure of the respiratory passages from rigidity of the muscular structures, from oedema, or other effusions into the substance of the laryngeal structures. In the one case death occurs from incom- petence of the pulmonary organs, and would not be re- lieved by operative interference ; in the other, the open- ing of the trachea might possibly relieve the urgent symptoms of suffocation. Death from exhaustion occurs as a result of protracted and severe muscular rigidity, and particularly depends upon the frequency of the con- vulsive attacks. Death from hyperpyrexia is associated with an eleva- tion of the temperature to such a degree that the organic functions of the heart and lungs are impaired and finally cease. By means of experiments in the production of electrical tetanus, it has been observed that death occurs in the rabbit from asphyxia, as is the case also in death from rabies, unless artificial respiration is maintained. In this way, death from asphyxia with muscular con- traction is much more rapid than death from asphyxia caused by strangulation (Richet). This seems to be due to the fact that the contraction of muscular fibre depletes the blood of a certain and a very considerable amount of its oxygen. In the dog, on the contrary, the tetanic state induced by a current of electricity does not prevent respiration ; but the temperature rises rapidly, so that in a single hour it may have reached a degree of elevation which is incompatible with the continuance of life. The death of an animal from electrical tetanus is then due in these cases to the fatal elevation of the body tem- perature (hyperthermia). A dog in which the tempera- ture is artificially reduced, and maintained below the fatal limit, will endure the strongest electrical current for hours, without succumbing. Tetanus is sometimes observed as a sequence of the pu- erperal condition. This has been noticed to occur at a period as late as the second week after confinement, and is usually preceded by a previously normal convalescence, in which there has been absolutely no indication of any threatening condition. In this form of tetanus, there is the same elevation of temperature, the same acceleration of the pulse, and the same danger to the patient from pharyngeal spasm, which quickly follows the initial tris- mus, as in other cases of chronic tetanus, although it usually results in complete recovery. The tetanus of hot countries is met w ith only in com- paratively restricted territories, and is usually associated with local conditions, the nature of which has not yet been satisfactorily determined, but which are probably similar in character to the paludal influences which, in some other similar localities, are associated with the ap- pearance of malaria and other serious infective or parox- ysmal disorders. Etiology.-The etiology of tetanus, in a person who is the subject of a w ound in any part of the body, is usu- ally associated with the fact of chill and dampness. It has been abundantly proved that sudden and extensive changes in the temperature, between the day and the night, may be endured by the wounded without the risk of tetanus, if the air be dry and evaporation be rapid. A great degree of humidity of the air, however, when associated with sudden changes in the diurnal tempera- ture, and especially if the nocturnal temperature be rela- tively low, is a potent causative factor in the induction of tetanus. Through the influence of cold, or the wound- ing of some peripheral nerve, a reflex vascular irritation, with an excitation of the vaso-motor centre of the central nervous system, is produced, and extends to the regions of the motor centres, and through this channel develops reflex phenomena. The early care of surgical lesions is an important meas- ure in the prevention of tetanus in the wounded, and is of particularly increased efficacy if suitable antiseptic measures are promptly carried out. The injurious influences which might operate to the detriment of a recent wound are desiccation of the wounded surface, cold, filth, the infection of the wounded surface by the various lower forms of organic bacterial life ; and, particularly, the fact that in military practice the wounded after a conflict are often forced to remain for some hours or even days on the field of battle, and are exposed to all the vicissitudes of the climate, and to the other conditions of the locality. The nature of the wounds which are most usually fol- lowed by tetanus has assumed a tolerably definite char- acter ; and the nature of the wounding agent is also held to exert a powerful influence upon the occurrence of the disease. The region of the body in which the wound is situated is likewise thought to be concerned in the greater frequency of tetanus. The injuries caused by firearms, especially within the cavity of the larger articulations, particularly those of a ginglymoid character, are often fol- lowed by tetanus ; and the same is true in regard to the crushing of nerves, the comminution of the bones, the laceration of tendons, vessels, etc., and the great loss of substance occasioned by the impact of large projectiles. To these should be added the shock occasioned by the concussion of explosive projectiles, which often cause ex- tensive damage to tissues or organs, of which at the time of the injury no signs are apparent. In military surgery, the origin of tetanus is most frequently attributed to the large wounds occasioned by the direct injury of parts from the explosion of bombs, etc., in which large, irregular, lacerated wounds are produced, with shreds and frag- ments of contused tissue and burning of the surrounding flesh ; and their contamination by particles of the explod- ing body, and other foreign substances. It is now generally conceded that the conclusions of Rose are in the main correct, that tetanus may be pro- duced by any unusual impression upon the nervous sys- tem, be that influence of a mechanical, chemical, thermic, or pathological character. Tetanus, then, being an affection of the nervous sys- tem, it would appear reasonable that an original injury to nerve-structures might more easily induce it than other varieties of injury. The observations of Weir Mitchell are confirmatory of this theory, as he states that in the majority of cases of this affection there has been antecedent injury or irritation of the terminal rami- 34 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tetanus. Tetanus. fications of certain nerves. The seat of this irritation has been considered by Mitchell to be located in the ex- pansions of the nerve-filaments at the seat of their ter- mination in the nerve-plate upon the fibres of muscular tissue. The situation of the original injury has a great bearing upon the frequency of tetanus, and it is a notice- able fact that all authors have considered wounds located upon the hand or foot, less so upon the arm and leg, as peculiarly liable to be followed by tetanus. Most authors have also called attention to the fact that the presence of a foreign body in a wound, and particularly the contact of a foreign body with the substance of a wounded nerve, seems to be a specially predisposing cause of tetapus. There is no doubt that many cases of this dis- ease are observed in consequence of wounds of the ex- tremities in which there is laceration of these sensitive organs. This irritation may be due to any cause, even to the compression of a portion of a nerve by the liga- ture of an artery. This has been especially observed after castration, in which operation portions of the nervous supply are particularly liable to be included in the ligatures applied to the arteries of the part. The same thing has been observed in the operation of removal of the ovaries. For the same reason it is sup- posed that certain cases of tetanus are due to the impli- cation of the terminal nerve-filaments of a.part in the cicatrix of a healing wound, the tetanus being devel- oped only when the contraction of the cicatricial tissues began to exert injurious pressure upon the nerve-filaments entangled in its structure. Idiopathic or spontaneous tetanus is observed only in countries lying under or near the equatorial latitudes. In certain parts of these regions the disease is endemic, but much more generally it is epidemic or spontaneous in its character, and seems to be due to unknown local or regional causes, as it frequently is observed only on the sea-coast, or in low and unhealthy regions of the in- terior. It is also worthy of note that the colored popu- lations of these regions furnish by far the greater number of cases of this disease. In all those portions of the globe in which spontaneous tetanus is prevalent, it is associated with rapid and great changes in the diurnal temperature, and always with the existence of cold and dampness. The latter factor seems to be the determin- ing one in these cases. A curious fact is that which was first discovered by Professor Rose, that the brain of te- tanic patients is materially heavier than that of the aver- age of persons of the same age dying from other causes than tetanus. Two theories of the nature of tetanus have been ad- vanced and supported with much ingenuity by able men. One ascribes the disease to some irritation of the nerves of the periphery of the body, from which the irritation is transmitted to the central nervous system, and has there induced an augmented reflex excitability of the spinal cord ; while another theory reposes upon the belief that the symptoms of tetanus are produced by a general intoxi- cation of the system by a poison which may be introduced into the blood from without, through a wound of the surface ; or may be formed within or upon the body, and be introduced into the circulation by absorption through the uninjured surface. The action of each of these modes of supposed origin is the same, viz., to bring about an aug- mented excitability of the nervous centres located in the spinal cord, the first indications of which are observed in the domain of the fifth pair of nerves, and therefore signify that the earliest portion of the nervous system to be affected is that portion near the point of exit of this nerve, or in its immediate vicinity. From this situation the in- creased irritability rapidly descends to other portions of the cord, causing contraction of the muscles of the trunk and limbs, and by unceasing spasm quickly induces ex- haustion and a fatal issue. The thermic centres are also in- volved, the heat-regulating apparatus of the body is dis- turbed in its function, and elevation of the temperature ensues, which may rapidly reach the fatal thermic limit, and thus put an end to the life of the patient. Another recent theory in the causation of tetanus is the formation within the body of some substance of the character of a ptomaine, such as is known to occur in certain other con- ditions of disease, which may induce most serious symp- toms, which are in some cases of a convulsive nature, though most frequently the action of these poisons is of a profoundly depressing character. In a recent contribution to the Fortschritte der Medi- cin, Dr. A. Bonome describes a series of experimental studies in the Pathological Institute at Turin, in which certain of the victims of the earthquake at Bajardo, in whom, in consequence of lacerated wounds, tetanus had appeared, furnished the basis of the experiments. The lines of Bonome's investigations were similar, in the main, to those previously followed by Nicolaier, Hochsinger, Vanni, and Garri. These experiments were made inde- pendently of any knowledge of similar studies made in 1886 by Bosenbach. The material for inoculation was obtained from foul wounds of the soft parts, associated with fracture of bones and laceration of the tissues. The inoculation of mice, guinea-pigs, and rabbits with the secretions from these wounds was uniformly fol- low'ed by the appearance of tetanus in from twenty-four to fifty-two hours. The character of the invasion of tet- anus was variable within certain limits, according as the material injected was of great concentration, and also according to the location of the point of inoculation. A certain bristled bacillus was always found in the fluid and tissues of the part, in cases in which tetanus existed, and not in any others. The injection of material con- taining this organism into the tissues was uniformly fol- lowed by tetanus; its introduction into the blood was productive of no symptoms. Dried infective material preserved its virulency undiminished for four months, there being no appreciable difference whether the infec- tive material were derived from man or from one of the inoculated animals used in the experiment. The separa- tion of this bacterium from that of decomposition is ex- ceedingly difficult, as the conditions in which each is developed are similar, and exist in foul and infected wounds; and the culture of these germs is apparently affected by all the different methods of culture in the same way. The infection of the victims of the earthquake was thought to have occurred from the introduction into the wound of material from the wrecked edifices, and the inoculation of rabbits with small quantities of dust from the same source was followed by the appearance of tetanus in the animals. A horse was also injured, by be- ing crushed at the same time, and the existence of the same organism in him was proved by inoculation and propagation in rabbits. In the ram, castration was fol- lowed by the appearance of tetanus, in which animal also was demonstrated the existence of the same organism, the identity of which was proved by inoculation. The conclusions at which Bonome arrived are as follows: Tetanus belongs to the specific infective diseases, and it is probable that it is always associated with the presence and active existence of a fine bristled bacillus, which is found in the earth, and in the dust and debris of old and mouldy buildings. The presence of this organism in the exudations of an open wound is capable of inducing the various phenomena of traumatic tetanus. Tetanus, in the United States, most frequently follows lacerated and infected wounds of the extremities. Of late years it has very frequently been associated with the celebration of the day of national independence, and is caused by the wounding of the left hand from the pre- mature explosion of a cartridge in a toy firearm, by which the force of the explosion is directed toward the palm of the hand, and the paper and other material used as wad to close the end of the cartridge, together with any other foreign substances which may be associated with it, are projected into the flesh of the hand, most fre- quently without the fracture of any of the bones. The injury is, therefore, most commonly a simple lacerated wound, into which more or less septic material has pene- trated. The cases arising from this cause are almost al- ways fatal.* * In the Acad6mie des Sciences, session of October 23, 1887, M. Ver- neuil spoke of the different theories concerning tetanus as follows: The Dualist theory admits two methods of causation of tetanus: traumatism, 35 Tetanus. Tetanus, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Diagnosis.-The diagnosis of tetanus is, in most cases, not accompanied with any considerable amount of diffi- culty, as the symptoms are usually sufficiently distinct to be immediately recognized, and the progress of the case is so rapid that little doubt can long exist, even if the nature of the disease be at first somewhat obscure. The chief points of interest in the early recognition of tetanus are the advent of the disease without fever, by a tonic contraction of the muscles controlled by the fifth pair of nerves, with a tendency to the extension of the tonic spasm to other muscular groups, until the entire body, with the exception of limited portions of the ex- tremities, is in a state of constant and violent contraction. To this are added paroxysms of painful convulsion, which recur with increasing frequency, and are not followed by relaxation of the former tonic contraction. There is no disturbance of the intelligence, the patient may be able to sleep, is not delirious, and progresses slowly to a more and more profound state of exhaustion, until death oc- curs. Tetanus might be confounded with meningitis during its early stages, but this error in diagnosis could not long exist undetected. Meningitis is accompanied by rapid febrile action, pain in the back, and is not associated with the enormously augmented reflex excitability which dis- tinguishes tetanus. In tubercular meningitis there is usually rigidity of the cervical muscles, but the trismus is not a prominent symptom, and there are commonly delirium, retraction of the abdomen, and other classical symptoms of this affection -which do not belong to the phenomena of tetanus. Tetanus may sometimes resemble strychnine-poisoning, to a certain extent, but no one could be long in doubt as to the nature of the malady. The tetanic spasm which is caused by strychnine is first developed in the limbs,and only later is the musculature of the jaw affected. There is alternate contraction and relaxation, and the teeth are often suddenly closed upon the tongue, thus wounding that organ, while tetanus causes continual contraction of the jaw, and the teeth cannot be separated at any time. In strychnine-poisoning there is hyperaesthesia of the ret- ina, and objects appear to possess a greenish tint. Tetanus presents certain points of resemblance to ra- bies, but the two diseases are in their general characters so widely different that confusion could in no case long exist. Rabies is always communicated from without, there is generally the history of a sufficiently clear path- way of infection of the system, and the disease is most often distinctly referable to the bite of an animal of some class known to be susceptible to the rabic disease. (See Rabies, Vol. VI., page 130.) A wide difference exists in the behavior of the two diseases in the intervals between the convulsive attacks, the patient with rabies being able to open the mouth, speak freely, and go about, while the contraction of tetanus is not relaxed in those groups of muscles in which it has once occurred, and the mouth cannot be opened at all. It is hardly conceivable that any form of hysteria should be seriously confounded with tetanus, for the nature of the hysterical phenomena is in no way compa- rable with the tetanic spasm, and it is not followed by a similar extension of the symptoms to other and important domains of the muscular structures of the trunk and limbs. The great distinction in the diagnosis of tetanus from all other spasmodic diseases .lies in the existence of a wound, usually, or at least frequently, of lacerated or irregular character, and often accompanied by much bruising or other injury to the surrounding parts,with, not infrequently, the comminution or crushing of the bones as an accompanying condition. It is also a dis- ease, therefore, more frequently confined to military service, and belongs more exclusively to the class of accidents associated with modern warfare than to the occupations of peace, and the pursuit of the ordinary avocations of civil life. Tetanus presents certain points of resemblance to rheu- matism in some of its forms, particularly when this is located in the muscles of the neck ; but the progress of the disease leaves little room for doubt after the interval of a few hours. In rheumatism of the neck (torticollis), there is no attending permanent contraction of the mus- cles of the jaw. Tetanus is markedly a disease of youth and middle age. It appears in the vast majority of cases before the fiftieth year, and after this period is comparatively rare. In a case known to the writer, in which a gentleman, aged seventy, fell down a flight of steps, receiving a simple fracture of the right radius, tetanus appeared within seventy-two hours, and was fatal in about eigh- teen hours. The disease is far more common among men than among women, about eighty per cent, of cases, as tabulated by Mr. Poland, occurring among men, while only about twenty per cent, were in women. The tetanus which is observed in torrid countries is worthy of a short description. The severe character of the disease shows itself immediately the malady is devel- oped. The most trifling causes, the lightest form of trauma, the most trivial accident, are sufficient to occa- sion its onset, especially if with these is associated ex- posure to cold or dampness. The disease passes rapidly through its several stages, and often a few hours, or at most a day or two, are sufficient for its entire course and fatal termination. Poncet quotes the case of a negro who was wounded by a fragment of porcelain, and was dead in a quarter of an hour ; that of a child, who died of tetanus in three days after drinking a glass of cold water while in a state of perspiration ; and to these many other examples might easily be added. The diagnosis of tetanus, the progress of the malady in any of its forms, the duration of the disease, the fatal result, and all other essential characteristics of its course, have not been ma- terially modified since the days of Hippocrates, and the description of the disease given by this renowned observ- er is almost literally the same as is obtained from the study of the disease in our own time. Treatment.-The treatment of this desperate condition is of necessity limited to the accomplishment of certain measures of relief from its most distressing manifesta- tions. In the concise and well-expressed language of Poncet, "all measures of treatment should have for their object to diminish the augmented reflex activity of the spinal cord. Our endeavors should therefore be ad- dressed to all the paths by which nervous force is trans- mitted-to the point of original irritation, to the centrip- etal nervous tracts (conducteurs), to the nervous centres, to the centrifugal motor tracts," and, we may add, possi- bly to the muscular structures themselves, the organs to which the nervous influence is finally distributed, and which are thereby stimulated to dangerous activity. Treatment may be considered under the two headings of local and general measures for the relief of the patient. The local treatment may consist in any effort to modify the condition of the original wound, to act upon the ner- vous structures of the region, both sensitive and motor, or to totally remove and abolish the source of irritation by radical surgical or other measures. The measures belonging to general treatment may comprise the administration or exhibition of certain in- ternal remedies, by which we may hope to produce an amelioration of the tetanic condition from a direct action upon the central nervous organs by powerful therapeuti- cal methods. The local treatment comprises the various methods of which produces the surgical variety of tetanus, and that due to exposure to cold, which determines the form of tetanus termed "medical" or " spontaneous." Second, the theory of the " Unicists," which allows for tetanus but a single cause, the solution of continuity of the surface, either traumatic or pathological, internal or external. M. Verneuil has decided in favor of the Unicist theory, which gains great support from the recent assumption that all cases of tetanus are caused by, and origi- nate from, an external virus. This virus, which penetrates the organ- ism, determines the phenomena of the tetanic condition. This theory allows the explanation of certain cases of tetanus of so-called "sponta- neous" character, in patients who present no observable lesion of the sur- face of the skin or of the mucous membrane. It may be possible that the virus is sometimes absorbed by the mucous membrane of the respir- atory passages, or possibly through the skin under certain conditions, even when there exists no solution of continuity of the skin. In closing, M. Verneuil stated that it is sufficient to allow two varieties of tetanus, that from traumatism and that from absorption of the virus; but no case is admissible under the theory of spontaneous development. 36 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tetanus. Tetanus, dressing the wound, cauterization of the surface, various operations upon the nerves, and, as a last resort, the am- putation of the injured part. The general treatment should have for its object the reduction of the reflex activity of the spinal cord, with the lengthening of the intervals between the paroxysms, thus securing to the patient longer intervals of freedom from the convulsions by which the vigor of the system is so rapidly exhausted ; and allowing periods for sleep, and permitting efforts toward the nutrition of the pa- tient. It will be at once apparent that these efforts have a tendency to change the character of the disease from an acute to a chronic form, and with this change is al- ways associated a vastly more favorable prognosis. The result of acute tetanus is almost uniformly a fatal one, but cases of chronic tetanus not infrequently recover. In many ways chronic tetanus bears a close resem- blance to certain of the zymotic diseases, in that it seems to possess a quality of self-limitation, and to tend to re- covery independently of any active treatment. At the best, all modes of treatment are but palliative and symp- tomatic, and the disease progresses to its final termina- tion uninfluenced, except it be indirectly, by any known mode of medication. We may, it is true, alleviate the pain which is caused by the constant contraction of the groups of affected muscles, we may reduce the excita- bility of the nervous structures, both central and periph- eral, but this is only palliative in nature and transitory in character, and has no actual curative tendency. The treatment of the local lesions, that is, the seat of the original wound, is of primary importance, and should be directed toward removing all foreign substances from the recent wound, as also from the tissues about the le- sion, then to the restriction, as far as possible, of any in- terference with the parts, in the way of unnecessary ex- amination, by which the tissues may become infected with septic material or other matters from without. Three ways of treating the tetanic phenomena locally have been advised and practised. These are, cauteri- zation of the wounded surface, by either thermic or chemical means ; the stretching of the nerve-trunks of the part, or those leading to the body ; and the amputa- tion of the limb upon which the wound is situated. All these methods have been recommended, and all of them have been employed by competent surgeons ; but the lat- ter procedure has been generally abandoned, from the great degree of uncertainty with which its application has been accompanied, so far as its influence upon the development or progress of tetanus is concerned, and by reason of the hesitation with which a surgeon would proceed to remove one of the important members of the body without a fair prospect of benefit from the opera- tion. The application of the actual cautery has been followed in many reported cases by relief from the tet- anus, but in other cases the disease was not perceptibly affected by this heroic measure, and it is not now gener- ally advocated, although the possibility of annihilating the sensation of pain to the patient during the process of cauterization, by means of anaesthesia, which was not for- merly possible, has removed the most serious objection to the employment of this remedial measure. (See case reported in the Lancet, November 5, 1887, in which re- covery occurred in a case of tetanus following a wound of the toe, after the removal of all cicatricial tissue about the wound, and treatment by bromide of potash and chloral.) The operation of elongation, or stretching, of the nerve- trunks of the part, has been advocated, with the idea that the temporary disturbance of the normal function and natural activity of these organs might so modify the nervous transmission from the seat of the disease that the tetanus might be held in check, and at length sub- side without infecting or affecting the entire system. This operation has been performed many times, and a careful survey of the reported cases would seem to indi- cate that it is often of positive benefit in restraining the development of the more severe symptoms of tetanus; and in many cases the disease seems to have been im- mediately checked. The effect seems to be produced by the temporary introduction of a new and independent traumatic neuritis, of a different character from the affec- tion already existing in the nerve, at the point of original injury; the stretching of the nerve-filaments suspends for tlie time their conducting power, and there is motor or sensory paralysis, or both, in the area supplied by the stretched nerve. When this condition has been thus suddenly induced, it has often been observed that the rigid condition of the jaw, the trismus, was immediately dissipated, and recov- ery from all the symptoms of the disease soon followed. It is but fair to observe that in several cases the extrem- ity or part to which the nerve was directed has, after the operation of nerve-stretching, undergone atrophy, with permanent loss of sensation and of motion. In certain cases, also, the operation of stretching the nerve is not followed by the least benefit to the tetanus, and the patient experiences no relief from the violence of the spasm, but dies quite as quickly as if nothing had been done for his relief. Amputation has been found of no avail by Langenbeck, Dupuytren, etc. Electricity has more theoretical than practical grounds for applica- tion as yet. (See article by M. Rosenthal in " Real-En- cyclopadie der gesammten Heilkunde," for valuable ref- erences to literature.) In the way of general treatment, nothing is of more importance than that the patient with tetanus should be strictly isolated, that every possible source of irritation by which the convulsions might be induced should be eliminated, and, as the more important of all measures, that the patient should be prevented from making the slightest physical exertion or avoidable movement by which the exacerbations of spasm might be induced. The patient should be in the care of only one or two per- sons, and should not be molested for any purpose, if this can be avoided. The room should be somewhat dark- ened, and its temperature should be maintained at about 72° to 75° F. (22° to 24° C.), and absolute silence should be secured, as well as freedom from the excitement caused by the entrance of unnecessary persons. Gentle purga- tives may be required to overcome the inclination to- ward constipation ; the catheter may become necessary in some cases to relieve retention of urine ; but the greatest care and gentleness should be observed in all of these details of treatment. Chloral. This substance has the undoubted power to relieve the contractions of tetanus to a considerable ex- tent, and thus to secure for the patient suffering from this disease a great amelioration of his distress. The spasm may quite disappear, the patient sinks into a quiet and refreshing sleep, the jaws may be separated, and the patient may make certain voluntary movements without the occurrence of the spasm. This is a great gain to the comfort of the patient, but in many cases the symptoms are only temporarily relieved, not dissipated, and the disease goes on to a fatal termination, but without the suffering for the patient and his friends, that it would surely cause were no relief to be obtained from its sever- ity. In some cases the patient passes into a state of per- fect comfort, and sinks to sleep, from which he can be roused with some difficulty, until the stupor becomes more profound, and death takes place from failure of the heart. It is not known whether chloral acts by decomposition within the body, forming chloroform and formic acid, or whether it acts through its depressing influence upon all the organs of the body. The injection of chloral into the vascular channels of the limbs, particularly into the veins, has been performed, but the results have not been encouraging, as this drug causes coagulation of the blood, and several cases of sudden death have occurred after its use in the form of intravenous injection, in which the pulmonary arteries were occupied by firm thrombi, and the left ventricle was found filled with clots from the same cause. In more than one instance there have been serious ulcerations of the tissues where the injection has been made, from the destruction of the vitality of the parts, and consequent gangrene. Chloroform has been employed for its relaxing effect 37 Tetanus. Tetany. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. upon the muscular structures, and has the power of alle- viating spasm for a short period ; but the contraction always returns. The dangers from chloroform, from its depressing effect on the organs of circulation, are much more pronounced than are those from chloral, so that the treatment of tetanus by this agent, except for short peri- ods, has been abandoned. The course of the disease or its termination is not perceptibly modified by the use of chloroform. Alcohol, opium, tobacco, calabar bean, and many other agents have been employed to relieve the agonies of tetanus, but none of these seems to possess more than an occasional and accidental power for the re- lief of the spasm, and they often fail entirely. Curare has been thought to be of service by some ob- servers, but other equally competent practitioners have not been so fortunate in its employment. Bromide of potassium. This salt has been extensively employed in the treatment of all spasmodic affections, and its known effect in the reduction of reflex activity in the spinal cord, by diminution of the circulation in the central nervous structures, has led to its employment in the treatment of tetanus. It has been used in this disease with most encouraging results. The contractions be- come gradually less marked, and often disappear for a certain length of time, to return with diminished vio- lence, and at longer intervals. • The action of the bromides is favorably increased by the administration at the same time of a moderate amount of chloral, by which the seda- tive effect of its action "is obtained, without the depress- ing result caused by large amounts of this substance, taken for a considerable length of time. The dose neces- sary to produce a beneficial effect in cases of tetanus is often considerable, and frequent repetition is necessary in order to prolong the amelioration already obtained. The proportion in which these drugs should be combined may not be always the same, but a very useful ratio in many instances is that of double the amount of the bro- mides to that of chloral, to which a moderate quantity of morphine may be added with advantage. The dose of the mixture may be so graduated that the patient may obtain about one gramme (15 grains) of chloral and two (30 grains) of bromide, with about one centigramme (^ grain) of morphine. This amount may not be sufficient in many cases, but the combination is one which can be repeated with safety until it has effected its object, or until it has become evident that the case is not to be bene- fited by antispasmodic treatment. It must be acknowl- edged that no known form of treatment is capable of allaying the phenomena of acute tetanus in many cases, and that while certain cases are seen to recover under the administration of various remedies, it does not fol- low that the remedy has overcome the malady, or that it would relieve another patient suffering from the dis- ease. At the same time it is generally agreed that, at the present time, the best results are obtained from the use of chloral. It is also maintained that the character of the disease is a variable one, and that the severity of the symptoms is not constant or uniform, at all times nor in all cases, which fact should not be forgotten in esti- mating the benefit to be derived from any remedy. It is also well known that patients affected with tetanus, oc- casionally, though rarely, recover without respect to the treatment employed. Infantile Tetanus.-Tetanus Neonatorum, Tetanus Nascentium, Infantile Trismus ; This is a disease which has been variously considered by many authors, but there seems at present no doubt that it is really identical with tetanus of the adult in all essential respects, and that it is a variety of traumatic tetanus. Like tetanus of the adult, tetanus neonatorum is endemic in certain parts of the globe, and is chiefly confined to the latitudes under or near the equator. Like tetanus of the adult, it also shows a distinct predi- lection for the children of colored parentage, and makes frightful ravages among the infants born of the negroes in those regions. This disease seems to be produced by some unknown influence affecting the sanitary well-being of the inhabitants of the regions in which it is specially developed, and these infective influences seem to be of a miasmatic or fermentative character. In some of the colder countries, the disease is at times also developed in epidemic form, and rages with great severity. Thus, during the third decade of the present century, it ap- peared in Russia, in Sweden, and in other northern coun- tries, and raged with terrifying violence. It is stated by Poncet that the disease befell no less than sixty per cent, of the new-born of those districts at that time. The dis- ease appears usually within the first forty-eight hours, and frequently within the first day, and the initial symp- toms are referable to spasm of the pharyngeal muscles, with obstruction in swallowing. The breast is eagerly sought by the child, but no milk is swallowed, and the nipple is soon rejected with cries, the voice being of a lower pitch than usual, and the cry prolonged and low in quality. The facies of tetanus is soon developed ; the jaw becomes fixed, the cheeks are rigid, the features im- movable. The saliva flows from the mouth ; the ex- haustion becomes more marked, and the cries become less frequent, at length being heard only when the attack of spasm appears. The disease advances rapidly, the mus- cles of the neck, the back, and the extremities are soon affected, opisthotonos supervenes, high fever is devel- oped, which quickly reaches a dangerous degree of in- tensity, the temperature often reaching 41° to 43° C. (105° to 109.5° F.), the face becomes livid, there is no relaxa- tion of the spasm, the child writhes in agony, but the voice is now lost; the mouth is tightly and permanently closed, the disease rapidly exhausts the strength of the patient, and death soon ensues by asphyxia. In other cases the course of the disease may not be so rapid, but the child may live for four or five days, dying at length from exhaustion of the vital forces. In still other cases the disease may assume a chronic form, and with this change is always associated a vastly improved prospect of recovery. Cases of tetanus of the new-born in which the respiration is not embarrassed, the skin is cool, the face rosy, not livid, usually recover perfectly. The etiology of tetanus neonatorum is much clearer than that of the adult. It is thought to be due to chill, sudden changes of temperature, and other climatic phe- nomena, some of which are not yet well understood. The origin of the tetanus is thought to be in the healing surface of the umbilicus, and one of the most frequent exciting causes has been thought to be the exposure of the infant during the first week of life, by presentation in the church for the performance of certain religious rites, at a time when the umbilicus is still uncicatrized. Marion Sims advanced the theory that a partial disloca- tion of the occiput, by which the medulla oblongata is exposed to injury from pressure, may be the predisposing cause of many cases of tetanus neonatorum ; and he re- corded several cases in which relief from this condition was obtained by reposition of the occiput. The condi- tion of the umbilical cord, in many cases, is thought to have an exciting influence upon the development of teta- nus. It is often seen in children in whom the cord is in an unhealthy condition, is gangrenous, or otherwise the seat of septic changes, and is accompanied by foul and offensive suppuration. Tetanus is also not infrequently observed in cases in which there is nothing of this char- acter to be detected. Lack of proper care may also be the predisposing cause of tetanus in children not otherwise exposed or susceptible to the disease. The infection of the wound of the umbilical cord by septic organisms or by the specific virus of tetanus, if such virus exist, is also the immediate cause of tetanus in many cases in which the disease might not otherwise occur. The performance of the rite of circumcision among Hebrews is thought to have been the exciting cause of many cases of tetanus occurring in children of this race. There is no doubt that sanitary precautions, and the introduction of antiseptic measures into the care of the parturient woman and that of the new-born child, have operated to materially diminish the frequency of tetanus among new-born infants, as well as among the mothers.; which would seem to lend support to the theory that tet- anus is a disease depending upon invasion of the body by some external agent, much the same as occurs in 38 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tetanus. Tetany. erysipelas, anthrax, and other acute infectious diseases. This view has been adopted in part by Huettenbrenner, and seems to have much claim for consideration in the etiology of the disease. Certain authors have considered tetanus of the new- born to be due to uraemic poisoning, and that the expos- ure to cold furnishes only the occasion for the develop- ment of symptoms already existing in an unrecognized form in the patient. The temperature in tetanus neona- torum has been carefully observed by Monti and other practitioners, and has been found to be subject to many varying conditions; there is, however, elevation of the body-heat in most of the severe and fatal cases. O. Soltmann has advanced the theory that tetanus is due to an absence of the inhibitory processes in the thermic centres of the new-born, which are not in operation in the infantile organism as they are in that of the adult, and that therefore the disease is of reflex character, and is always accompanied by elevation of temperature and increased reflex excitability in an organism in which this function is notoriously augmented at all times. Diagnosis.-The diagnosis of tetanus neonatorum is usually not difficult. It is a disease of the earliest days of extra-uterine life, it is associated with the process of cicatrization of the umbilical cord, and it usually betrays itself before the ninth day. It is hardly to be confounded with tetany, which is usually connected with the period of dentition, and sometimes appears, or recurs, at the age of puberty. The characteristic features of tetanus in the new-born are hardly to be confounded with the symptoms of any other infantile disease, even when convulsions of other kinds may be present. There is hardly another conceiv- able condition in which the spasm is constant, commenc- ing in the jaw, and rapidly involving other muscular groups, without relaxation or intermission. It is a note- worthy fact, also, that other convulsive diseases are rare in the earliest days of infantile life. Prognosis.-The prognosis is best judged by the range and elevation of the temperature. The more moderate the degree of febrile action, the more favorable the chance of recovery (Monti). The existence of profound exhaustion, or serious complication by internal intercur- rent diseases, would naturally diminish the chance of re- covery. Treatment.-The treatment of tetanus neonatorum is in no way different in its aims from that of the disease in the adult; and, as in these patients, the best results have been obtained from antispasmodic remedies capable of reducing the activity of the reflex functions of the spinal cord. These are chiefly chloral, the bromides, eserine, curare, etc., which should be used in doses appropriate to the age of the patient, that is, in small doses frequently re- peated. Some of these remedies may be employed by means of immersion of the body of the patient, or by cat- aplasm, to which class, the popular remedy in some parts of America, tobacco, applied in the way of a hot fomen- tation of the leaves, and frequently renewed, belongs. The application of cold to the region of the cervical spine has also seemed to act, in some cases, as a sufficient sed- ative in reducing the reflex activity of the spinal cord ; but it must not be forgotten that in a certain number of cases, both in infants and in adults, recovery takes place under the most unexpected circumstances, and that these cases may possibly be instances of " spontaneous " cure of tetanus. One of the most serious complications in the treatment and care of tetanus neonatorum consists in the proper nourishment of the patient, which is often beset with great difficulties. The infant is often unable to take the breast, and the spasm of the throat is sufficient to prevent swallowing. The administration of food by the oesophageal catheter is, in these small patients, a procedure accompanied with danger and difficulty ; and many cases undoubtedly are lost from sheer inanition. With all our efforts, the best results in the treatment of tetanus neonatorum have accrued from hygienic rather than from medicinal measures. This is prophylactic rather than curative, but the result is no less important. The rapid advances in the department of bacterial pa- thology, and especially in the domain of epidemic dis- eases, is indicative of greater knowledge in the investiga- tion of the more obscure causes of infectious maladies; and we may reasonably hope to acquire the knowledge of the specific element of tetanus, and, with increase of wis- dom, may also obtain the means of limiting the distribu- tion and of ameliorating the character of this most fright- ful disease. The treatment of tetanus neonatorum comprises the most scrupulous care of the cord, the judicious manage- ment of the child, great attention to the ventilation and other hygienic surroundings, and proper clothing. The reposition of the occiput (Sims) has been thought to have some bearing on the relief of tetanus, but this is not fully accepted by authorities. All depressing or deplet- ing influences should be carefully avoided. The treat- ment is to be directed to the diminution of the increased reflex excitability of the central nervous system, and is best accomplished by chloral and extract of calabar bean. Monti has used this remedy in doses of one-tenth to one- fifth grain (0.005 to 0.01 gramme), to be repeated pro re nata, and he records a series of sixty-six per cent, of re- coveries. Chloral is given in doses of three to five grains (0.20 to 0.25 gramme). Welch reports the administration of three to four grammes (45 to 60 grains) of chloral in twenty-four hours, with the result of curing the patient. (See a very extensive review of the literature of the sub- ject of tetanus in the " Dictionnaire des Sciences Medi- cales.") Albert N. Blodgett. TETANY OR TETANILLA. The " little tetanus" is a disease characterized by attacks during which there occur tonic spasms of various groups of muscles, most frequently of those of the upper extremities. We shall see that, although the disease has a very distinct symptom- atology, it is often confounded with other diseases, and is so little known that no special mention is made of it in some of our largest treatises, that it is referred to inci- dentally only in Reynold's "System of Medicine," as a symptom associated with others of spinal irritation, and that in Pepper's "System" it is merely alluded to in the article on Tetanus.* History of our Knowledge of Tetany.-In 1830, Steinheim described this disease as a special form of ar- ticular rheumatism ; in the following year Dance pub- lished "Une Observation sur une Espece de Tetanos in- termittent," and in this article expressed the view that the intermittent character of the spasms proved the disease to be of the malarial order. In 1852 the entire subject was reviewed by Lucien Corvisart, and it was he who proposed the name tetany. Previously to Corvisart, the great Trousseau, as early as 1845, had observed this disease in nursing women, and supposed a connection between tetany and the function of lactation ; he there- fore termed it "contracture rhumatismale desnourrices," but, having observed the same trouble later on in children and adults after intestinal obstruction, he was forced to abandon his "nourrice" theory. It was Trousseau also who first discovered the very important fact that these attacks could be excited by compression of the arteries and nerve-trunks of the affected extremity. Many of these cases were regarded, in Germany par- ticularly, as cases of professional neuroses, professional spasms, until Kussmaul showed conclusively that there was a distinct difference between this affection and the ordinary professional neuroses. Riegel insisted on the causal relation between the disease and the presence of en- tozoa in the intestines. Erb and Chvostek examined the electrical behavior of the affected muscles, Chvostek di- recting particular attention to the increased mechanical excitability of the affected muscles and nerves. In 1874, Langhans published the first case of tetany in which a careful post-mortem examination had been made, and in 1881, the late Dr. Nathan Weiss, of Vienna, published * An excellent chapter on Tetany will be found in Gowers' Piseases of the Nervous System, which has appeared since the above was written. 39 Tetany. Texas. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. an excellent monograph on " Tetany " * (Volkmann's Vor- trage, No. 189), in which he described the disease most carefully, reviewed the entire literature of the subject, and showed an interesting connection between tetany and the surgical removal of goitre. Etiology.-The disease is most apt to occur in young persons; in children between the ages of four and six years ; then again at the age of puberty ; while the major- ity of cases of tetany are observed in persons between the ages of sixteen and thirty -five years, f Pregnancy, child- bed, and lactation appear to be predisposing causes. It is now well established that it is not one of the profes- sional neuroses. Persons who have been exposed to cold or wet seem particularly liable to attacks of tetany. Intestinal irritation is another cause ; stubborn constipa- tion or protracted diarrhoea has been followed by tetany. Riegel {Deutsch. Arch. f. kl. Med., Bd. xii.) instances a case in which attacks of tetany were inhibited by the removal of the ova of taenia mediocanellata and tricho- cephalus dispar ; and Weiss makes mention of a case in which tetany occurred as a complication of typhoid fe- ver ; the attacks of tetany disappeared as the typhoid (intestinal) symptoms subsided, and returned with a re- lapse of the intestinal symptoms. Tetany has also been observed in the wake of small-pox, Bright's disease, ma- laria, cholera, and in children during the period of den- tition. It has also been observed after severe mental shocks. The causal connection between extirpation of goitre and tetany, as proven by the cases of Weiss, was referred to above. And finally, it is to be noted that tetany occurs frequently as an epidemic, j and that it is of much more frequent occurrence in some countries than in others. The present writer observed a number of cases of tetany in Vienna, while he has not seen a single typical instance in this country, among a large number of neurological cases of every description. Symptomatology.-In describing the symptoms of the disease we must describe the symptoms noticed during the attack and during the period of latency. The attack is preceded by vague tingling pains, by for- mications in the hands, forearms, and legs ; these sensory symptoms are followed by a feeling of stiffness in the hands and legs, and soon after the spasms are fully de- veloped. These tonic spasms occur most frequently in the upper extremities, and give rise to such a marked rigidity of the muscles that passive movements are im- possible. The position of the hand varies according to the groups of muscles affected by the spasms, whether flexors or extensors. It is a common occurrence for the hand to assume the shape of the accoucheur's hand as it is ready to be introduced into the vagina. Occa- sionally also, the thumb is so firmly pressed upon by the flexed fingers that the nails are buried in the skin of the palm of the hand. In some rare cases there is complete extension of all fingers. As a rule, the forearms are flexed, the upper arms in adduction ; it is exceptional for the arms to be in abduction and removed from the trunk of the body. Mild cases of tetany are apt to consist only of a series of such attacks as have just been described ; and this is true even of the earlier stages of severe forms of tetany. In a large majority of cases, however, and particularly in the later stages of the disease, spasms are apt to affect other groups of muscles, viz., the muscles of the lower extremities, causing adduction of the thighs, with exten- sion of the hip- and knee-joints, and plantar flexion of the foot, the toes being bent forcibly toward the soles of the feet. The spasms may also affect the muscles of the ab- domen, chest, and back. The tonic contractions of the abdominal and thoracic muscles may interfere with the movements of the diaphragm and with respiration, caus- ing severe dyspnoea and universal cyanosis. If the mus- cles of the neck be involved additionally, the return of venous blood from the brain may be retarded, and Weiss reports one case in which loss of consciousness was the result. Opisthotonos is frequently the result of spasms affecting the muscles of the back. Trismus is occasion- ally observed, but never in the beginning as in tetanus. In other (severe) cases again, spasms have been observed of the ocular muscles, of the oesophagus, of the larynx (spasmus glottidis), and of the muscular apparatus of the bladder (desire to urinate, but micturition impos- sible). During the attack patients complain of severe pain in affected muscles ; there is, furthermore, marked diminu- tion of tactile sensibility in the extremities, the patients not being able to distinguish the character of objects placed upon the skin, and having the feeling, when stand- ing on the bare floor, as though they were walking bn velvet. In a few cases a rise of temperature to 104° F. has been observed ; Weiss observed a rise in one case only out of twelve. Headache, vertigo, tinnitus aurium, and excessive per- spiration, are other symptoms which are occasionally ob- served during an attack of tetany. The attacks may last only a few minutes, but may at times last for hours and even days. Severe attacks of tetany may bear a striking resemblance to genuine tetanus, but it may be noted that there is no initial spasm of the masseters in tetany, and that in this form the spasms spread from the periph- ery centripetally, and not centrifugally as is the case in tetanus ; and, furthermore, it is evident that the reflex excitability is not nearly as great in tetany as in tetanus. There is also this further distinguishing characteristic, that in cases of tetany the patient may be entirely free from attacks for hours, days, weeks, and even months. Symptoms of the Latent Period.-In the intervals be- tween the attacks, the patient may be entirely well, but some exhibit even at this time weakness, with rigidity of the affected muscles. The calf muscles are particularly apt to be the seat of slight tonic contractions. Weiss observed in one case, during the latent period of the dis- ease, tonic rigidity of the calf muscles, and fibrillary as well as fascicular contractions in the quadriceps cruris and vastus externus ; in another case Chvostek observed slight contractions of the orbicularis palpebrarum. The intervals between the attacks of tetany may vary in duration from several hours to a few days, and even a few months. Of course, we can speak of a latent interval in the course of the disease only in case the disease can be proven still to exist. This can be done by proving the presence of Trousseau's symptom, and of increased elec- trical and mechanical excitability. Trousseau's Symptom.-This symptom refers to the fact discovered by Trousseau, that in persons afflicted with tetany, a characteristic attack can be elicited by pressure upon the large nerve-trunks and arteries of the extremi- ties usually affected during an attack. The attacks cease as soon as the pressure is removed. Kussmaul and Quincke maintain that in some cases pressure on arteries only is necessary, while in other cases the slightest press- ure on a nerve-trunk is sufficient to produce contractions of all the muscles supplied by this nerve. Trousseau's symptom is present in no other convulsive disease. Increased electrical excitability is another symptom ob- served during the latent period. Erb, Chvostek, and Weiss showed that the motor nerves of the extremities and of the trunk, in cases of tetany, exhibited an increased response to both the faradic and galvanic currents. They could not only obtain K. C. C. (kathodal closure con- traction) with very small currents, but were able, with moderate currents, to obtain K. C. Tetanus, and even an An. O. Te. which had not been observed in any other condition ; while Chvostek reports having obtained a K. O. Te.-a condition unheard of in man. Erb failed to obtain these phenomena in the facial, but Chvostek and Weiss claim that they were as well able to obtain these phenomena with the facial as with any nerve of the ex- tremities. Erb found the electrical excitability greatest at a time when the attacks were most frequent, and it ♦ The present writer is greatly indebted to this monograph for many of the historical and other facts to be found in this article. He has made liberal use of Weiss' monograph, without in each instance acknowledging his indebtedness. + Gowers has tabulated 142 cases, and of these he found that 42 oc- curred from one to four years, and 36 from ten to nineteen years of age. t Cases of epidemic tetany have been reported as occurring in schools and prisons of France. 40 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tetany. Texas. was he who first ventured the suggestion that the in- creased electrical excitability might be used as a diagnos- tic test during the latent period of the disease. Increased mechanical excitability is another well-marked symptom ; a simple tap with a percussion hammer upon a nerve-trunk being sufficient to produce contractions of the muscles supplied by the nerve. The present writer remembers a case, in the Vienna General Hospital, in which pressure with a lead-pencil upon the focal point of the pes anserinus was followed by contractions similar to those which a strong faradic current applied to this point would have produced. Increased reflex excitability of the nerve must be taken as an explanation of this phe- nomenon. At all events this should be the first employed diagnostic test during the latent period of the disease, as it certainly is better to try this test than to attempt to ex- cite an attack by pressure upon a large nerve-trunk or a large artery. Pathological Anatomy.-In spite of the post-mortem examinations made by Langhans and Weiss, there is little or nothing known of the pathology of tetany. Langhans claimed to have found a periarteritis and periphlebitis of the blood-vessels of the white commissure, and of the an- terior horns in the cervical portion of the spinal cord. Weiss found nothing of the sort in his case. He has built up an ingenious theory of the disease, according to which he believes that the attacks of tetany are due to an irritable condition of the gray matter of the medulla and spinal cord, and that this irritable condition is due to sympathetic disturbances, causing irregularities in the vascular innervation of the blood-vessels of the spinal cord; but this is mere theory. A satisfactory explana- tion of the disease or of the attacks cannot be had.* Differential Diagnosis. -There can be no difficulty as to this. There is the mere possibility of confounding an attack of tetany with genuine tetanus. It is necessary to remember the distinctly centripetal character of the attack of tetany, the fact that the disease never begins with trismus, and, above all, the shortness of the attacks, and the existence of a latent period-all of which differs widely from real tetanus. During the latent period Trousseau's symptom, and the increased electrical and mechanical excitability, help to establish the diagnosis. Prognosis is favorable except in those few cases in which the spasms affecting the respiratory muscles might lead to serious lung trouble. Treatment.-In the way of treatment, it is necessary above all things to remove the active or predisposing cause, to change the patient's abode, to procure absolute rest for him, and if there is suspicion of intestinal irrita- tion, to look to this, to purge the bowels, and to remove entozoa that may happen to be present. During the attack, the physician will have to resort to the hypodermic use of morphine, possibly of hyos- cyamine. Applications of ice to the back of the neck helped to inhibit an attack in one of Weiss' cases. As soon as the attack is over it will be well to administer chloral hydrate in daily dose of 3 j.- 3 ij-; or the combined bromides in doses of 3 jss.- 3 ijss. pro die. During the intervals careful electrical treatment (stabile currents ascending from peripheral nerve-trunks), as well as me- thodical luke-warm baths, deserve a trial; but it is grati- fying to know that the majority of cases will get well without any treatment at all. By way of warning, we would suggest to the physician to do without counter-ir- ritation and the faradic current. B. Sachs. TEXAS, CLIMATE OF. The wide extent of this State, its peculiar location on the North American Con- tinent, and the physical aspects of its surface, give a great variety of climatic conditions. Its counterpart in all these respects cannot be found on the globe. To study its cli- mate to advantage a brief summary of some of the more important points of its physical relations is necessary. Geographically, it extends through eleven degrees of latitude and thirteen of longitude. But a better idea of its relations to the other portions of the country may be ob- tained by comparison with those sections embraced within similar geographical lines. From this it will be seen that it extends from a parallel very nearly coincident with the extreme southern portions of Florida to one touching the southern boundary of Virginia ; while east and west it is bounded by the meridians coincident with Sedalia, Mo., and Leadville, Col. Measured by statute miles on the thirtieth parallel, from its Louisiana border to the Rio Grande, the distance is about 668 miles, while measured on the parallel of El Paso the breadth is 750 miles. From the mouth of the Rio Grande to the northern boundary of the Panhandle, the distance is 695 miles ; and follow- ing the sinuous line of the Rio Grande from El Paso to the Gulf, the distance is about 1,200 miles. Its area, ac- cording to the State Land Office, is 267,072 square miles -quite equalling in extent the joint areas of South Caro- lina, Georgia, Alabama, Mississippi, Louisiana, and half of Tennessee. Its continental relations also have much influence on its climate. Situated on the northwestern border of the Gulf of Mexico, and midway between the Atlantic and Pacific Oceans, its western portions following the water- shed of the Rio Grande in the direction of the axis of the continent, the general slope of which is toward the sea- level of the tropics, it is in a position differing from all others and subject to agencies the most opposite in char- acter. This may be seen in the nature of its atmospheric perturbations, for w'hile its southern coast is not infre- quently devastated by tropical cyclones, its northern bor- ders are annually swept by the besom of arctic blizzards, often scarcely stopping in their course short of the equa- torial zone. The topography of the State is not especially peculiar. Its eastern and southern portions are but a few feet above tide-water level, but from this there is a gradual rise of the surface in a northwestern direction, until an altitude of 7,000 feet is attained in the Chinati Mountains. The intermediate country is made up of high, wide, rolling prairies and river bottoms, and not until we approach the western districts do we find the slight rocky upheavals, mostly in the form of successive terraces, which are seen to become more prominent as we proceed in the direction of El Paso, until they culminate in the Guadalupe and Chinati ranges. These physical conditions give a great variety to the flora of the State. The eastern border is heavily timbered with superb forest trees, among which are seen the oak, pecan, southern pine, and in the lower country, the cy- press and beautiful magnolia; but on the western border there are only the stunted mesquite and the forbidding cacti. Or if we proceed from the lower Gulf coast, where the sub-tropical flowers abound and the trees are shrouded by long festoons of gray moss from the topmost limbs to the ground, northward to the Llano Estacado, or treeless Staked plains, we find only the Spanish dagger or yucca representing tree life; while round about El Paso, save where the hand of man has intervened, absolute barren- ness prevails. In the intermediate regions are the prai- ries, covered bountifully with luxuriant grasses, and the streams bordered with excellent timber growths; these are lands on which every variety of cereal, of fruit, and of flower, common to the temperate latitudes, may be successfully cultivated. From the foregoing, and from a careful inspection of the tables following, the causes of these differences in the natural productions of the State will be readily under- stood. There are some things, however, that require spe- cial attention. There are not such differences in the mean temperatures of the northern and southern, or eastern and western, portions, as will explain the variations of vegeta- ble life in this State, or the differences between that which obtains in this State and that in those adjoining it. More- over, it is quite clear that these mean temperatures give but a slight insight into the peculiarities of the climate, and in some respects are very misleading. The extreme ranges, the suddenness of their occurrence, the differences between the means of the spring, summer, autumn, and * Gower, relying on cases in which a wasting of the mnscles has fol- lowed upon tetany, believes that the trouble starts in the motor cells of the spinal cord. 41 Texas. Texas. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. winter temperatures, together with concurrent meteoro- logical conditions which belong to each of these, must be studied in detail to obtain a correct view of the climates. Before entering upon these subjects more closely, how- ever, a hasty glance over the field is necessary. The highest temperature on record on the Gulf coast is 102° F. at Brownsville, and 100° at Indianola, while it has reached 113° at El Paso, and 111° at Fort Davis, although these stations are nearly 4,000 feet higher and several hundred miles farther north. In respect to the opposite extreme the differences are still greater.. The lowest temperature on record on the Gulf is 14° at Indianola, and 18° at Fort Brown and Galveston, while at El Paso it has been 5° below, and at Fort Davis zero, giving a mean difference of 18.5° between the northern and south- ern portions of the country for the lowest ranges, and one of 12° for the highest. The extreme annual ranges on the Gulf stations have been 80° for Galveston, 84° for Indianola. At El Paso the extreme annual range has been 118°, and at Fort Davis 111°. The rainfall and the mid-day relative humidity show still more strongly the climatic differences between the eastern and western districts, as well as those between the southern and northern. The annual rainfall of Galveston has averaged, during the period from the commencement of meteorological ob- servations to date, 52.30 inches, with an extreme rainfall of over five feet, but at El Paso the precipitation falls to an average of 13.14 inches, and some years it scarcely exceeds four inches. At Fort Davis the rainfall averages 20.38 inches. The degree of mid-day saturation is the condition most appreciable to the senses, and its effect on vegetation is equally marked, but in a different way. The contrasts in this respect are very great. At Galveston it averages 69.5 per cent., and about the same at the other Gulf sta- tions. At El Paso it is but 31.8 per cent., and at Fort Davis 35.5 per cent. Such differences in the degree of saturation during the busy hours of the day have an important bearing when considered in connection with the curative influences sought in a change of climate. The atmospheric movements are equally diverse. At Indianola, barely situated above the storm tides of the Gulf, there is an average hourly velocity of the wind of 12.9 miles, a rate exceeded by but eight stations in the United States, the chief of which are Mount Washing- ton, Pike's Peak, Cape Mendocino, and the stormy capes of the Atlantic. At San Antonio, 130 miles northwest, the rate is 4.9 miles, and the same at Fort Bliss or El Paso, than which there are but eight signal stations show- Table I.-Synopsis of Wind Movements in Texas, by Seasons, in Hourly Velocities and. Mean Direction. Gulf Coast. Southwest. Northwest. Central. EA8T- ERN. Place. 6 « j 5 o £ Antonio, roville Clark. Ringgold. o o I 1 i g 0) £ 3 M O tn O I .g ■5 '-5 " H $ t t t t t E S cu « - o O O 0 o 0 5 ft tn O fe fe Pm O Q Pt Winter 10.7 14.3 7.8 5.3 5 5 6.3 I 6.7 8.9 7.4 6.7 5.1 6.2 7.8 10.2 Spring 10.4 14.6 8.4 5.3 6.6 9.2 8.6 10.5 10.7 6.6 6.1 6.9 7.7 9.8 Summer 7.8 1 10.5 6.7 4.4 6.0 9 5 9.0 8.8 10.7 5.1 4.4 6.1 7.0 7.4 Autumn 10.2 12.3 5.2 4.7 4.4 6.2 6.2 7.9 8.2 5.1 4.0 5.4 6.4 8.5 Mean yearly average.... 9.8 12.9 7.0 4.9 5.5 8.5 7.6 9.0 9.2 5.9 4.9 6.2 7.2 8.9 Average for districts.... 9.9 .... । .... 6.6 7.2 6.7 8.9 Winter N. N. N. N. & N.W. N. & N. E. S. & S.W. N.W. N. & N.& N.E. & Spring S.E. E. N.E. S.E. N.W. S.E. S.E. E. S.E. & N.E. S.W. & N. & W. S. S.E. & S.W. W. N.W. N.W. S. & S. & S. N. & S. Summer &S.E. &S.W. S. 1 S. S.E. S.E. S.E. S.E. & S.E. S. S. S.E. S.W. W. & E. S.E. S.E. S. & s. Autumn &s. S. S. & N. N. E. N. S.E. & E. S.E. S. S.E. N.E. & N.W. & S.E. N.W. & .... s. N.W. 1 S.W. w. 1 S.E. ing less. An inspection of Table No. I. will show this great difference of the wind movements over this area. It is an interesting study. From the foregoing it is quite apparent that the climate of Texas is too diversified to be treated as a unit. In- deed, there is no unity in it. On the contrary, it embraces many important elements of difference which require separate consideration. To do this it is necessary to di- vide the State into districts in such a manner that each shall have a common relation throughout its extent, yet be distinctive from the others. Historians have been compelled to do this extensively, one making eight divi- sions. The United States Census for 1880 makes but three. Neither of these extremes will suit our purpose. The Census grouping is extremely faulty in this, that districts the most opposite in physical and climatic conditions are thrown together. It is necessary, how- ever, to make at least five districts, every one of which is distinctive in its geological and climatic peculiarities, its soil and natural productions-to say nothing of the all- important differences bearing upon human health. The first district, or Eastern Texas, includes the eastern timbered portions of the State, limited by a line running north from Houston through Palestine to the Red River. The second, or Gulf District, will embrace the Gulf coast for a distance of one hundred miles inland. The third district, designated as Southwest Texas, em- braces a triangular section bounded by the Gulf District on the south, by the Rio Grande as far north as the mouth of the Pecos, on the west, thence easterly to a point sixty miles east of San Antonio, near Seguin. The fourth district, or Northwest Texas, embraces all that portion of the State west of a line running from the mouth of the Pecos northward to the Red River, at its junction with the eastern line of the Panhandle. The fifth district, or Central Texas, includes the re- maining central portions of the State. The first district is comparatively level, with a gentle slope toward the Mississippi delta and the Mexican Gulf. Palestine, near the middle of the western boundary, is 533 feet above tide-water, and is probably about the highest portion of it. It is heavily timbered through- out-in the higher portions with oak, pecan, southern pine, and walnut; the overflowed tracts with cypress and cottonwood. Approaching the coast, the magnolia grandiflora is frequently seen. Nearly the whole of this section is subject to visitations of epidemic yellow fever, Palestine and some of the higher portions on the western boundary being the exceptions. It is this exemption that has been taken as a basis for drawing this and the coast line. The existence of its dense forests indicates the charac- ter of the climate. It is subject to heavy rains and over- whelming floods ; it has a high relative saturation of the atmosphere; its winds three-fourths of the time come from the Gulf, and for the other fourth from the north 42 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Texas. Texas. and northeast, with a mean velocity of 8.9 miles per hour. The tables relating to Palestine, which is the only signal station in this district, give a very correct idea of the climate of the better portion. That border- ing on the Gulf is essentially like the climate of Louisi- ana in the same latitude. Its mid-day saturation at Pal- estine, calculated for a period of five years, is 59.2 per cent.; being thus ten per cent, dryer at this hour of the day than the coast stations. Its yearly mean is seventy- three per cent.; in this differing from the coast-line but four per cent. Its mean temperature is set down at 65°. For the spring months the daily range is 18° ; for the summer, 19.8° ; for the autumn, 19.1° ; and for the win- ter, 20°. The mean annual range from the commence- ment of observations is from 98.2° to 6.5°, a difference of 91.7°. The rainfall at Palestine is 48.88 inches, which is about the average for the whole district; at Clarks- ville, on the Red River, it is 39.85 inches. As a winter resort this portion of the State is rarely sought. On the contrary, many of the better classes leave it for the more desirable winter climates of the cen- tral and western parts of the State. It will be seen from the foregoing that the climate is essentially a humid one, and better adapted to agricult- ure than as a health-resort. Cotton, corn, and fruits are grown with great success, and from this region fruits are abundantly supplied to the less favored western dis- tricts, so that the invalid there is always within reach of these comforts. The Gulf District presents a sea-coast line of about three hundred and seventy-five miles, on which there are but three stations-Galveston, Indianola, and Fort Brown, or Brownsville, as the Signal Service has it. The records are very complete and give a correct idea of the climate. It is essentially sub-tropical; hot, humid, and windy. This description does not, however, apply to Corpus Christi. The cold deep bottom currents of the Gulf come to the surface near this shore, and temper the heat of the air very greatly. The difference between this place and the remaining portion of the district, as regards climate, is indeed quite remarkable. As we re- cede from the coast-line these conditions rapidly change, so that at Fort Ringgold, one hundred miles distant, with an elevation of 230 feet, the ranges of the tempera- ture are excessive, the atmosphere is exceedingly dry, and the rainfall is but a moiety of that on the coast. This region is comparatively level, much of it consist- ing of low savannas and undulating prairies, with occa- sional dense forests near the Gulf, and open timbered lands farther back. Very little of it lies more than 400 feet above the sea. Sugar-cane and rice are cultivated along the coast with success, and in the higher portions cotton, corn, and other cereals, excepting wheat. The whole of it may be said to be liable to the ravages of epi- demic yellow fever, but exactly where the boundary line should be drawn is not yet determined. Undoubtedly, the dryness of the climate of some parts of the district exercises a great influence in fixing the line of exemp- tion nearer the Gulf. Quite certain it is that Austin and San Antonio are beyond it, for into both these cities cases have been introduced repeatedly without a single one arising therefrom. It has followed the Brazos and Colorado Rivers farther inland, however, and has pre- vailed severely at Navasota, Bryan, and Lagrange. This will probably be found the rule in respect to all the large river bottoms in the event of other epidemic visitations. The general trend of the Gulf coast has a marked in- fluence on the climate. Table II. presents the principal features of difference, but conveys an inadequate idea of some of the more important elements. What has been stated in regard to Fort Ringgold applies to the whole coast boundary with the exception of that portion north of Houston, at which the more humid Eastern joins the Gulf District. In view of the fact that the winds, during nine months or more of the year, are from the sea, and with a gradual rise in the surface of the ground, one would naturally expect a somewhat even distribution of the rainfall and degrees of saturation. Professor R. G. Forshey, of the Texas Military Institute, referring to this subject, says(" Baker's Texas Scrapbook," p. 503): " The wind comes from the Gulf loaded with vapor almost to saturation. At every degree farther inland it has less and less of the vapor, so that the vigor it imparts to vegeta- tion, even in the most obstinate droughts, within the first seventy miles, is greatly lessened, and at two and a half degrees it is nearly inappreciable." " This south wind is doubtless supplied along the border of the trades by the descent of the upper stratum of the reflex trades." As, however, the vapor referred to by Professor Forshey is not precipitated in the form of dews or showers on the lands traversed by the currents, it is difficult to explain from his standpoint the phenomena in question. It is rather due to a mixture with a hotter and dryer air. But this is not the place to enter into an elaborate discussion of the subject, and we stop with a mere statement of the fact. A most singular circumstance, however, presents itself in connection with Indianola, which lies in the middle of this region. It is more frequently the turning point of the cyclones, and has the heaviest winds, with a rainfall much less than Galveston and much more than Fort Brown. The Gulf division, away from the river bottoms, is gen- erally healthy. Malarial fevers are not unusually severe in the high lands, and with the mild character of the winter it gives comparative exemption from respiratory diseases, except directly on the border of the Gulf. For those seeking an opportunity to be in the open air, or wishing to engage in outdoor pursuits, it presents many advantages over any other district. Southwest Texas is still higher ; at Fort Clark the ele- vation is 1,136 feet above the sea, but much of the north- ern portion rises to a height of 2,000 feet. The whole district is well drained. The stations selected give an excellent idea of its climatic conditions. Fort Ringgold, at the southwest angle, Fort Clark near its northwestern, and San Antonio near its eastern angle, with Castroville more central, are so distributed as to embrace every im- portant feature of its meteorology. Taken as a whole, the climate is a moderately dry one in the eastern part, but decidedly so on the Rio Grande line, and the country is singularly exempt from exhalations from marshes and stagnant waters. The mean precipitation is 27.78 inches. The average for six stations on the Rio Grande, viz., Forts Ringgold, McIntosh, Duncan, Inge, Lincoln, and Clark, is 27 inches ; at San Antonio and Castroville, 31 inches. The mid-day saturation is 52.4 per cent. Its mean relative humidity is 67.7 per cent. In this respect there is a great uniformity throughout the stations, as an inspec- tion of Table II. will show. With the exception of narrow borders of timber along the streams, and, in a few instances, moderate tracts of post-oaks, the principal timber growth is mesquite, the greater portion of which has grown up within the last thirty years. Before it came under the domination of the white race it was annually burned over by the In- dians, which had the effect of destroying all the young timber growths of every kind ; but since the Indians left the mesquite has grown up rapidly, until in many parts it has attained a height of twenty or thirty feet; in fav- orable localities the growth is very dense. Among it, and scattered over the western portion very generally, the various forms of cacti are seen in large quantities ; that known popularly as the "prickly pear" (C. Tuna and G. Opuntid) being the most common. Up to within a few years this had been considered as of little value, except during the periods of extreme drought, when its juicy nature afforded starving cattle both food and drink. Lately it has been found to be a most nutritious article of food for cattle, and machines have been exten- sively introduced for the purpose of breaking off the spines and cutting it up to mix with other food for fattening purposes. This utility makes amends for the generally forbidding aspect it gives to the landscape, and modifies oui' first impressions of the sterility of the soil and climate. In the eastern part the rainfall is generally sufficient to give excellent crops. Winter sowing, how- ever, is required, and the harvesting must be done by the 43 Texas. Texas. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Mean Tempebatubes by Months. Cloudiness. Relative humid- ity. c 'S » District. Altitude a b c the sea, in fe Place. Observations. January. February'. March. April. May. June. July. August. September. October. November. December. Annual mean. * No. of fair days, in- cluding clear days. No. of cloudy days. Amount o f, in tenths. Mean annual r fall in inche Remarks. Normal 52.5 57.0 63 6 69 5 76 4 82.6 84.5 83.6 79 6 72 6 62 1 66 5 Gulf Coast ■ 20 Galveston Indianola Maximum .... Minimum .... Normal Maximum .... 60.0 63.3 69.0 47.4 51.6 58.4 52.4 57.5 64.7 59.3 64.4 70.4 75.fi 81.7 65.8 71.2 69.9 76.1 77.8 82.8 88.1 78.1 82.0 89.5 89.6 79.2 83.6 90.9 88.8 78.6 82.7 89.6 84.2 78.7 67.5 63.5 75.5 69.0 56.7 51.9 79.3 72.8 62.3 56.3 85.3 79.9 68.7 63.8 >78.4 >70.8 270.7 281.4 94.3 83.6 4.3 4.0 77.0 79.0 52.30 3S.72 Means of precipitation for 13 years; other observations for 12 years. Means for 12 years. Minimum .... Normal 48.8 50.1 57.8 64.9 70.0 57.7 61.8 68.7 74.4 79.0 76.2 82.8 77.4 84.1 76.6 82.9 73.6 67.7 55.6 50 1 79.6 75.2 65.7 60.6 88.6 83.8 74.0 70.2 72.4 68.8 57.0 52.8 .. .1 1 20 Fort Brown Mean for district.. Maximum .... Minimum .... 65.9 70.8 76.5 83.0 87.1 48.9 53.7 60.4 66.8 71.4 I I 90.8 75.5 91.9 76.8 91.9 74.8 ^■72.7 73.9 260.0 270.7 105 94 3 5.1 4 4 80.0 78 6 33.01 41.34 Means for 7 years. r 673 San Antonio -■ Normal Maximum .... Minimum .... Normal 51.8 55.7 63.3 70.1 75.5 61.6 67.7 72.5 81.5 85.8 41.8 45.8 52.2 60.0 65.7 42 6 53.5 62.2 67.8 75.2 81.9 94.1 72.9 85.3 82.9 94.0 73.7 82.1 82.1 92.7 71.8 78.6 77.5'70.0 58.6 53.9 87.8 80.0 67.5 64.3 68.3 59.6 47.2 43.4 75.5 63 6 47 2 54.8 287.0 78.0 4.6 71.0 32.31 Means for 6 years; means of pre- cipitatic.n 7 years. Southwest Texas.... 777 Castroville Maximum .... Minimum .... Normal b7.0 80 0 89 0 94.0 94.0 16.0 24.0 34.0 32.0 58.0 42 6 52.7 62.0 69.5 73.7 102.0 64.0 83.9 101.0 70.0 80.7 95.0 59.0 76.4 96.0 90.0 82.0,82.0 53.0 38 0 23.0 27.0 76.7 64 9 46 2 48.9 2.1 66.8 22.71 Means for 4 years. 1,136 Fort Clark J Maximum .... Minimum .... Normal 82.0 83.0 91.0 92.0 16.0 31.0 35.0 33.0 56.7 62.5 70.0 76.8 94 0 60.0 80.5 98.0 64.0 85.4 98.0 66.0 86.7 93.0 62.0 83.5 93.0 85.0 81.0 57.0 84.0 22.0 81.6 73 9 64 7 79.0 13.0 59.7 1 22 63.6 29.12 Means for 4 years. 290 Fort Ringgold Maximum Minimum .... 66.5 74.3 80.4 89.6 47.3 53.2 60.4 66.8 1... 1 92 4 70.6 98.6 74.5 100.3 76.1 97.6 74.5 92.8 84.8 71.7 66.1 73.9 55.5 70.1 51.1 >73.5 68 1 319.0 303.0 46.0 62.0 3.3 3 0 68.0 67.3 22.52 26.66 Means for 6 years. Central Texas • 445 640 767 Corsicana } Austin Denison J Normal Maximum . .. Minimum ... Normal Maximum .... Minimum .... Normal Maximum .... Minimum .... Normal 39.2 48.4 57.2 67.3 78.0 80.0 86.0 94.0 8 0 23.0 34.0 35.0 50.0 54.4,60.9 67.6 72.1 81.3 79.1 83.1 24.2 27.3 34.1 46.1 43.5 49.2 56.4 64.4 59.9 64.6 71.3 75.9 29.0 27.6 41.0 55.6 46 0 50.1 57.4 66.3 75.6 93.0 61.0 74.7 93.2 57.9 71.7 87.2 66.4 71.8 85.1 104.0 65.0 81.4 96.3 68.8 78.5 90.8 69.4 79.8 81.4 100.0 63.0 83.9 98.1 66 9 81.7 102.6 70.5 80.1 80.9 100.0 59.0 83.8 99.4 70.7 80.8 95.4 66.0 76.8 74.2 63.3 98.0 86.0 51.0 41.0 78.0 66.8 89.6 84.7 60.0 41.6 73.6 64.5 91.3 81.6 60.4 45.8 73.4 64.1 44.9 79.0 14.0 58.3 82.0 29.9 50.6 74.8 36.1 49.7 46.3 80.0 6.0 50.8 73.6 22.4 44.6 63.5 22.1 48.!) ^■63.8 <67.6 1-63.3 ) 2.0 66.8 67.8 39.38 35.78 41.44 Means of precipitation for last 5 years, 35.78 ; for 17 years, 33.93. Means of temperature, 8 years. . 1,217 1,243 FortMcKavett J Fort Griffin J Mean for district.. Maximum .... Minimum .... Normal Maximum .... Minimum .... 66 1 67.1 72.6 81.4 88.8 26.2 36.5 48.7 53.4 64.2 43 5 46.2 52.6 58.7 67.5 53.2 58.7 69.8 78.6 81.2 32.7 33.7 46.0 54.2 65.6 93.3 68.2 76.1 91.1 71.9 98.6 68.2 77.6 99.7 75.3 93.5 64.4 74.6 92.1 69.6 87.6 81.0 73.2 55.6 46.5 36.7 70.8 62.1149.0 M.6 78.1 62 2 64.6 53.5.40.5 66.8 29.3 45.1 53.2 31.2 <63.7 ■■68.6 65.4 ) 2 0 62,1 59.0 63.9 23.58 24.57 32.95 Means of temperature, 7 years; precipitation, 5 years. Means for 7 years. Normal 42.3 47 8 54.4 64.6 72.1 80.0 82.5 79.8 73 3 65.1151 2 45.5 Northwest Texas.... - 1.888 4,950 4,918 Fort Concho Fort Stockton Fort Davis Maximum .... Minimum ... Normal Maximum Minimum .... Normal Maximum .... 56.0 61.6 72.0 80.6 S6.0 31 7 36.8 44.4 50.3 59.1 43.0 48.7 56.7 64.0 71.7 56.7 63.8 71.1 79.8 86.3 29.2 34.8 43.1 49.2 57.0 43.2 48.3 54.3 60.7 68.1 55 3 61.9 67.4 75.0 82.8 94.6 69.6 79.0 94.6 65.9 74.9 91.9 96.6 70.6 80.6 94.4 68.0 75.5 89.9 94.3 68.6 78.0 90.9 65.5 71.7 85.6 86.3 77.3 62.8 55.5 71.9 63.4 84.0 76.6 59.4 51.6 67.2 GO .9 80.2 74.3 62.9 40.0 50.6 65.2 39.1 50.6 63.0 58.4 35.1 45.5 59.8 33.5 45.1 58.9 p.3.2 I /59.2 303.0 336.0 328.0 62.0 29.0 37.0 3.8 2.5 3.2 66.0 61.0 55 0 30.99 20.09 20.38 Means for ~ years. Means for 7 years. Means for 5 years. Means for 6 years. 3,956 Fort Bliss (El Paso)... - Mean for district Minimum .... Normal Maximum .... Minimum .... 29 1 34.0 40.1 45.7 52.9 44.5 50.3 56.7 63.1 71.9 57.3 63.3 71.2 81.0 89.9 30.2 36.0 42.4 46.9 55.9 62.1 80.6 100.3 65.1 63.8 82 0 99.3 67.6 60.9 78.9 95.0 65.5 55.4 48.0 72.5 63.6 87.6 78.2 58.5 48.6 1 37.5 51.0 65.0 36.3 32.6 46.3 59.7 32.0 ^63.4 62 1 330.0 325.0 35.0 40.0 3.2 3 1 49.0 56 0 13.14 21.15 Eastern Texas .. ... • ■ 533 Palestine J Normal Maximum .... Minimum .... Normal 42.0 51.9 59.2 65.6 51.3 61.2 69.3 75.6 32.9 43.0 50.1 57.0 42.2 50.8 60.5 71.4 70.3 80.0 62.0 78.8 78.6 89 0 70.2 88.3 81.5 92.3 72.9 85.5 79.8 91.0 71.2 85.1 75.6 67.0 >6 0 76.9 67.1 58.6 77.0 68.7 57.0 66.4 48.8 48.1 49.9 60.2 41.8 74.3 ^■64.8 J 287.0 78.0 4.2 71.0 47.56 Means for 5 years. 300 Clarksville J Maximum .... 71 0 79.0 81.0 9S.0 93.0 101.0 100.0 100.0 93.0 83.0 70.0 71.0 >67 0 70 0 39 85 Means for 2 years. Mean for district Minimum .... 15.0 25.0 34.0 33.0 1 1 69.0 73.0 66.0 64.0 56.0 44.0 19.0 10.0 65.9 287.0 78.0 4.2 70.5 41.85 * The mean annual here given is from the Signal Service records, and differs only in tenths of a degree from the sum of the normals divided by twelve. Table II.-Consolidated Table for a Period of Fire Years, or Lonejer, according to Reports, arranged by Districts. 44 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Texas. Texas. first of May, in order to give a reasonable expectation for a fair return. But if the seasons are favorable, three crops in one year may be grown on the same land. The soil is generally excellent. This district is beyond the ravages of epidemic yellow fever, yet the mildness of its climate has a very decidedly beneficial influence on the eruptive fevers and diseases of the kidneys. We shall refer to this subject again. The possibility of outdoor employment during the whole year makes this portion -better suited for those in delicate health, who wish to remain a length of time, and, as they say, " rough it," than any other portion of the State. Life on the ranches, though lonely for many, is novel and in- teresting, and often beneficial. But to derive the full benefit of this, persons must come here before they are so broken down that they are unable to endure the labor and exposure which that life imposes ; and they must be careful to select ranches supplied with pure spring or deep-well water. Water from the streams is never healthy. The impression prevails abroad that the summer tem- perature of this portion of the State is exceedingly op- pressive. Aside from the length of the summer season, this is a great mistake. The temperature in midsummer is frequently not as high, by several degrees, as in the Northwestern States, and the heat is so tempered by the winds that its intensity is greatly modified, so that it is not more often the subject of complaint than is that en- countered in higher latitudes. The nights are always cool and dry. From May to October there is rarely any dew, so that persons may sleep in the draughts, on their porches, verandahs, housetops, or under the trees, with perfect freedom from liability to take cold. Everyone seeks the draughts at night, when with a moderate cov- ering a delightful, refreshing rest is obtained. The writ- er has had every opportunity of judging of climates of various parts of the United States, ranging from Lake Superior to the Gulf, and from the Atlantic to the Pa- cific, and he avers without reservation that the summer nights of Southwestern Texas are more delightful than those of any interior region south of the great lakes. This will be more readily understood when we note the difference in temperatures of the night observations and the de\v point for the same hour. At San Antonio and Ringgold this difference exceeds ten degrees, and the same is true of the whole district. The sense of chilli- ness which comes from the saturated summer night atmosphere of the sea-coast and mountain stations is rarely, and we might say never, felt here, No wraps are required to shelter the invalid from a disagreeable sense of dampness while enjoying the beneficent night breezes of this region ; and further, this difference gives complete exemption from fogs in summer, and they rarely appear in winter. The length of the warm season becomes tiresome to many. It may be said that there are six months of summer, four months of spring, and two months of autumn, when the seasons are compared with those known in the North- ern States. Winter in this country is autumn elsewhere. Winter can hardly be said to commence here, however, before Christmas, and as a rule it ends by the last of February. The huisacht, a variety of the acacia, blooms then, and spring opens. The first wTeek in March the peach-blooms show their colors, and the primroses ap- pear. The cool weather, it will be seen, scarcely lasts sixty days. The December temperatures are mild, with an occasional rain in the nature of a wet " norther," as they are termed, followed by moderate frosts. These are not, usually, severe enough to kill the roses, honey- suckles, or verbenas, or seriously injure the garden vegetables. Lettuce and radishes are in the market to the first of January, and not infrequently throughout the winter. The mean temperature for the month is over 52°, the average hourly velocity of the wind is less than five miles, the skies are clear; there is a mean rainfall of two inches ; a mean relative humidity of seventy per cent, with an average dew point of 10.4° below the night tem- peratures. From the foregoing it will be seen that this month is a pleasant one, and well adapted by its moder- ate conditions for that daily exercise in the open air which invalids require. Between Christmas and the tenth of January the first shock of the winter comes. It is always ushered in by a norther;" and usually heralded by untimely warm, pleasant weather, or warm rains from the south. These warm days are ominous, and if people would properly heed them, much of the discomfort experienced by the sudden change would be prevented. There should be no mistaking their import. The records of the Signal Service show their constant relation, and careful observ- ers in this section have learned their value. These phe- nomena will be referred to again. The mean temperature for January is 51.8°, which, with an average maximum of 61.6° and a minimum of 41.6°, show's that the climate is not severe even forthose in very delicate health. At Fort Ringgold, the range is from a mean minimum of 47.3° to a maximum of 66.5°. The mean for Fort Clark is 50.8°, with a range of 45°. The month of February is still warmer ; and the " north- ers" diminish in frequency and are lessened in severity. The temperature during the storm rarely goes below freezing, and the second day after it rises to an agreeable point, so that persons may go about with few outer wrap- pings. The mean temperature rises to 55.7°, with a mean minimum of 45.9° and a mean maximum of 65.7°. The lowest temperature on record at San Antonio for Febru- ary is 28°, and the highest 88°. At Ringgold the lowest is 32°, and the highest 92°. At Fort Clark the lowest recorded temperature is 13°, and the highest 82°. The mean daily range for the months of January and Febru- ary at Fort Clark is 23.4°, for Ringgold 20.1°, and San Antonio 23.5°. So far as the spring and autumn seasons are concerned, it is needless to go into details. Their essential features are clearly shSwn in the tables. Both are all one could wish for comfort and pleasure. The Northwest District is essentially dry and much of it arid. These facts will appear from the tables. The country is sparsely settled. There are few places where invalids can obtain those comforts which they require. El Paso is the only town of any sanitary importance in that region, but Abilene and Colorado City, on the Texas Pacific Railroad, are thriving places, and may ultimately possess some attractions for invalids. As El Paso, how- ever, has attracted a good deal of attention as a sanitary resort, a few words respecting it are necessary. It is a most barren place. The surrounding hills and most of the plains are treeless and grassless. These natural aspects produce a very unpleasant impression on the mind of an invalid. Only where a system of irriga- tion has been instituted is there any appearance of ver- dure. Not even the cactus will grow in the barren soil, save in its most stunted forms. The general appearance of the city otherwise is agreeable. The dwellings and public buildings are built mostly of brick and are taste- ful in design. The dryness of the climate and the alti- tude make the city attractive for certain cases which, duly selected, may derive great benefit from the high alti- tude and pure air. It has some drawbacks in its winter sand storms, yet there is a freshness in the air, when one is not exposed to the direct heat of the sun, that makes it very agreeable at all seasons of the year. But it is a climate of great changes, especially in the winter. The " northers " strike this section first, and with all their force. The mean annual range is for December, from 32° to 59.7°; for January, from 30.2° to 57.3°; and for February, from 36° to 63.3°. The mean for the season is 41.1°. It is one of the dryest stations in the United States, the annual mean precipitation being but 13.14 inches. Some years the soil is scarcely moistened by a general shower. Its relative saturation is forty-eight per cent, and its dew point at the night observations for the year averages 23.8° below the temperature at that hour. Of course there is no dew nor fog. The sky is bright and nearly cloudless, the fair and clear days amounting to 346 in the year. An inspection of Table No. III., giving the difference for each month of the year between the night observations of temperature and dew . point, will 45 Texas. Texas. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Table III.-Comparing the Mean 11. p.m. Temperature with the Mean Dew-point at the Same Hour, Washington Mean Time. District. Place. Mean temperature, dew-point, and difference. ■ T January. February. March. April. May. June. July. August. September. October. November. December. Annual means. Mean of monthly difference. , Temperature.. 50.0 55.9 62.6 69.4 75.1 81.7 83.5 83.4 80.5 73.3 63.5 58.3 69.7 Galveston Dew-point.... 44.7 50.0 56.8 63.2 68.1 72.9 75.3 73.9 72.2 65.1 55.5 52.1 62.5 Difference .... 5 3 5.9 5.8 6.2 7.0 8.8 8.2 9.5 8.3 8.2 8.0 6.2 7.2 7.3 Temperature.. 47.3 54.4 62.6 69.2 75.2 79.8 80 9 81.0 78.9 72 9 60.7 56.5 68.5 Gulf Coast. ■< Indianola J Dew-point . . 42 9 49.5 58.1 63.8 68.4 73.7 75.5 74.6 73.1 66.5 54.5 51.6 62.0 Difference ... 4.4 4.9 4.5 5.4 6.8 6.1 5.4 6.4 5.8 6.4 6.2 4.9 6.5 6.1 Temperat ire.. 52.3 58.0 65.5 71.3 75.5 79 6 80.3 79.5 77.2 79.3 65.5 59.7 69.8 Fort Brown < Dew-point.... 47.5 54.4 62.2 66.9 71.4 74.3 75.5 77.8 73.7 69.0 61.3 55.9 65.6 I Difference .... 4.8 3.6 3.3 4.4 4.1 5.3 4.8 1.7 3.5 10.3 4.2 3.8 4.2 4.5 r Temperature.. 42.8 54.6 58.5 66.8 72.1 78.4 79.9 81.4 75.5 65.8 58.1 52.3 67.2 i San Antonio -j Dew-point.... 31.2 37.1 48.2 57.5 62.4 68.5 69.9 68.3 69.1 56.6 47.3 41.9 56.9 1 Difference .... 11.6 17.6 10.3 9.3 9.7 9.9 10.0 13.1 6.4 9.2 10.8 10.4 10.3 10.7 Temperature.. 51.1 59.9 66.6 73.9 75.4 82.5 83.7 81.5 80.1 73.0 65.3 59.1 71.0 Fort Ringgold.... ^ Dew-point.... 41.3 48.5 57.9 62.7 68.2 70.2 70.2 70.2 72.5 66.1 55.5 50.6 60.6 Difference ... 9.8 11.4 8.7 11.2 7.2 12.3 10.5 11.3 7.6 6.9 9.8 8.5 10.4 9.6 Temperature.. 86.6 43.8 53.2 60.6 66.7 76.9 80.0 79.7 70.4 63.6 50.9 42.1 60.9 Fort Concho Dew-point.... 29.3 34.4 43.2 48 0 58.4 65.7 63.1 61.7 61.1 56.9 44.6 35.7 49.6 Difference .... 7.3 9.4 10.0 12.6 6.3 11.2 16.9 18.0 6.3 6.7 6.3 6.4 11.3 9.8 Temperature.. 37.3 46.3 54.0 60.8 67.8 77.3 80.3 78.2 71.2 61.8 52.5 43.7 60.0 Fort Stockton Dew-point.... 25.7 32.9 40.4 43.8 56.7 66.3 65.1 61.9 62.4 52.6 42.6 33.9 48.6 Difference.... 11.6 13.4 13.6 17.0 11.1 11.0 15.2 16 3 8.8 9.2 9.9 9.8 11.4 12.2 Temperature.. 39.8 47.4 §5.6 57.5 64.3 72.3 74.0 71.3 67.2 59.3 51.5 45.7 58.5 Fort Davis J Dew-point.... 23.7 27.0 34.4 34.4 41.4 52.4 56.2 54.7 53.1 45.2 34.6 39.0 40.4 Difference.... 16.1 20.4 21.2 23.1 22.9 19.9 17.8 16.5 14.1 14.1 16.9 6.7 18.1 17.5 ( Temperature.. 41.3 50.2 55.7 61.2 70.3 79.3 81.5 78.9 71.7 60.8 50.9 49.6 62.4 Fort Bliss (El Paso) -< Dew-point.... 21.7 26.0 29.7 29.2 37.4 48.5 57.7 56.6 52.8 43.9 32.4 29.6 38.8 Difference.... 19.6 24.2 26.0 32.0 32.9 30.8 23.8 22.3 18.9 16.9 18.5 20.0 23.6 23.8 Temperature.. 40 o 49.1 57.7 64.9 69.5 77.0 80.0 79.2 75.0 64.8 53.2 49.3 64.5 Eastern Palestine 7 Dew-point 32.1 37.7 44.5 54.8 62.6 71.1 72.7 69.4 65.5 57.2 46.5 40.1 54.5 Difference .... 1 10.1 11.4 13.2 10.1 6.9 5.9 7.3 9.8 9.5 7.6 6.7 9.2 10.0 8.9 present some of its salient features more clearly in con- nection with other portions of Texas, an!! other health- resorts of the United States. Central Texas is the largest and most productive por- tion of the State. The stations selected to represent this division are Denison in the northeast, Fort Griffin and the several military posts in the northwest, Fort McKav- ett in the southwest, Austin in the south, and Corsicana in the southeast. These stations give a very correct idea of its meteorology. The temperatures and rainfall for Austin are taken from observations published in Dr. Baker's "Texas Scrap Book," and embrace a period of seventeen years ; while the climatic elements of the north- west section have been obtained from the records fur- nished by post surgeons stationed at Fort Worth, Phan- tom Hill, Griffin, and Richardson in years past, and from the Signal Service, since it was established. The whole of this district is probably above the yellow fever line. The altitude ranges from 600 to 2,000 feet above the sea, the higher portions being situated on the western border. It embraces the best agricultural lands in the State, is well drained, has no swamp lands or stag- nant waters within its boundaries, and is well settled and prosperous. In the western portions there are some large stock ranches, but the remainder is largely cut up into farms of moderate size, considerable portions of which are under tillage. Austin, the capital of the State, built on a series of hills overlooking the valley of the Colorado River, is quite a health-resort, and is a very picturesque and attractive city. The distance between it and San Antonio is eighty miles. The cities of Dallas, Fort Worth, and Waco are also enterprising places, and attract many winter visitors. We have already gone over the ground, in respect to the physical agencies affecting the climate of this State, to such an extent that it is not necessary to repeat them here. The differences are in degrees only. This divi- sion is not affected by the tropical cyclones like the Gulf coast, but it is raked by the "northers" pretty severely over the whole of it, but more especially in the north- western parts. The mean annual temperature, taking the averages for Forts Belknap, Worth, Phantom Hill, Graham, Croghan, and McKavett, all of which are in the northwestern and western portions, is 64.4° ; the average for the winter being 47°, and for the summer 80°. The Signal Service shows that at Graham the ex- treme winter temperature has fallen to -4° ; at Jacksbor- ough (Fort Richardson) to -2° ; and at Griffin to +4°. The annual mean is about 64.5°. Fort Elliot, in the Panhandle, should perhaps be men- tioned, but the location of that portion of the State being intermediate between the Indian Territory and New Mexico, can hardly be said properly to belong to the Texas system, therefore its consideration is omitted. Denison, Corsicana, and Austin give a better idea of the climatic conditions of those portions of Central Texas most thickly settled, and most desirable for winter resi- dences for invalids. The general aspect of the country is pleasing, it is pro- ductive, and of easy cultivation ; and for one seeking a home in a mild and "healthful climate, it offers advantages scarcely surpassed in the United States. Being well wa- tered, it is adapted to stock-raising and agriculture. The highest temperature at Austin, which has the longest record in the State, is 107°, and the lowest 6°. For ten of the seventeen years the thermometer did not reach 100°. The lowest temperature of 6° occurred but once, and in only one other instance did it go as low as 10°. The average maximum is 99°, and the average mini- mum 19°. The rainfall averages 33.93 inches, but as the country has become settled this has increased very per- ceptibly, as shown by the following record : For the five years ending December 31, 1857, the average was 29.61 inches ; for the same period ending December, 1863, it was 33.31 inches ; and for a like pericjd ending 1867, the precipitation was 35.75 inches. This steady increase has been ascribed to the timber growths, chiefly the mes- quite, which have sprung up since the settlement of the country, and since the annual burning of the prairies has been stopped. It is a fact of much significance, and suggests a means of rendering fruitful other sections of the country now comparatively barren. There is nothing especially interesting in the meteoro- logical surroundings of Corsicana and Denison that re- quires comment. We will now turn our attention briefly to the " north- ers," those Texas bugbears which have attained a noto- riety far beyond their deserts. They are essentially a thinning out of the blizzards of the Northwest. They are not so severe as many suppose, nor so overwhelming. 46 Texas. Texas. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, Table IV.-Showing Mean Mid-day Relative Humidity compared with Monthly Mean Relative Humidity. District. Place. 0 b s e rva- tions. January. February. March. April. May. June. July. August. September. October. November. December. Mean of 3 p.m. annual means. Mean of annual means. Galveston 1 Mid-day.. 78.8 74.3 70.3 70.2 67.5 64.6 64.5 64.5 68.2 67.1 71.0 74.2 69.5 ... ( Monthly.. 79.0 78.0 79.0 76.0 74.0 73.0 73.0 73.0 74.0 74.0 77.0 80.0 76.0 Gulf Coast. ■ Indianola Mid-day.. 76.3 72.8 70.1 69.2 69.2 64.0 64.6 65.0 69.5 67.5 70.8 74.0 69.4 Monthly.. 82.0 78.0 80.0 77.0 78.0 76.0 76.0 76.0 78.0 76.0 78.0 81.0 78.0 Fort Brown Mid-day. . (18.1 64.9 64.1 60.5 63.4 61.4 57.6 57.4 61.5 64.4 66.1 66.9 63.8 Monthly.. 79.0 79.0 80.0 76.0 77.0 74.0 73.0 75.0 78.0 78.0 78.0 80.0 78.0 Mean for district.... 1 Mid-day.. Monthly.. 74.4 80.0 70.6 78.3 68.1 79.6 66.6 76.3 66.7 76.6 63.3 74.3 62.2 74.0 62.3 74.6 66.4 76.6 66.3 76.0 69.3 74.3 71.7 80.3 67.3 76.7 San Antonio Mid-day.. 60.1 52.1 54.6 51.2 52.9 47.3 46.3 46.5 54.1 52.5 53.9 54.3 52.0 Monthly.. 72.0 68.0 67.0 75.0 70.0 69.0 64.0 67.0 70.0 69.0 68.0 70.0 69.1 Castroville J Mid day.. 46.5 43.0 33.1 44.4 51.(i 37.3 48.7 54.7 57.4 43.2 57 7 61.0 51.5 Southwest. - 1 Monthly.. 61.9 62.1 52.0 63.1 69.2 56.0 69.4 71.1 73.0 65.5 69.7 75.6 68.8 Fort Clark. Mid-day.. 56.2 44.0 30.8 44.9 56.6 38.9 53.5 60.9 58.9 48.0 62.9 67.2 56.1 Monthly.. 73.2 62.5 60.9 58.3 71.1 58.9 58.0 70.3 68.7 63.3 64.1 70.7 66.1 Fort Ringgold J ... -J Mid-day.. 63.0 55.0 62.0 45.0 58.0 40.0 37.0 38.0 57.0 52.0 52.0 47.0 50.6 Monthly.. 72.0 66.0 71.0 67.0 69.0 67.0 60.0 67.0 69.0 72.0 66.0 68.0 68.0 Mean for district.... ( Mid-day.. 56.4 48.5 45.1 46.3 54.7 40.8 46.3 50.0 56.8 48.9 56.6 59.8 54.4 Monthly.. 69.7 64. (i 62.7 65.8 69.8 62.7 62.8 68.8 70.1 67.4 66.9 71.0 67.7 Fort Concho 1 Mid-day.. 48.9 42.1 40.2 35.8 47.5 44.2 44.6 48.3 51.5 49.4 47.0 44.9 44.2 Monthly.. 57.0 53.0 52.0 48.0 59.0 57.0 54.0 55.0 62.0 (il.O 59.0 59 0 55.0 Fort Stockton J Mid-day.. 54.7 53.4 43.8 39.4 47.0 41.3 43.2 45.4 52.3 56.8 54.4 54.0 47.8 Northwest. ■ 1 Monthly.. 68.0 64 0 60.0 58.0 63.0 60.0 58.0 62.0 66.0 69.0 66.0 65.0 64.0 Fort Davis Mid-day.. 41.2 31.0 31.2 24.2 28.7 28.0 39.5 41.7 43.9 37.3 39.7 36.7 35.5 ... ( Monthly.. 57.0 49.0 48.0 40.0 J7.0 48.0 55.0 58.0 60.0 55.0 54.0 54.0 53.6 Fort Bliss Mid-day.. 37.1 30.6 24.4 16.6 17.9 18.1 29.7 34.6 34.9 34.4 35.4 36.6 31.8 Monthly.. 52.0 48.0 40.0 33.0 34.0 36.0 46.0 52.0 54.0 55.0 55.0 55.0 48.0 Mean for district ... Mid-day.. 45.5 39.0 34.9 29.0 37.0 32.9 39.2 42.5 45.2 44.4 44.1 43.0 39.8 Monthly.. 58.5 53.5 50.0 44.7 50.7 50.2 53.2 56.7 58.0 60.0 58.5 58.7 55.6 Corsicana Mid-day.. 56.3 54.3 41.9 40.7 54.3 39.0 56.3 44.3 47.1 58.8 56.8 57.9 54.9 Monthly.. 72.0 63.0 61.0 65.0 71.0 71.0 67.0 66.0 64.0 63.0 67.0 67.0 67.6 Denison Mid-day.. 67.1 63.6 51.0 48.7 60.8 49.4 55.4 49.5 55.8 50.1 60.9 58.7 55.2 Central....- Monthly.. 71.0 63.0 60.0 63 0 72.0 72.0 70.0 66.0 67.0 59.0 65.0 66.0 67.0 Fort McKavett J 1 Mid-day.. 59.4 49.9 41.1 38.8 53.3 38.3 42.6 47.3 52.8 60.2 57.4 54.9 48.6 Monthly.. 65.1 58.1 49.3 53.7 72.5 53.2 61.0 70.9 74.6 68.0 70.5 70.2 64.5 Fort Griffin Mid-day.. Monthly.. 54.5 63.1 45.5 61.3 24.8 44.0 33.8 48.6 53.3 68.1 24.5 42.9 50.2 66.3 40.6 61.2 49.8 67.4 41.3 62.0 53.0 65.7 51.8 60.4 46.2 58.8 Mean for district ... Mid-day.. 59.3 52.6 39.7 40.5 55.4 37.0 51.1 45.4 51.3 52.6 57.0 55.8 49.8 Monthly.. 65.3 61.3 53.5 56.0 70.9 59.5 66.0 66.0 68.3 63.0 67.0 65.9 63.5 Eastern .... Palestine Mid-day.. 63.1 58.8 52.1 59.7 60.2 60.4 56.0 52.9 53.2 56.6 55.8 55.6 59.2 Monthly.. 69.0 68.0 65.0 72.0 76.0 77.0 74.0 72.0 72.0 74.0 69.0 69.0 71.6 In the Northwestern States they are announced by the Signal Service as " cold waves," but, after passing the boundary of the Indian Territory, when their fierceness has been greatly subdued, they get the cognomen of "norther," and from which it is popularly supposed that they are of Texas origin. When these storms are pass- ing over the great plains of Nebraska and Colorado no one seems to be frightened, but on reaching the genial climate of this State they become the objects of dread. So far, however, is this from being justified that, while admitting the full force of their harshness, paradoxical as it may seem, we do not hesitate to say that they are the people's blessing. They bring down an abundant supply of fresh, cool, dry, stimulating air from the sub-arctic regions, the invigorating influence of which is felt by everyone. In no other portion of the Gulf States are the tonic influences of a change of air so pronounced. It is the suddenness of their onslaught that makes them ob- jectionable, but this being provided for, they cease to be harmful. The frequency of their occurrence was a subject of in- quiry by Professor Forshey. The result shows that dur- ing the winter seasons these perturbations occurred on an average at intervals of about seven days, or perhaps nearly with the quarterly changes of the moon. Accord- ing to that observer, their duration averaged 2.2 days. The writer's observations make the time scarcely to ex- ceed thirty-six hours, and frequently less than twenty- four hours. A moderately warm wave follows soon and the weather is settled for the time. Their impetus often carries them across the Gulf of Mexico to Yucatan. At Vera Cruz the writer has experienced nearly as much discomfort from one as he has felt in Southwestern Texas ; the cold saturated air being especially disagreeable. The visible evidence of an approaching norther is seen in a long, low, dark gray cloud skirting the northern ho- rizon ; this even while the wind is from the south. Soon it rises, rapidly spreading over the heavens, until the ze- nith is reached, when the draughts of cold air beneath sweep over the earth, carrying down the temperature from summer heat to 10° or 15° below the freezing point in a few hours. The suddenness of these changes, how- Summary Table.-Showing Average Number of Days in each Year in which the Temperature falls Below 32° F. and rises Above 90° F. Gulf Coast. Southwest Texas. Northwest Texas. Central Texas. - Eastern Texas. Galveston.2 Indianola.2 Fort Brown.2 San Antonio.1 Castroville.4 Fort Clark.4 Fort Ringgold.3 Fort Concho.2 Fort Stockton.2 Fort Davis.2 Fort Bliss.2 1 Corsicana.4 Denison.3 Fort McKavett.4 Fort Griffin.6 Palestine.3 co 1 Clarksville.* Below 32° Above 90° '5.4 32.3 8.0 58.6 3.6 99.0 14.4 89.0 15.0 145.0 17.5 132.0 6.0 162-5 38.8 ; 101.3 50.0 91.3 48.5 50.3 51.0 118.0 30.0 109.5 34.8 77.0 46.0 111.0 55.0 108.0 16.8 72.0 1 Mean for seven years. 2 Mean for six years. 3 Mean for five years. 4 Mean for three years. 6 Mean for two years. * No report obtainable as to number of days of extreme temperatures. 47 TtaUamus Opticus. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ever, is dependent on the velocity of the waves ; the slower often do not bring down the temperature to the lowest limit for a period of twenty-four hours. The low- est temperature observed at San Antonio is 6°, the mean for a series of years being 16°; from 12° to 17° is the more common range. After the first few northers have passed the temperatures are less extreme, the thermom- eter rarely going to 25°. The average annual number of days during which the thermometer has recorded a tem- perature below 32° for San Antonio is 14.4. Table II. shows the same for the other principal stations in the State. Their effect upon vegetation and animal life is thus described by the authority cited : " Northers are intense- ly dry, and soon drink up all the moisture on the surface of the earth and of the objects upon it capable of yielding their humidity. Great thirst of man and animals is ex- perienced, with many an itching of the skin, a highly electrical condition of the skin of horses and cats, a wilt- ing and withering of vegetation even when the tempera- ture would not account for it." The skin is harsh and rasping. He remarks that nervous, rheumatic, and gouty people suffer most. The writer can confirm his remarks in respect to nervous people, but not as to the others. " To invalids, suffering from other maladies it [the north- er] has not been found unhealthy, and for persons of weak lungs, if not too much exposed to its direct fury, it is found to be more salubrious than the humid south winds. Further, many such persons resort to this region and find relief." As a sanitary flushing of the country its influence is invaluable. The air following in its track constitutes one of the chief curative agencies in this de- lightful climate. It is a vigorous tonic, the like of which we have never seen elsewhere. We now turn more particularly to the influence of the climate of this State upon human health, in a broader sense. Our statistics on this subject can at present come from only one reliable source, that of the Army sur- geons. The uniform rules and methods followed by these officers give results which we can find nowhere else. A less satisfactory line of inquiry may be seen in the mortality statistics of the Census of 1880. We shall make use of both. The Army statistics cover a period of six years-the Census, of but one. Only those diseases for which invalids seek a change of climate, viz., respi- ratory disorders, consumption, rheumatism, and kidney diseases, will be inquired into. We have no reliable information pertaining to this subject from Eastern Texas, Galveston, or Indianola. The only post in the Gulf District is Fort Brown. The records for the other portions of the State are more com- plete. ' Respiratory disorders will include every form of ail- ment of this system, from the slight colds and catarrhs to pneumonias and pleurisy; and in respect to kidney diseases the term, as in the arrangement of the Surgeon- General's Report, will embrace all forms of idiopathic disease of these glands without attempting to draw fine diagnostic lines. The Census Bureau has employed two terms, " Bright's disease" and "disease of the kidneys," to cover the same ground, but with doubtful utility. The following table, which gives in condensed form Table Showing the Average Rate per 1,000, Mean Strength, at the Military Posts in Texas, of those Diseases for which a Change of Climate is Sought, Computed for a Period of Eight Years. Phthisis Respiratory disc Rheumatism . Diseases of the Jases. kidnec K • • bx 161 187 Fort Brown. Gulf bx 161 187 187 Mean. o cn j 10.6 98 52 2.7 San Antonio. co 72 67 0.5 Fort Clark. South g 52 99 Fort McIntosh. 4 an H * z c 81 98 1.2 Fort Ringgold. % o' 75.7 79.0 1.4 Mean. p K o co 05 -1 yx to Fort Concho. - 66 73 1 Fort Stockton. bx 173 86 1 Fort Davis. w K 3 w 126 105 Fort Bliss. EST TE co 125 133 133 Mean of 4 Subi>osts. an io 112.4 92.8 1.7 Mean. 303 200 200 Fort McKavett.* CO CO CO 50 5© O Fort Richardson.* OX 180 95 95 Fort Griffin.* > F g 88 1 162.7 78 ; 103.7 I 78 | 103.7 Austin.* Mean. M X a the relative salubrity of the respective districts of the State, has a wider significance when compared with the prevalence of the same diseases throughout the whole army, and which in a certain sense represents the coun- try at large. For the last three years the average annual rate of respiratory diseases for the whole army was 157.2 ; for rheumatism, 90.7 ; renal disorders, 2.1 ; and for pulmonary phthisis, 3.0 per 1,000 mean strength. In addition to the foregoing, it is proper to state that but three cases of sunstroke have been reported from the Texas posts during the last three years, embracing a command of nearly 2,500 men. Two are reported from Fort Clark and one from Fort McIntosh. It is of very uncommon occurrence in civil life. From the table it would appear that San Antonio is unfortunate in respect to the prevalence of phthisis pul- monalis, but this will be better understood when we state that the excess is due to its being made a health-resort for invalids suffering from that class of disease as well as from other pulmonary ailments. It will also be no- ticed that the stations where the respiratory and rheu- matic diseases prevail in excess are at the most opposite quarters, namely, Fort Brown in the southwest and Forts Bliss and Davis in the northwest. In all other re- spects the table explains itself. It shows that the south- western portions of the State are justly entitled to favor- able consideration as a health-resort, for those suffering not only from consumption and other respiratory ail- ments, but also from chronic rheumatism and renal dis- orders. In respect to the latter, the writer's experience in the army in this Department for a period of seven years is especially confirmatory ; and to it may be added the long experience of Lieutenant-Colonel Vollum, the present medical director of the Department. These re- marks find additional support in the statistical tables of the Census of 1880, in which it will be seen that the pro- portion of the death-rate from disease of the kidneys barely exceeds 4 per 1,000 of the total deaths-a rate less than one-fourth that of the Northern States. The climate is especially adapted to the raising of deli- cate children-those who require to be in the open air much of the day for their growth and healthy develop- ment. Those brought here from the North almost in- variably improve. The mild temperatures of the greater portions of the winter seasons, and the especially delightful spring and autumn weather, give opportunities for exercise in the open air unsurpassed elsewhere. Humoral, asthmatic, and catarrhal affections of the pulmonary system are benefited, but exactly how far nasal catarrhs improve here is an open question. Some are unquestionably bene- fited, but many are not, by reason of the dry and stimu- lating nature of the atmosphere. For these a residence on the Gulf coast is more desirable. The Gulf coast also affords inestimable advantages for those who require a soft, equable summer temperature and sea-bathing. The 48 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Opticus beach at Galveston is a very popular resort; the hotel accommodations are ample, and the hospitality of the citizens makes the stay of the invalid very enjoyable. The surf-bathing is unsurpassed at any resort on the Atlantic coast, and the soft breezes allow of the full in- dulgence of this exercise without risk in regard to colds. There is another important factor which should not be omitted, namely, the climatic influences on the results of severe injuries and surgical operations. The atmospheric conditions are essentially aseptic and antiseptic ; hence it is that severe injuries to the extremities, which in many localities require amputation to save life, here do well and make most excellent recoveries without a resort to such severe measures. For the same reason it is to be commended to those who are so unfortunate as to re- quire the more important surgical operations. The meas- ure of safety is greatly increased, and many questionable operations in other States become practicable certainties in this, with little trouble. References. Baker's Texas Scrap Book. Report of Superintendent of Blind Asylum at Austin. Thrall's History of Texas. Report of the Medical Hygiene of the Army, 1875, S. G. O. Army Meteorological Register, 1855, S. G. O. Reports of the Surgeon-General, United States Army, for 1884, 1885, and 1886. Report of the Medical Director of the Department of Texas for the years 1886 and 1887. Reports of Chief Signal Officer, United States Army, for 1877, 1878, 1880, 1881, 1882, 1883, 1884, 1885, and 1886. Mortality Statistics, United States Census, 1880. Morse K. Taylor. THALAMUS OPTICUS (Couche oplique ; SehhugeV). The optic thalamus is the name given to one of the large basal ganglia of the b^in. In anatomical and physio- through which fibres pass on their way from the cortex to the crura cerebri, pons, medulla oblongata, and spinal cord, but it is now well established that fibres origi- Fig. 3886.-Superior and Posterior Surfaces of the Lobus Caudicis (Stamm- lappen), of the Thalain-, Mes-, and Met-encephalon. (After Meynert.*) J., Island ; P., Occ., parietal and occipital divisions of the projection- systems from the cortex: Nc., caudate nucleus; St., stria cornea; Th., optic thalamus; Pulv., pulvinar ; Ge., external geniculate body; Tr., optic tract; Gi., internal geniculate body; V., third ventricle; Hb., habenula conarii ; con., conarium ; cp., posterior surface of the posterior commissure; Fr., frenulum ; ve., superior medullary velum; Bs., B., corpus bigeminum superius et inferius; brs., bri., brachium superius et inferius corporis quadrigemini; Ls., Li., lemniscus superi- or et inferior (upper and lower fillet); 5, locus coeruleus; J auditory nucleus; 7, 6, common nucleus of the sixth and seventh nerves; 8, ascending root of the eighth nerve (Engel); Br., brachium pontis; II., restiform body ; Pr., processus cerebelli ad cerebrum ; VIII., striae medullares nervi acustici transversal (auditory striae); 12, region of the hypoglossal nucleus; 10, ala cinerea, Arnold (nucleus of the vagus, Stilling); ob.. obex; cun., fasciculus cuneatus; Gr., fasciculus graci- lis; RL., tuberculum cinereum, Rolando; L., lateral column. nate in both these ganglionic bodies. This has long since been known with regard to the optic thalamus, and re- cently Edinger1 has established the same fact with refer ence to the corpus striatum. In order fully to understand the importance of the op- tic thalamus it will be well to describe, in due order, its anatomy, physiological functions, and pathology. Anatomy.-The optic thalami are developed from the lateral and posterior portions of the fore-brain vesicle. In the fully developed human brain they are ovoid bodies situated at the anterior end of the brain-axis, resting on the corresponding crura cerebri, which they appear to embrace. Each thalamus presents three free surfaces, and three surfaces that are contiguous with the surround- ing brain-substance (ride Figs. 3885 and 3886). The ex- act position of the thalamus can be appreciated best by opening the third ventricle from above, or by preparing such a specimen as is represented in Fig. 3886. The median free surface abuts almost vertically upon the third ventricle, is gray in appearance, and is joined to its fellow of the opposite side by a gray commissure (com- missure medias, mollis}, while it extends caudad as far as the posterior commissure (Fig. 3887). The superior sur- face has a whitish appearance, due to a layer of medullated fibres known as the stratum zonale. The surface presents several eminences, one anteriorly (the tuberculum ante- rius), a median elevation (the tuberculum medium), and a posterior tubercle (the pulvinar), beneath which lies the corpus yeniculatum externum (Ge., Fig. 3886). Through the midst of the superior free surface the sulcus choro- ideus passes, to which the tela choroidea is fastened. An- other set of white fibres (stria medullaris or taenia of the optic thalamus) forms the boundary line of this superior surface toward the ventricle, and separates the superior median surfaces. There remains at the posterior margin Fig. 3885.-Superior and Posterior Aspect of Brain-axis, and of the Cerebellum. (After Meynert.) J., Island; F., P., Occ., frontal, parie- tal, and occipital portions of the projection-system (radiating fibres from the cerebral mantle) ; Nc., caudate nucleus ; Str., stria cornea : L., linea nspera ; Ga., anterior commissure; Fx., descending crus of the fornix; V., third ventricle ; Cm., median commissure : Th., optic thalamus; Tb. a., its anterior tubercle; Tb. m., its median tubercle (elevation); Pulv., pulvinar ; con., conarium ; Bs., superior bigeminal body ; Bi., inferior bigeminal body ; brs., superior arm ; bri., inferior arm of the corpus quadrigeminum. logical importance it is second only to that other basal ganglion-the corpus striatum. The optic thalami and corpora striata are not only most important way-stations * This drawing reproduces the exact position of the CKsbntl trunk within the cranial cavity, taking into account the parietal flexure. 49 ■ 11 <11 dill 11 9 VpilVIl^a REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. of the median surface a triangular space, the trigonum habenulae, bounded by the sulcus habenulae and the sul- cus subpinealis. The outer surface of the thalamus is adjacent to the internal capsule and the caudate nucleus ; from the latter it is seoarated by the stria cornea (Fig. 3885). Macroscopically, it is evident enough that the optic thalamus consists of a mass of gray substance intersected by white fibres known as the lamina medullares externa. Within these external laminae medullares, the gray sub- stance of the thalamus can be divided into three tolerably distinct nuclei (Fig. 3888). These gray nuclei are not at every point completely isolated from one another, for the lines of demarcation are occasionally lost. If we exam- ine a section through the thalamus we find a white strand, the lamina medullaris interna, separating the inner from the outer nucleus. Anteriorly the lamina medullaris in- terna passes into a capsule radiating inward from the stratum zonale and bounding an anterior nucleus. The nucleus cinereus anterior seu superior (so designated by Burdach) is greatest within the area of the anterior tubercle; the fibres of Vicq d' Azyr's bundle spreading out in funnel-shaped fashion upon the ventral aspect of this nucleus. The nucleus cinereus extemus (Burdach) is separated by the lamina medulla interna from the inner nucleus except upon the dorsal aspect and near the entrance of Vicq d' Azyr's bundle, where the two nuclei become con- fluent. The outer nucleus is much larger than the inner one, extending ventro-latera of the anterior nucleus and passing back also into the substance of the pulvinar. The outer nucleus is of a brighter color than the inner one, this brighter color being due to transverse medullary fibres (radiating fibres of Meynert, radiations from the corona radiata) passing from the lamina medullaris ex- terna to the lamina medullaris interna. In the region of the pulvinar these transverse fibres must be regarded as the inner thalamic fibres of the optic tract, passing un- derneath the corp, geniculat. laterale, the outer thalamic fibres for the optic nerve coming from the stratum zonale Fig. 3887.-Horizontal Section through Human Brain. (After Edinger.) and passing over the corp, geniculat. laterale into the optic tract. Of the nucleus cinereus internut little need be said ; it has no transverse markings, and is continuous with the central gray substance and with the soft commissure, extending only a little beyond the latter anteriorly.* The histological character of the gray substance of the thala- mus deserves a passing notice. Examined under a high power the gray substance reveals a considerable number of large- sized, pigmented ganglion-cells of the spindle-shaped or pyra- midal order. The external geniculate body contains spin- dle-shaped cells lying in the direction of the radiations of the optic tract (Mendel). With the preceding descrip- tion of the thalamus the anat- omy of this ganglion is by no means exhausted. We have yet to consider the fibres con- necting the thalamus with the cortex and the periphery, re- spectively. A. Cortical Connecting Fibres. -1. The stilus anterior, a bun- dle of fibres coming from the frontal convolutions, passing * We do not consider it necessary in an article of this description to refer to Luy's description of the thalamus, nearly every detail of which has been amply disproved by Forel and Schnopf- hagen. Fig. 3888.-Horizontal Section through Human Brain. (After Mendel.) c, Claustrum ; g, corp, callos.; *4, nucleus caudatns ; ta, its lower end; m, lateral ventricle ; n, 3d ventricle : between in and n, foramen of Monro; nucl. cinereus ant. (of thalamus) ; pa, N. ciner. med.; p3, nucl. ciner. ext.; p4) N. cinereus post. (Between the nuclei, the laminae medullares are visible ; y, stratum reticulatum (of Arnold); a, tri- gonum habenulae; a, corp, quadrigemina ; /3, commiss. post.; brc, brachium conjunctivum anterius. 50 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. JJalZmus Opticas' iu the anterior division of the internal capsule between the caudate and lentiform nuclei, and entering the ante- rior portion of the thalamus (Fig. 3890). 2. The stilus medius radiates from the parietal lobe to the stratum zonale and to the external and internal gray nuclei of the thalamus. 3. The stilus posterior radiates from the occipital lobe, passing chiefly into the pulvinar (optic fibres of Gratiolet). but we can distinguish the fasciculus retroflexus (Mey- nert's bundle) arising in animals, according to v. Gudden, from the ganglion interpedunculare, and fibres into the lemniscus. The remaining fibres, chiefly from the lam- inae medullares, are gathered into a mass of fibres lying in the subthalamic region (Forel) and passing from there into the tegmentum of the crus. But how they reach the crus is not accurately known. Meynert's supposition that the posterior longitudinal fasciculus is mainly instrumental in effecting this union has not been sufficiently proved. Blood supply of the Thalamus. - The blood is carried to the thalamus mainly by small arteries which arise from the A. com- municans posterior, or the A. cerebri pos- terior. These smaller arteries, all of them being terminal, are named on the median surface: Aa., thalamica internee, ant. et post, (arteres optiques internes, Duret); on the dorsal surface : Aa., thalamica dorsales (arteres optiques ventriculaires, Duret); furthermore, the Aa. thalam. externge, arising out of the arch which the posterior cerebral artery forms around the crus cerebri. Physiology.-The true functions of the optic thalami are still a matter of debate, in spite of long-continued discussions and oft-repeated experiments. Renzi, Four- nier, and others claim that these ganglia have distinct sensory functions, and more than this the most recent studies of Schrader,2 a pupil of Goltz, have not been able to establish. Magendie, Longet, and their followers claim that destruction of the thalamus is followed by rotatory movements, inabil- ity to stand, ataxia, etc. Among recent authors, Bechte- rew3 has given a great deal of attention to this subject. From experiments on animals, Bechterew claims that the thalamus holds special relations to the expressions of emotion in animals. After removing the cerebral hemi- spheres in animals he found that these animals were not capable of voluntary or emotional expression ; but such expressions of emotion could be elicited in a reflex way by applying various irritants ; after the removal of the hemispheres and the optic thalami, expressions of emotion are lost entirely, and cannot be excited even as a reflex action. Bechterew observed, also, that irritation of the optic thalamus produced movements of those parts and muscles which subserve ordinarily the expression of emo- tion. If the author destroyed the optic thalami only, voluntary motion was not interfered with, but the animals were no longer able to give expression to their emotions. Bosenbach4 has furnished interesting clinical evidence pointing in the same direction, and Nothnagel had some years ago surmised as much from examination of a large number of clinical cases, inasmuch as he discovered that the thalamus and its corona radiata were unimpaired in those cases in which the voluntary innervation of the facial muscles was deficient, while they could be used perfectly in such reflex acts as laughing and crying. Pathology.-Our knowledge of the pathology of the thalamus is as imperfect as is our knowledge of its physio- logical functions. Focal lesions, limited to the thalamus, are very rare ; so rare, that Nothnagel had to exclude all but a few cases in the chapter on the optic thalami in his masterly treatise on the topical diagnosis of the brain. The symptoms frequently referred to lesions in the thala- mus may as well be ascribed to the close proximity of the thalamus to the internal capsule. Motor and sensory pa- ralysis cannot be accepted, therefore, as sufficient evidence of a thalamus lesion. Homonymous lateral hemianopsia follows frequently upon focal lesions in the thalamus, particularly if the pulvinar be involved in the lesion. Hemichorea, athetosis, and tremor of one-half of the body may be due to a lesion in the thalamus; the same is true of disturbances of the muscular sense. Meynert (" Psy- chiatry," p. 162) has published a very interesting case of tumor of the right optic thalamus ; the head of the five- Fig. 3889.-Frontal Section through Human Brain. (After Mendel.) g, Corp. Callos.; A, sept, pellucid.; k, nucl. caudat.: lv l3, divisions of lenticular nucleus ; e, internal capsule ; m, lateral ventricle; n, 3d ventricle; p„ nucl. cinereus ant. (of thalamus); p2, nucl. ciner. med.; p3, nucl. ciner. ext.; y, ansa lenticularis ; 6, Vicq d' Azyr's bundle ; e, corp, mammil- lare ; tj, stilus inferior (of Thal.), constituting, together with y, the substantia innominata; A, optic tract. The above three sets of fibres form a reticulated layer of fibres upon the outer side of the optic thalamus which is known as the stratum reticulatum of Arnold. 4. The stilus inferior (internus, Meynert) (r), Fig. 3889), contains radiating fibres from the temporal lobes and the island of Beil. Meynert insists that, in the region of the substantia innominata, this bundle is made up of two dis- tinct divisions, the lower fibres passing over the median surface of the thalamus upward to the stratum zonale, the upper fibres spreading out in the substance of the thala- mus. 5. Fibres of Vicq d' Azyr's bundle (Meynert's stilus superior), which enter the anterior nucleus, and which Meynert supposed constituted a direct connection between the fornix and the gyrus fornicatus ; but this is doubtful, Fig. 3890.-Ideal Section through Brain, showing Cortical Connections of Thalamus. (After Edinger.) for the corpus maminillare is interposed in the path of the fibres. B. Peripheral Connecting Fibres.-1. The thalamic fibres of the optic tract: a, from the substance of the pulvinar (the inner thalamic root); b, from the stratum zonale (the external thalamic root). 2. Fibres passing to the region of the tegmentum. These cannot be easily unravelled. 51 B IB 1 I ■ M O 11M t, I v-1 9* REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. year-old boy was turned to the left side ; while at rest, there were flexion of the left upper extremity and exten- sion of the right upper extremity. Meynert claims that the lack of sensations of innervation (muscular sense-im- pressions ?) created delusions with regard to the position of his extremities, in consequence of which he assumed the typical pathological, the so-called forced position. This theory of Meynert, though ingenious, is a trifle fanci- ful. Nothnagel stated, nine years ago, that the diagnosis of isolated lesions of the thalamus would be possible only under an unusually favorable combination of symptoms, and this is true at the present time. Literature. In the preparation of this article the following general works have been consulted: Wernicke: Gehirnkrankheiten. Henle : Nervenlehre. Schwalbe : Anatomic des Nervensystems. Meynert: Psychiatry. Translated by B. Sachs. Mendel: Article on the Brain in Eulenburg's Encyclopaedia. Edinger : Vorlesungen liber den Bau der nerv. Centrdorgane. Nothnagel: Topische Diagnostik der Gehirnkrankheiten. Herman's Physiologie. Ferrier : Functions of the Brain. Foster's Text-book of Physiology. Sacks. 1 On the Importance of the Corpus Striatum, etc., Journal of Nervous and Mental Diseases, 1887. 2 Schrader : Zur Physiologie des Froschgehirnes, Arch. f. d. ges. Phy- siologie, vol. xli., p. 15. 3 See Bosenbach's review, in the Neurol. Centralblatt, 1886, p. 371. 4 Bosenbach: Neurol. Centralbl., p. 241. THALLINE. The name thalline was given by Skraup, of Vienna, to a body prepared by him synthetically in 1884, of which body the sulphate and tartrate salts have recently been used in medicine. Sulphate of thalline, the commoner used salt, is in the form of a cream-colored powder, of a pleasant odor, resembling a perfume of some flower, and of a taste which, though at the outset biting and bitterish, leaves an aromatic flavor upon the palate. The salt dissolves freely enough in water, spar- ingly only in alcohol, and is insoluble in ether. Thalline is a fairly efficient antipyretic medicine, op- erating after the general manner of antipyrin and kair- ine, and holding rank about midway between those two agents. With efficient dosage a fall of from 2° to 4° F. can be procured within an hour or so after administration ; but very soon after the extreme of reduction is obtained the temperature begins to rise again, and quite rapidly, commonly regaining its original elevation in from two to four hours. This after-rise is quite frequently accom- panied by a chill, lasting from a few minutes to even an hour. Other symptoms commonly observed are a slight diminution in pulse-rate and respiration-rate, and a very considerable diaphoresis. Vomiting occasionally occurs, but collapse has not been reported, though the subjects may show some depression of strength and present a more or less cyanotic appearance when under the full in- fluence of the drug. Thalline may be detected in the urine within an hour and a half after administration, and its presence may give that secretion a characteristic darkish- green color. Experimentation upon animals has shown that the medicine, in sufficient dosage, is competent to cause arrest of the heart in diastole, to hasten coagulation of the blood, and to exercise a destructive influence on the haemoglobin of the red blood-corpuscles. Some consider that the autipyresis wrought by thalline is due to this action of the drug on luemoglobin (Brouardel and Loye). Thalline is used in medicine as an antipyretic, the dose of the sulphate ranging from 0.25 Gm. (four grains), given hourly, up to 1.00 Gm. (fifteen grains), to be re- peated in from two to three hours. So large a quantity as 7.33 Gm. (one hundred and ten grains) has been given in twenty four hours without inconvenience (Maragliano). Thalline sulphate may be administered in form of pill, wafer, or in aqueous solution, aromatized to taste. Edward Curtis. THALLIUM, POISONING BY. Thallium, a rare metal discovered by Crookes in 1861, derives its name from OaKKis, a green twig, in allusion to the single brilliant green line which is characteristic of its spectrum. It occupies a somewhat peculiar position among the metals. It forms a series of salts which resemble in many respects the cor- responding salts of the metals of the alkalies, such as potassium. On the other hand, it closely resembles lead not only as a metal, but also in forming a black, insoluble sulphide, and in the properties of its haloid salts. Our knowledge of the physiological action of the thal- lium salts is chiefly derived from a few experiments on animals, and is still far from complete. According to Paulet, one gram (15.5 grains) of the carbonate killed a rabbit in a few hours. Lamy, who in 1862 discovered the element independently of Crookes, and who first rec- ognized its metallic character, states that 4.86 grams (75 grains) were sufficient to kill two hens, six ducks, two puppies, and a medium-sized dog. Two of the puppies did not die till four days after they had taken the poison. Ninety-seven milligrams (1.5 grain) killed a puppy in forty hours. The prominent symptoms were dyspnoea, abdominal pains, salivation, convulsions, and paralysis. There were no noticeable post-mortem ap- ,pearances. ! Marine's experiments show that the more soluble salts are fatal to rabbits in doses of 0.04-0.06 gram (| to -ft grain) injected beneath the skin or into the veins ; and in doses of 0.5 gram (7.7 grains) administered by the mouth. They are fatal to dogs, administered through the same channels, in doses of 0.150 gram (2| grains) and 0.5-1 gram (7.7-15.5 grains), respectively. Ac- cording to Marnie, they are cumulative poisons. Their action is partly local, manifested by redness and swelling of the mucous membrane of the stomach and intestines, extravasations of blood, and an increase in the secretion of mucus; partly remote, manifested by pulmonary haemorrhages. They act upon the heart in somewhat the same manner that the salts of potassium do, but not to the same degree. They are absorbed quickly, and can be detected within a few minutes after their administra- tion, in the various fluids and tissues of the body. They are eliminated in great part with the urine, to some ex- tent with the bile. Elimination is slow, and frequently is not completed till after the lapse of three weeks. ' Rabuteau states that thallium produces symptoms similar to those produced by the salts of lead. His ex- periments were made with frogs, guinea-pigs, and dogs. Frogs were not affected by the salts of thallium. Thal- lious iodide, administered to guinea-pigs in doses of 0.05- 0.06 gram was fatal in two or three days. The same salt was administered to dogs in doses of 0.05 gram. During the first two days no symptoms were observed. On the third, there were anorexia, great muscular weakness, a weak and rapid pulse, bloody discharges from the intestines, and albuminuria. The salt was de- tected in the urine. According to Grandeau the thal- lious salts are as poisonous as the corresponding salts of lead. Practically, nothing is known concerning the action of the thallium salts on the human system. Crookes states that he swallowed 0.065-0.130 gram (1-2 grains) of thal- lium salt without any effect ; and that the vapor of the metal, to which he was much exposed, caused no injury. Pozzi and Courtade employed the iodide of thallium in doses of 0.010 gram (£ grain) daily, in a few cases of syphilis, in the place of mercurials, and with favorable results. They claim that it acts as an alterative. Pain in the stomach and vomiting are mentioned as occa- sional results. In a few of the cases the gums were pain- ful and swollen, and exhibited a blue line at their junc- tion with the teeth. William B. Hills. THAPSIA (Thapsie, Codex Med.). The root of Thap- sia garganica Linn.; Order, Umbellifera. This is one of four perennial plants constituting the genus, having com- pound pinnate leaves, nearly naked umbels, small yel- lowish-white (or purple) flowers, with inconspicuous ca- lices, dorsally compressed fruits with broad lateral wings, and acrid, purgative principles in their roots. The above species grows half a metre high, has numerous divisions to its leaves, a long, turnip-shaped root of gray exterior, 52 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Th a lam ns Opticus. Thermometers. and white fleshy substance. It is a native of the Medi- terranean coast of Africa and of the southeastern coun- tries of Europe. The root is either sliced and dried, or peeled and the gray bark dried in quills. This is an old drug which, after having fallen into disuse, has been re- vived again during the present century as a local irritant. Thapsia (formerly called False Turpeth Root) contains, besides sugar, gum, and other common derivatives, a brownish-yellow, or, if pure, yellow, resin in which its irritant quality resides. It is essentially an irritant; the dust made in handling it or grinding it reddens and even blisters the face, and causes violent sneezing ; internally it is a violent irritat- ing purgative. Preparation and Use.-Thapsia at present is em- ployed only as a rubefacient, like mustard, or as a blis- tering agent. For these purposes a resin is first made, and from this a plaster, simple or compound. Resin of Thapsia, according to the Codex, is prepared by first macerating the chopped bark in warm water, to extract the gum, sugar, and other soluble matters, then drying it, and exhausting it with warm alcohol. This tincture is finally evaporated in a still to recover the alcohol, and the resinous residue washed with water until clean, and evaporated to a soft-solid consistence. Thapsia Plaster {Sparadrap de Thapsia, Codex) consists of: Yellow wax 420 Gm. Resin 150 " Burgundy pitch 150 " Turpentine, boiled to a plaster-like con- sistency 150 " Venice (larch) turpentine 50 " Glycerine 50 " Resin of Thapsia 50 " melted together, strained, and spread on cloths. It is a rubefacient dressing. Allied Plants.-Carrots. See Anise. Allied Drugs. - Cantharis, Mustard, Croton Oil, Tartar Emetic, various spices ; also, Cashew Nuts and Poison Sumach. IK P. Bolles. THERMOMETERS, CLINICAL (bippt), heat; perpov, a measure). Definition.-Instruments for determining the tem- perature of the body in disease. History.-The ancients had no better means of esti- mating the temperature of bodies than that of observing the sensation of heat or of cold which they imparted to the hand. Hippocrates applied this method to the clin- ical investigation of diseases, and was fully sensible of the value of the information which he obtained by it, re- garding the temperature of the body as of the utmost im- portance in the diagnosis and prognosis of the acute dis- eases. The idea of the existing temperature which was ob- tained by placing the hand in contact with the body or diseased part, depending solely upon the acuteness of the observer's perception, could at best be only approximately correct, and must often have been wholly false. It is not surprising, therefore, that, with Galen and his fol- lowers. who attached so great importance to the charac- ter of the pulse, the temperature of the body gradually lost its significance, and later was almost wholly disre- garded. The first successful attempt to represent differences of temperature to the more accurate sense of sight has been attributed both to Drebbel, of Holland, and to Sanctorius, of Italy, living in the early part of the seventeenth century. The first instruments for this purpose, called weather- glasses, depended for their action upon the expansion of air under the influence of heat; they were, however, both rude and inaccurate. Their mechanism was less simple than that of modern thermometers. The open end of a glass tube, having a bulb at the opposite extremity, was im- mersed in a cup containing a colored liquid. This liquid was then caused to rise a suitable distance into the tube by applying suflicient heat to the bulb to displace a cor- responding quantity of air. Atmospheric thermometers of a much better pattern were afterward devised by Boyle and the academicians of Florence. In their man- ufacture a smaller tube with upright stem was used. The liquid was colored spirits of wine. After the spirits had been boiled to expel the air, the tube was hermet- ically sealed. A system of markings, or a scale, had next to be devised. The fixed points at first selected were the cold of snow or ice, and the greatest warmth known at Florence. A great deal of discussion arose, however, throughout Europe in regard to the most suitable fixed points upon which to base the scale, as well as upon the most suitable substance for use in the instrument. New- ton discovered that snow and ice melt at invariably the same temperature, and that the heat of boiling water is almost as constant. These points were then selected, and are still maintained, except that the temperature of the vapor arising from boiling water is taken as being more constant than that of the water itself. Deluc and Ro- mer are each credited with having demonstrated the even expansibility of mercury under the influence of heat within a wide range, and with having adopted it in the construction of their thermometers ; but to Fahrenheit is generally given the credit of having brought the mercu- rial thermometer into general favor. Sanctorius is said to have adapted the thermometer to the investigation of human temperature, but fully a cen- tury elapsed before any systematic use of the instrument for that purpose was recorded. Boerhaave, Van Swieten, and De Haen are the three names which appear most prominently in the literature of thermom- etry in the eighteenth century. But it required another hundred years to bring thermometry into favorable clinical use. There is hardly a better example of the apathy with which the medical profession of the time regarded the in- troduction of methods destined to become of inestimable value in the study and cure of dis- ease. The universal use of the clinical ther- mometer at the present time is due to the labors of a multitude of investigators and teachers, prominent among whom are Baerensprung, Traube, Wunderlich, Becquerel, Maurice, Ait- ken, and Seguin. Description.-The mercurial thermometer has been almost exclusively used for clinical purposes. It consists of an exhausted capillary glass tube of even bore, one end of which is expanded into a globular or cylindrical bulb containing mercury (Fig. 3891). Its action de- pends upon the great difference in the extent to which glass and mercury expand when exposed to the same degree of heat. The scale of the thermometer is generally en- graved on the stem and illuminated by a white or black stripe incorporated in the glass behind the mercurial column. Formerly the scale was printed on a strip of paper, wood, ivory, or other material, and attached to the stem, or en- closed with it in an incasing tube. A range of 10° C. (18° or 20° F.) is quite sufficient for the scale of a clinical thermometer. This should embrace from 35° to 45° C. (95° to 113° or 115° F.), limits which include the range of probable physiological and pathological temperatures. Even for the purpose of regulating the tem- perature of the bath this range is usually suffi- cient. The thermometer must be long enough to bear a legible scale (not less than three inches); for the sake of portability, however, it should not exceed five inches. The bulb or reservoir should be conical in form, from an eighth to a fifth of an inch in diameter, and formed of as thin glass as is com- patible with strength. Thermometers having rather long but narrow reservoirs, which become quickly heated (e.g., the "minute thermometer"), register more promptly than those whose bulbs are short and thick. Their great- est faults are the difficulty with which they are made to fit snugly into the axilla, and the ease with which they are broken (Fig. 3892). Fig. 3891. - Self- register- ing Clini- cal Ther- mometer. 53 Thermometers Thermometers REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. No advantage is gained by the adoption of a double reservoir, or by giving fantastical shapes to the single one ; on the contrary, much is lost of the simplicity which is necessary to secure perfect cleanli- ness in the use of the instrument. For convenience of use, thermometers are now generally made self-registering. This was first attained in the instruments used by Currie, in the early part of the present cen- tury, by means of a small piece of iron rest- ing upon the surface of the mercury. The expansion of the mercury caused this to rise, but its contraction did not draw it back. The register had to be restored by shaking, in the manner which is used to restore the index at the present time. The register which is now generally used is that known as the "inde- structible " index, secured by a constriction of the tube near the bulb so narrow as to prevent the passage of an unbroken column of mercury through it. The expansion of the fluid causes it to pass the constriction, but a greater force than that of gravity or of the cohesive power of mercury is required to draw the column back into the reservoir. The index must be "shaken down." This is best accomplished by grasping the upper end of the instrument between the thumb and fingers and giving it a short, sharp swing from the wrist or elbow. Instruments are still manufactured in which the index is a short column of mercury separated from the rest by a minute air-bubble. Their construc- tion is objectionable, however, because of the ease with which the index may be lost in the bulb, an accident which destroys the ac- curacy of the instrument. The reading of the register is greatly facil- itated by the so-called " lens-front," which consists of a conical form given to the face of the instrument, so that the column of mercury viewed through it appears greatly magnified. The avitreous (Immisch's) thermometer (Fig. 3893) is an instrument but recently intro- duced to the medical profession. While its action depends upon the same principle as does that of the mercurial thermometer just described, its construction is entirely differ- ent. In appearance it resembles a miniature watch, a little more than an inch in diameter, in gold or silver case, with heavy glass face. Its mechanism is simple and not likely to become deranged, and, in case of accident, may be repaired. It consists of a small metallic tube bent into a circular form, having one end fixed to a sup- port, the other free to move, but connected by a fine spring to a shaft which- carries a needle or dial-indicator. The tube is filled with a highly ex- pansive fluid, sensitive to the smallest elevation of temperature. In consequence of its expansion the tube uncoils, producing a corresponding vibration of the indicator. Upon cooling the tube curls and the indicator returns to its point of repose. The dial over which the indicator moves is graduated according to both the centigrade and Fahrenheit scales, and embraces a range of twenty degrees of the former (from 20° to 40° C.) and forty of the latter (from 70° to 110° F.). In the Fahrenheit scale, which is given the preference upon the instruments sold in this country, each degree is divided, from the seventieth to the ninetieth, into halves ; and from the ninetieth to the one hundred and tenth, into fifths. A device for " regis- tenng the temperatures has recently been added, in the form of a stop-catch passing through the stem, and so arranged that its withdrawal arrests the needle, while its return releases it. The case is impervious to liquids, and may be inserted into the mouth as well as into the axilla. The instrument appears to answrer the purposes of a clin- ical thermometer, except for insertion into the closed cavities, which are accessible to the mercurial instru- ment (rectum, vagina, etc.), and is in some respects preferable to those constructed wholly of glass. The chief points of excellence claimed for it, aside from the ingenuity displayed in its construction, are the especial suitability of its form for insertion into the axilla, and for use in practice among children, its freedom from breakage and from alteration by age, the ease with w hich it is read, and the automatic restoration of the index. The accuracy of the instrument is guaranteed by a cer- tificate from the Kew Observatory, England. In action this thermometer is slower than that of the mercurial thermometers now most in use ; for, in order to insure accuracy, the entire instrument must be raised to the temperature of the body. Tice surface thermometer is designed chiefly for determining differences in temperature of the surface of various regions of the body. The efforts which have heretofore been made to devise a reliable instrument for this pur- pose have generally culminated in the produc- tion of a modified form of the mercurial thermometer. The reservoir is usually given a flattened extremity (Fig. 3894), or is made into a coil, the object in either case being to expose as great an amount of the expansive medium as possible to the temperature of the surface to be investigated.. In using the in- strument the bulb must be carefully covered, in order that the result may not be altered by the temperature of the surrounding atmos- phere. It is claimed for the avitreous ther- mometer of Immisch that it is applicable to the investigation of surface temperature, and may be used with entire confidence. The re- sults obtained from surface thermometry have not generally been satisfactory. The metastatic thermometer is an instrument devised by Walferdin for the purpose of de- termining with great accuracy the fluctuations of temperature within certain narrow limits. It consists of a capillary tube of very small calibre, at either extremity of which is a rather small reservoir. At the junction of the up- per of these reservoirs with the tube there is a slight constriction. The quantity of mer- cury contained in the reservoir and tube must bear such relation to the capacity of both that an elevation of temperature amounting to three or four degrees, Celsius (from five to seven degrees, Fahrenheit), will cause the en- tire lumen of the tube and reservoirs to be filled. In order to prepare the instrument for use, it must be warmed to about the highest temperature that is anticipated in the investigation to be made. The column of mercury is then broken at the point of constriction by a quick tap on the instrument. The mercury in the tube rapidly falls, but is not followed by that in the upper reservoir. The instrument is now ready for use. For this purpose its lower bulb is inserted into one of the thermometric cavities, and permitted to remain a consid- erable length of time, while the fluctuations of tempera- ture, indicated by the rise and fall of the mercury in the tube, are carefully observed and recorded. The only ad- vantage possessed by the instrument is its great delicacy, depending upon the wide space allotted to each degree. Walferdin was able with it to detect variations of tem- perature amounting to but one two-hundredth of a de- gree, Celsius. The recognition of such minute variations of temperature, is, however, of no value. The thermo-electric apparatus has been used in clinical investigations. It was introduced into physiological ex- Fig. 3892.- The Minute Thermome- t e r. The column o f mercury ap- pears mag- nified by means of theso-called lens-front. Fig. 3894.- The Sur- face Ther- m o m eter of Seguin. Fig. 3893.-Immisch's Avit- reous Thermometer. (Ex- act size.) 54 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Thermometers. Thermometers. perimentation by Becquerel, especially for the purpose of determining the differences of temperature which ex- ist in different regions of the body. The apparatus was perfected by Dutrochet. Its action depends upon the physical law that when, in any metallic circuit composed of two or more different metals, the points of contact are exposed to a temperature different from that of the other parts of the circuit, an electric current is produced, which is readily recognized by the magnetic needle, and may be measured by a galvanometer. The thermo-electric pile constructed in conformity to this principle has been applied to the measurement of temperatures in physio- logical experiments on animals by Gavarret, Heidenhain, and others, and to the determination of human tempera- ture by Lombard and Hankel. Its action is both delicate and prompt. It can be applied to the investigation of internal temperatures by means of a properly constructed needle, composed of two or more elements brought into contact at its point. The instrument is not, unfortu- nately, suitable to general clinical use, on account of its inconvenient size, although an apparatus has been con- structed by Redard with especial reference to porta- bility. The Thermograph.-Instruments have been devised by Marcy and W. D. Bowkett for the purpose of automati- cally registering changes of temperature, by which con- tinuous observations can be made over a considerable period of time. To these the name thermograph has been applied. They have not, however, been much used for other than experimental purposes. Graduation of Thermometers.-Thermometers are graduated according to the scales of Celsius, Fahrenheit, and Reaumur. The Celsius, or centigrade, scale is used exclusively on the continent of Europe ; the Fahrenheit, almost as exclusively in the United States and Great Britain ; whereas that of Reaumur, at one time preferred in France and in some parts of Germany, is now retained only in Russia and Sweden. The relative position of fixed points in these scales is shown in the following table from Wunderlich : In the same manner the terms of the Reaumur scale may be converted into those of Fahrenheit by the for- mula : R X 2.25 + 32 = F; or. - R + 32 - F. 4 Consequently, to convert Fahrenheit into Reaumur : F -32 4 2.25 =R; or, (F-32) = R. To convert degrees of the Reaumur scale into their equivalent in the centigrade scale, it is only necessary to multiply them by 1.25. The following table of thermometric equivalents, within the range of physiological and pathological tem- peratures, will be found convenient for the rapid con- version of the terms of the centigrade scale into those of Fahrenheit, and vice versa : Cent. Fahr. 35 = 95 35.55 = H6 36 = 96.8 36.11 = 97 36.66 = 98 37 98.6 37.22 = 99 37.77 = 100 38 = 100.4 38.33 = 101 38.61 = 101.5 38.88 - 102 39 = 102.2 39.44 = 103 39.5 = 103.1 Cent. Fahr. 40 = 104 40.5 = 104.9 40.55 = 105 41 = 105.8 41.11 = 10G 41.66 = 107 42 = 107.6 42.32 = 108 42.77 = 109 43 = 109.4 43.33 - 110 43.88 = 111 44 = 111.2 44.5 = 112.1 45 = 113 The scale of the clinical thermometer should be made to represent not only the degrees, but also, by a series of short marks, the tenths of a degree on the centigrade scale, or the fifths on the Fahrenheit scale. The entire scale should, however, be sufficiently long to enable the eye readily to subdivide into halves the space between these fractional marks, thus permitting the observation of a variation amounting to a twentieth of a degree Cel- sius or a tenth of a degree Fahrenheit. The centigrade scale, based upon the decimal system of numeration, is now almost universally used in scien- tific observations, and its adoption by the medical pro- fession is recommended on the highest authority. The Fahrenheit scale, based as it is upon an error, has noth- ing to recommend it but usage. More important to the clinician than the kind of scale which is adopted is the use of a thermometer of known accuracy. It is not essential that the thermometer shall be precisely correct in its readings throughout the entire scale so long as the exact amount of error and its loca- tion are known, for the correction may then be made in reading the register. To insure this, a certificate may be obtained through the manufacturer, guaranteeing the accuracy of the instrument, or stating to what extent it is inaccurate. Unfortunately, mercurial thermometers do not retain their accuracy. Owing to the liability of glass to under- go molecular contraction, the bulb not infrequently be- comes reduced in size and thus causes the instrument to register erroneously high temperatures. In order to avoid this accident, the scale should not be engraved upon the stem until the instrument is one or two years old. It is advisable, also, that all thermometers be tested by comparison with a standard instrument at least once a year. Instruments are thus tested and certified for a small fee at the Yale Observatory in this country, and at the Kew Observatory in England. Application of the Thermometer.-The object to be attained in the use of the clinical thermometer is usu- ally to determine as nearly as possible the temperature of the interior of the body, the blood-heat. Several locali- ties are available for this purpose, on account of the nearly constant character of their temperature. These are, the axilla, the mouth, and the rectum. At times the condi- tions of disease render necessary the selection of other lo- calities, as the groin, the urethra (female), the vagina, or the closed hand, and it has been proposed to take the tem- perature of freshly voided urine. Each locality has its Celsius 0 25 50 100 Fahrenheit ....() 32 77 122 212 R6aumur 0 20 40 80 It will be observed that the higher fixed point of the three scales is the same, being the temperature of the va- por of boiling water. But the lower fixed point, the zero, of Celsius and Reaumur corresponds to the thirty- second degree of the Fahrenheit scale, representing the temperature of melting ice. Fahrenheit's zero was placed at the temperature produced by a mixture of ammonium chloride and snow, in the belief, as some suppose, that it represented the absence of all heat and consequently the greatest possible degree of cold. The subdivision of the scale between the fixed points is arbitrary ; hence we find that Celsius divided it into 100 parts, or degrees, Reaumur into 80, and Fahrenheit into 212. The conversion of the terms of either scale into those of the other is easy, if the relations between them be borne in mind. Since the null or zero of the centigrade scale corresponds to the thirty-second degree of Fahrenheit, 100° C. = 180° F., and 1° C. =1.8° F., or F. If, therefore, it is required to convert a given temperature expressed in terms of the C. scale (e.g., 40° C.), the number is first multiplied by 1.8. The product in the example is 72. To this 32 is added, in order that the degrees may be counted from the same fixed point. This gives us 104. Therefore, 104° F. = 40° C. If, therefore, C. represent a given temperature ex- pressed in the centigrade scale, the unknown equivalent of which in the Fahrenheit scale is F, the formula for finding the latter term is: 9 C X 1.8 4- 32 = F ; or, C + 32 = F. 5 Conversely, a temperature expressed in the scale of Fahrenheit may be converted into that of Celsius by means of the formula : F-32 5 = C; or -(F-32) = C. 55 Thermometers. Thermometers, REFERENCE HANDBOOK OF TIIE MEDICAL. SCIENCES. advantages and its disadvantages. The mouth is the most easily accessible of the cavities for the insertion of the mercurial thermometer. If it be selected, the bulb of the instrument should be placed under the tongue, and the lips closed on the stem. The mouth must remain closed during the entire observation. If oral respiration has been carried on previous to the introduction of the instrument, a minute or more should be allowed for the rise of the mercury beyond the time that would otherwise be given. In order to insure absolutely accurate observation, the thermometer should remain in the mouth at least five minutes. With most of the mercurial instruments that are now manufactured half this time is sufficient. Tak- ing the temperature in the mouth is in a measure incon- venient to the physician, because it prevents conversation with the patient, and is often objected to by the patient; to many it is repulsive. Obviously, it cannot be prac- tised on patients whose nasal passages are obstructed, or on those in delirium or coma, or upon children. In a majority of cases the axilla will best answer the purposes of thermometric investigation. The insertion of the thermometer here does not fatigue the patient, is in no way repulsive, and does not interfere with the further investigation of the case while the mercury is ris- ing. The arm-pit must be thoroughly dried, if moist, before the introduction of the thermometer. The instru- ment should then be inserted into the middle of the axilla in such a manner as to insure contact with the skin only. The cavity is then to be closed by pressing the arm firmly against the chest, the forearm being drawn slightly for- ward. It is advisable, when practicable, to use the ther- mometer in the axilla of the side upon which the patient has been lying. Liebermeister advises closure of the axilla for a short time before the introduction of the in- strument, and Wunderlich recommends warming the in- strument before insertion to nearly the temperature that is anticipated. From five to ten minutes are usually re- quired for an absolutely correct register of the axillary temperature, but a shorter time is generally sufficient for clinical purposes. It is often extremely difficult to ob- tain a correct reading of the axillary temperature with the mercurial thermometer in very emaciated patients. Attention must always be given to retaining the instru- ment in position in these cases, as well as in the case of patients who are restless, delirious, or comatose. Taking the temperature in the rectum is preferred by some authorities, as yielding the most trustworthy results, particularly in children ; by others it is objected to as re- pulsive and not altogether devoid of danger. The use of the urethra or vagina for this purpose is resorted to only under circumstances which render the use of other locali- ties objectionable, as in Asiatic cholera, a disease in which the temperature of the axilla has been found as much as 7° C. (12.6° F.) below that of the vagina ; the temperatures of the mouth and rectum are also unreliable. One thing is essential: Whatever locality is selected for the applica- tion of the thermometer, in an individual case, the same must be used for all subsequent observations. Thermometric observations should be made at stated intervals, the frequency of which must depend upon the character of the case and the object of the examination. In the commencement of a febrile disease it is often nec- essary, in order to arrive at a correct diagnosis of the con- dition, to take the temperature at frequent intervals, every half-hour, every hour, or every two hours; but regular morning and evening observations are, as a rule, suffi- cient for the requirements of treatment. These are best taken between 7 and 9 a.m., when the temperature is nor- mally lowest, and between 5 and 7 p.m., when it is high- est. If, however, the points of maximum and minimum temperature are found not to occur in these intervals, the times for using the thermometer must be made to conform to the peculiarities of the case. In addition to the periodical observations, the thermom- eter should be used upon the occurrence of any phenom- enal event during the progress of the disease, as after a rigor, a sweat, or psychical disturbances. The systematic observation of temperature-changes is essential to the intelligent treatment of almost every fe- brile disease. It entails an expenditure of time, however, which is rarely at the disposal of the general practitioner. Fortunately the use of the self-registering thermometer is so simple that any intelligent person may be intrusted with it; for it is not necessary that the assistant shall un- derstand the significance of the observations which he makes. The attendant of every febrile patient should therefore be provided with a reliable self-registering ther- mometer, with instruction how and when to use it in the absence of the physician. It is not enough that the temperature be regularly measured ; it must be regularly recorded on a chart pre- pared for that purpose. Every chart should bear the name of the patient, the diagnosis of his disease, the re- gion in which the temperature is taken, the date and time of day. Its value is enhanced if it have recorded upon it the rate of the pulse and respiration at each ther- mometric observation, the occurrence of critical evacua- tions, the alvine dejections and urine, the explanation of any anomaly of temperature or other feature of the disease. Such a chart is shown in Fig. 1167, Vol. ILL, p. 87. The Temperature in Health.-Unfortunately the results of thermometric observations taken in the several localities to which reference has been made are not uni- form, even in health ; for the temperature of the body is not the same in all parts, nor is the temperature of any one part the same at all times. In speaking of the body- temperature, therefore, whether physiological or patho- logical, reference is usually had to the temperature of but a single thermometric region, which region, accuracy of statement requires, should always be indicated in clin- ical reports. The temperature of the axilla in health averages about 36.89° C. (98.4° F.), as stated by Liebermeister, or 37° C. (98.6° F.), according to Wunderlich. It varies, however, between 36.40° C. and 37.77° C. (97.5° and 100" F.). Lan- dois states, as the average of five hundred observations, 36.49° C. (97.68° F.). The temperature of the mouth is from a fifth of a degree to a degree higher than that of the axilla. The last-named authority gives as the aver- age 37.19° C. (98.94° F.). The rectal and vaginal tem- peratures vary from 37° C. to 38° C. (98.6° F. to 100.4° F.). Thermometric observations in the closed hand are too variable for clinical purposes, as they are so liable to be altered by external conditions of heat and cold. Ro- mer places the variation which is liable to occur in this region at 6° C. (10.8° F.). The factors which are generally recognized as influ- encing the results of thermometric observations may be summarized thus: 1. The region in which the observa- tion is made ; the closed cavities are warmer than ex- posed parts, the trunk is warmer than the limbs. 2. The temperature is higher, according to most authorities, in the extremes of life than in middle age. 3. The tak- ing of a full meal causes a slight temporary depression of the temperature ; digestion elevates it. Certain arti- cles of food and drink exert a greater or less influence upon the temperature. Fasting lowers it. Alcohol pro- duces a prompt but transitory depression, after which the temperature again rises to about the normal. 4. Physi- cal exercise short of fatigue causes a slight rise of tem- perature, whereas mental exertion is said to depress it. 5. The body is coolest in the morning, gradually becom- ing warmer until evening, reaching the maximum, as a rule, between five and seven o'clock. A gradual decline to the morning minimum occurs during the night. This daily fluctuation ordinarily amounts to a little more than 0.5° C. (1° F.). 6. Climate exerts very little influence upon the human temperature. Prolonged exposure to heat, however, causes a slight elevation of temperature, similar exposure to cold causing a slight depression. A much more marked effect is produced by agencies which promote or retard the radiation and convection of heat from the body. 7. The nervous system exerts a consid- erable influence over the bodily temperature, as has been shown by the experiments of H. C. Wood and others. The Temperature in Disease.-A large proportion of diseases are accompanied by an elevation of the body- temperature. In a comparatively few, there is at some 56 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. TIiermoineterB. Tlierinometers. period or other a sinking below the normal. In order to denote the existence of a morbid process, however, in the absence of other positive signs of disease, the tem- perature must remain for at least several hours outside the bounds of health. Not only does the temperature rise in febrile af- fections and tend to remain abnor- mally elevated, but experience has shown that it almost invaria- bly undergoes a fluctuation from morning to even- ing, and from day to day,which is typical of the underlying mor- bid process. By the use of the thermometer we are able not only to recognize this fluctuation and esti- mate from it the severity of the disease, but also in a great measure any variation which may occur in the course of the affection as a result of complications, acci- dents, treatment, etc. The thermometer is therefore a valuable aid in diagno- sis, in prognosis, and in treatment. Zn Diagnosis.-The sense of touch may be educated to a delicate appreciation of heat and cold, but it is always li- able to error from various sources. For example, the skin of the indi- vidual examined may impart a sen- sation of consider- able hotness when the thermometer reveals an entire absence of fever; and, on the other hand, the integu- ment may be cold to the touch dur- ing the existence of a more or less pronounced elevation of temperature. The idea of tem- perature obtained by touching the patient can never be relied upon, for many minutes at least, after coming from a cold atmosphere. The subjective impressions of the patient are, as a rule, even more deceptive, for he often complains that he is "burning up" when his temperature is normal, or even subnormal, as a result of haemorrhage, vomiting, diarrhoea, an asthmatic attack, etc. ; and, again, he "freezes," particularly in the cold stage of febrile diseases, especially of malarial intermittent, when the ther- mometer in the axilla registers several degrees above the normal temperature. We have, as a rule, a more trustworthy indication of the presence of pyrexia in the rate of the pulse and respira- tion. A careful counting of these with the watch for a half-minute will often enable the clinician to determine whether or not the use of the ther- mometer is necessary. The early diagnosis of contagious diseases, scarlet fever, small-pox, etc., is of the utmost importance. By the use of the thermometer we are often able, more than by any other means, to corroborate our suspicious of their existence, or, on the other hand, to dis- prove the evidence of fictitious symptoms. And there is no more certain method in-many instances of detecting the malingerer. Complications arising in the course of a fever and relapses from convalescence are usually indi- cated by a more or less pronounced alteration of the tem- perature-range, or by a return of high temperature. Themometry is no less valuable in the diagnosis of certain chronic affections, but more particularly for de- termining their activity or latency at the time of the observation. This is particularly true of tuberculosis. The thermometer has in some instances led to the dis- covery of this affection in individuals, especially in the insane, who had exhibited no subjective manifestations of the disease. An inequality of temperature existing between corre- sponding surfaces of the body, in the absence of local in- flammation, often points to the existence of paralysis of the cooler part, or of other nervous disorder, a fact which is especially of value in the presence of coma. A diagnosis cannot be based upon a single thermomet- ric observation, by which we are able to determine only the presence of pyrexia and its degree, or its absence. A series of observations must be made before we can learn enough of the temperature-range of any febrile disease to render a differential diagnosis possible. The absence of abnormal temperature conveys more positive informa- tion, as a rule, than does its presence. Notwithstanding the value of thermometry, its results are not infallible. For, although a sudden rise of the temperature, amounting to several degrees, may be due to pyaemia, insolation, fibrinous pneumonia, erysipelas, or, at least, an intermittent fever, it may arise solely from an acute attack of indigestion, and no careful clinician would stumble upon such a diagnosis of the condition without having interrogated as to the possible presence of pus, exposure to heat, the occurrence of a chill, pain and its seat, and other symptoms of relatively as much diagnostic value as the pyrexia. The taking of food, ex- ercise, and excitement are liable to elevate the tempera- ture in disease, as does also the retention of urine or of faeces. (Fig. 3896.) Due caution is always to be exercised in estimating the diagnostic as well as the prognostic importance of an elevated temperature in women, when accompanied by hysterical manifestations, as frequently happens at the catamenial periods, when the pyrexia often appears to be due solely to the peculiar condition of the nervous system. Children are subject to sudden, often pronounced, eleva- tions of temperature as a consequence of the most trivial disorders, such as a simple angina or a disturbance of di- gestion. In Prognosis.-The thermometer is an aid to prog- nosis in the extent to which it enables us to detect an approach of the temperature to the danger-line. But the points at which the temperature crosses the lines of dan- ger are not fixed points, and depend in most instances upon a combination of circumstances peculiar to the in- dividual case. A few more or less positive rules may, however, be stated. The average temperature of the axilla in health, as has Fig. 3895.-Chart Illustrating the Temperature- range in Uncomplicated Measles. Fig. 3896.-Chart Illustrating the Rapid Eleva- tion of Temperature at the Onset of Scarlatina. fIOi 3897.-The Temperature-chart of a Case of Relapsing Fever, showing one Relapse on the Fif- teenth Day. been stated, is 37° C. (98.6° F.), but a variation of 1° C. (1.8° F.) on either side of this is not incompatible with health. Occurring during illness, however, it would be considered pathological, although in itself of little sig- nificance. When the temperature reaches a height of 57 Thermometers. Thirst. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. from 39° to 40° C. (102° to 104° F.), it is considered a factor of considerable gravity in the prognosis of the case, particularly as the latter limit is approached. When 40.5° C. (105° F.) is passed the febrile state is termed " hyperpyrexia," and the gravity of the prognosis rapidly increases until 42.5° C. (108.5° F.) is reached, when death is usually imminent. A few carefully ob- served and authentically recorded cases of recovery from a temperature of 43.3° C. (110° F.) have occurred. In a few untrustworthy or doubtful instances recovery has been reported after hyperpyrexia ranging from 44.5° C. to 50° C. (112° to 122° F.). Anomalies of such rarity, even if real, have little or no scientific value. It is not when considered by itself that the temperature is of most value in prognosis, but when taken in connec- tion with the other features composing the natural his- tory of the disease in which it occurs; for in some dis- eases hyperpyrexia is of frequent occurrence, whereas in others it is exceptional. A temperature, therefore, which in one malady would be looked upon as of the gravest im- port, would in another be considered of less significance. Acute articular rheumatism, scarlatina, relapsing fever (Fig. 3897), and tetanus, for example, are often attended by hyperpyrexia, 41° to 42° C. (105.8° to 107.6° F.), which is not necessarily of serious import. Yet persistently high temperature is an evil omen in these diseases no less than in others. A high evening temperature is less to be feared if the morning remission be considerable than if it be but slight. An evening hyperpyrexia followed by an equal or by a still higher morning temperature is very apt, in the later stages of disease, to foreshadow death by a very short interval, the temperature, as a rule, continu- ing to ascend until the fatal issue (Fig. 3898). It fol- low 34° C. (about 93° F.), it has been called "algide collapse. " A rapid fall of temperature may augur evil to the pa- tient, without, however, reaching a subnormal degree. This will most frequently be the case when the decline is not accompanied by a corresponding diminution in the rapidity of the pulse and respiration, or if, on the con- trary, these become more rapid. Here, also, the natural history of the disease must be taken into account. A sudden decline of temperature is especially to be feared in thoracic diseases. Of course, it is always important to distinguish the decline of collapse from the normal crisis which usually terminates the pyrexia of croupous pneumo- nia (Fig. 3899.) In some conditions the temperature falls from the norm without having previously at- tained an appreciable elevation, as, for in- stance, in certain forms of insanity, in emphy- sema, asthma, in car- diac lesions, and in the coma of alcohol and the narcotic poisons. In these the prognosis is not always so grave as the tem- perature would, under other circumstances, indicate. Several well-authenticated recoveries have occurred af- ter temperatures as low as 37.7° C. (90° F.), the result of alcoholism. There can be little doubt, however, that the subnormal temperature which results from narcotic poi- soning is often a potent factor in the fatal issue, although a factor which is probably too frequently disregarded in the treatment of tlie condition. In Treatment.-The value of the thermometer, as a guide in the treatment of febrile diseases, may be inferred from what has been said of it in diagnosis and prognosis. Here, however, no less than in those departments, a thor- ough knowledge of symptomatology, including the usual temperature-range of the affection in which the observa- tion is made, is imperative. It is generally recognized that a high temperature, par- ticularly if it exhibit a tendency to ascend, demands a prompt recourse to the application of cold, or the admin- istration of medicines which, in the manner most suited to the case, tend to reduce the temperature. Per contra, a subnormal temperature calls for the application of heat and the use of such measures as promote heat-production and retard its radiation. The cause of the pyrexia must in all cases be taken into account. Not infrequently the persistent temperature-elevation in a delayed convales- cence may be traced to improper food, or to the retention of effete matter, faeces or urine ; and, in the same manner, a hyperpyrexia may arise from a single infraction of the rules of diet or medication. In either instance a correc- tion of the error will lead to a prompt decline of the tem- perature to the standard of health. It is hoped that these few facts regarding the signifi- cance of abnormal temperature, while they convey to the experienced practitioner nothing that is new, will suffice to indicate to others the importance of a thorough study of temperature as a part of the natural history of every febrile disease, and the necessity of a systematic use of the thermometer. A more complete consideration of the subject of temperature in disease will be found in the articles on Fever ( Vol. III., p. 65 et seq.), and in the spe- cial treatises on the febrile diseases. There is hardly a branch of nosology in which general- ization is more likely to mislead than in the study of pyrexia. Temperature-charts, although of unmistakable value, can never more than approximately represent the peculiarities of individual cases, much less serve as the index of the course a disease will pursue. Individuality is everywhere a characteristic of the temperature-range. Wunderlich expresses this in the following happy man- ner : "When one studies the rules which may be de- Fig. 3899.-The Temperature-range of a Typical Case of Fibrinous Pneumonia, terminating by Crisis. Fig. 3898.-Temperature-chart of a Case of Small-pox, terminating fatally with Hyperpyrexia. lows, as a corollary to this, that a high morning tempera- ture is more to be feared than a high evening tempera- ture. A sudden pronounced rise of the temperature after it has, in the ordinary course of the disease, declined to near the normal, is generally of evil prognostic import, because it so often denotes the development of a com- plication. The malarial fevers, small-pox, and relapsing fever are noteworthy exceptions to this rule, inasmuch as recurrences of febrile elevations of temperature form a part of their natural history. A persistence of pyrexia, even of low degree, after the other symptoms have apparently subsided, very often in- dicates a delayed convalescence, generally from the pres- ence of a complicating affection, as when a catarrhal pneumonia or tuberculosis follows measles or small-pox ; or when septic trouble follows typhoid fever. Many febrile diseases undergo a more or less rapid def- ervescence, involving a fall of the temperature to or be- low the normal ; but under other circumstances a sudden marked decline of the temperature is often as much to be feared as a sudden rise, particularly if the fall be ac- companied by acute prostration, denoting, as a rule, a collapse. The designation " collapse temperature" has been applied to a fall below 35.5° C. (96° F.) ; falling be- 58 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Thermometers. Thirst. duced from the comparison of separate cases, one never feels quite satisfied, although they may be derived from one's own extended experience. These rules, however cautiously they may be drawn from a great number, of separate observations, are never complete, exhaustive, or exact expressions of the facts. All the faults of empir- ical abstractions are common to them; they fail to bear the stamp of inevitability, and fresh experiences of an- other kind may probably modify and possibly overthrow them." James M. French. THIRD NERVE. Third Pair-Oculo-motor Nerve (for anatomy, see Cranial Nerves). Physiology.-This is a purely motor nerve, and sup- plies : 1. Fibres to the levator palpebrae superioris, and to all the external muscles of the eyeball, excepting two- the external rectus, supplied by the abducens or sixth nerve, and the superior oblique, supplied by the patheticus or fourth nerve. (Occasionally the oculo-motor has been found supplying the external rectus, to the exclusion of the abducens.) 2. Fibres to the sphincter of the iris. 3. Fibres to the muscle of accommodation or ciliary mus- cle. The fibres for the two last are given off from the branch which supplies the inferior oblique muscle. They form, combined, the short root of the ciliary or ophthalmic gan- glion, and emerge from it under the name of short ciliary nerves. Anastomoses.-In the sinus cavernosus it receives communicating branches from the sympathetic plexus surrounding the internal carotid artery. Sensory.fibres are received from the ophthalmic branch of the trigemi- nus, as it passes through the superior orbital fissure. Stimulation of the nerve produces those changes in the eye accompanying accommodation for near vision- namely, an inward and downward movement of the eye- ball, with contraction of the pupil, and increased con- vexity of the lens. Normally, the stimulation is almost invariably a reflex act, occurring unconsciously in look- ing at near objects. The contraction of the pupil which occurs when light falls upon the eye is caused by the stimulus to the optic nerve-endings in the retina, being conveyed to the centre in the corpora quadrigemina and thence reflected along the motor oculi to its termini in the sphincter of the pu- pil. Hence the pupil ceases to contract, 1, when the optic nerve is destroyed ; 2, when the centre is the seat of lesion ; 3, when the oculo-motor is severed. The dilator muscle of the iris is supplied chiefly by the cervical sympathetic, but in part, also, by branches of the trigeminus. These nerves antagonize the oculo-motor so that, when their conductivity is in any way interfered with, the action of the oculo-motor causes tonic contrac- tion of the pupil. Simultaneous stimulation of both nerve- paths causes contraction, proving the greater power of the oculo-motor. Besides the contraction which occurs reflexly from the effects of light, the pupil is observed to contract as an associated movement during various actions. Thus, dur- ing accommodation for near objects, or when the eye- balls are rotated inward, there is pupillary contraction, and the latter condition is said to be the cause of the con- tracted condition of the pupils during sleep (Landois). Certain drugs act upon the oculo-motor nerve in its re- lation with the iris, and, according as they cause contrac- tion or dilatation, are called mydriatics and myotics. Among myotics the preparations of calabar bean, espe- cially its alkaloid physostigmine or eserine, rank first. Instillation into the eye causes, besides contraction of the pupil, spasm of the ciliary muscle. "These effects are due either to stimulation of the fibres of the third nerve, or of the circular muscular fibres of the iris, but are cer- tainly not due to paralysis of the sympathetic, since stimulation of the sympathetic will, during the influence of the poison, cause dilatation of the pupil" (Brunton). The "pin-point" contraction of the pupils after opium- poisoning is due to a central cause, though its exact mode of action is obscure. Among mydriatics, belladonna preparations and du- boisine are all that need here be considered. They act both locally and when taken internally. Belladonna acts primarily by paralyzing the nerve-ending of the motor oculi, and secondarily, if the dose be large, by paralyzing the muscle fibres themselves. And it has, be- sides, a direct action upon the dilator fibres of the iris, so that the dilatation is not merely a passive but an active one as well. Pathology.-Morbid reflex stimulation of the motor oculi is not uncommon in children, from the irritation caused by worms, diarrhoea, and other disturbances of the digestive tract, and causes internal squint. Clonic rhythmic spasms occurring in both eyes, give rise to a condition known as nystagmus (see Nystagmus). Tonic contraction of the pupil is called myosis spastica ; clonic contraction, hippus. (For detailed accounts of these va- rious anomalies of innervation, see under the different eye diseases.) Paralysis of the motor oculi nerve causes, 1, drooping of the upper eyelid (.ptosis), from lack of innervation of the levator palpebrae superioris ; 2, squinting downward and outward, from unantagonized action of the superior oblique and external rectus muscles, while at the same time there is fixation of the eyeball and diplopia ; 3, slight protrusion of the eyeball, from the action of the superior oblique and relaxation of the recti; 4, moderate dilatation of pupil (mydriasis paralytica), with loss of re- flex contractility ; 5, lack of accommodative ability for near objects. Paralysis may be partial, or it may be confined to cer- tain branches of the nerve only. BIBLIOGRAPHY. Brunton, T. Lauder: Pharmacology, Therapeutics, and Materia Medica. London, 1885. Erb, W.: Handbuch der Krankheiten der peripheren cerebrospinal Nerven. Leipzig. 1876. Landois, L. : Manual of Human Physiology. Philadelphia, 1885. Schwalbe, G. : Lehrbuch der Neurologic. Erlangen, 1881. Walter Mendelson. THIRST. Under nearly all physiological and under most pathological conditions, we understand by thirst a peculiar, definite sensation which conveys to the con- sciousness the fact that the economy has been deprived of a certain amount of its needed water. The sensation is referred to the back of the mouth and throat as a dry- ness ; and if we had any certain way of determining the amount of moisture in the mouth at this time, the quan- tity would probably be found to be lessened, since rins- ing the mouth, or holding a pebble or other small object in it, to excite the flow of saliva, is often enough to tem- porarily allay thirst. But that the sensation in the mouth is simply the index of the wants of the tissues at large is shown by the fact that thirst is allayed when water is in- troduced, either through rectal injections or by a tube passed down into the stomach without contact with the mouth, and also conversely by the fact that, in animals having (esophageal or gastric fistulas, drinking large quantities of water does not allay their thirst. In this respect thirst is the parallel of hunger. When we consider the importance of the presence of water in the tissues, necessary for that metabolism which takes place simultaneously with, and is, indeed, but an expression of, their functional activity, it is not surpris- ing that the sensation of thirst should be so imperative a one as it is. For all accounts of shipwreck, etc., agree that, while the pangs of hunger can be borne with com- parative fortitude for some time, and even after a while become lessened, those of thirst soon prove intolerable. With regard to the length of time the demands of thirst may successfully be withstood, no absolute state- ments can be made, for we not only see the power of re- sisting thirst varying with different species of animals, but also varying greatly with different individuals of the same species ; and as it is with the lower animals, so is it with man. The powers of the camel in this direction, though usu- ally exaggerated, are still considerable, but Burckhardt has made the observation that they vary in different 59 Thirst. Thomasville. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. countries. Thus, in the Arabian and African deserts, where water is very scarce, four days is about the aver- age time a camel can go without water, though occasion- ally even nine or ten days may elapse before drinking, but this is the utmost length of time. In Syria and Egypt, however, owing probably to the opportunity of- fered by the relative abundance of water, the camels re- quire frequent draughts. So, too, savages inured to all kinds of deprivations will stand the deprivation of water for a length of time almost impossible to a civilized man, and-to bring the matter nearer home-it is an observa- tion, frequent enough among physicians, that some indi- viduals drink large quantities of water habitually, while others rarely imbibe more than that forming part of the food, or taken as tea, coffee, milk, and other similar beverages. Thirst being but the expression of a dearth of water in the tissues, any process which causes a more rapid elimination of water than usual will increase it. Hence exercise, which promotes the free secretion of sweat and an increased exhalation of watery vapor from the lungs, greatly stimulates thirst. So, too, from the same causes, do occupations carried on at high temperatures. An iron-puddler told me that while at work he drank a bucketful of water in about an hour. lie worked at the furnace door naked to the waist, and his body was as wet as though the bucket of water had been poured over him, instead of through him. Those who, while thus losing much water, neglect the admonitions of the senses and fail to slake their thirst, are frequently the victims of heat-stroke, a condition in which the tissues and blood are deprived of water to a de- gree inimical to the further proper performance of their functions. To the thickening of the blood which en- sues, and to the retention of heat within the system from the inability to properly perspire, most, if indeed not all, the symptoms of heat-stroke are due. Hence the thirst of all exposed to severe heat, especially if they are obliged to exercise as well, should be freely and frequently grati- fied with moderately cold water. Effects of Various Ingesta.-The thirst which fol- lows the use of various articles of food may be from a two- fold cause, namely, a general and a local. The ingestion of unusual quantities of salt operates through the general economy by causing an increased transudation from the tissues to the vessels, for the rea- son that the salt absorbed by the blood having increased the latter's specific gravity, there is, through the mechan- ism of that particular degree of osmosis to which the tis- sues are adjusted, a tendency to restore the normal equi- librium, and this is brought about by the passage of enough liquid from the tissues into the vessels to reduce the percentage of salt in the blood to the normal. The increase in the blood-volume which follows this absorp- tion gives rise to increased urination, and the loss of water by the tissues, to thirst. So we see how salt (all salts act in this way in varying degrees) acts both as a diuretic on the one hand and producer of thirst on the other, though the thirst is only indirectly connected with the diuresis. Thirst follows the consumption of sugar only when the latter is eaten as such, and is most marked when it is taken in a solid form. The effects of the sugar are local, and due to the action upon the mucous membrane of the mouth, in which the nerve-endings lie. Proof that the thirst is of local and not of general origin is found in the fact that no unusual thirst follows the consumption of large quantities of starchy foods, which are converted into sugar in the small intestine. Were all the sugar taken in as such, or formed in digestion from starches, thrown at once into the circulation the same thirst would follow as that caused by salines. But owing to the arrest of the sugar by the liver, and only its gradual return to the general circulation, this does not occur. When it does occur, as in diabetes, which will be discussed di- rectly, thirst is the invariable result. The effects of such substances as pepper, mustard, and other condiments-effects of which it is hard to say whether they should be regarded as physiological or pathological-are purely local, acting by irritating the nerve-endings of the mouth, fauces, oesophagus, and stomach. Of the same nature is the thirst-often most agonizing in its intensity-resulting from poisons, as Paris green and other forms of arsenic, from acids, alkalies, etc. Pathology.-Thirst is a symptom common to many diseases. In one class of cases it results from the same causes as physiological thirst, i.e., abstraction of water from the system, while in another it is due to local irritation of the nerves terminating in the mucous membrane of the mouth and stomach. Often both these causes obtain. In cholera and diarrhoeas generally the rapid abstrac- tion of large quantities of water by the bowels leads to a feeling of thirst, which will be intense and frequent in proportion to the copiousness of the discharge. In cholera thirst is one of the most striking of the symptoms, but even in spite of the large quantities of water ingested the pinched and sunken countenance is too often indicative of a diminished supply of fluid to the tissues. Abstraction of large quantities of blood, as occurs in severe haemorrhage from any cause, is always marked by the same pinched expression and by the appearance of thirst, often intense, which continues so long as the total quantity of fluid in the body is much below normal. In diabetes mellitus the thirst is not the result of an effort to replace the amount of fluid secreted by the kid- neys, but, on the contrary, the polyuria is secondary to the polydipsia. The latter is caused by an abnormal in- crease in the glucose of the blood, which, by altering its specific gravity, leads to increased transudation from the tissues into the vessels, as is shown by the dryness of the mouth, the skin, etc. The cry for water from the tissues, expressing itself in the sensation of thirst, is responded to by drinking more water, but the increased quantity of fluid in the blood-vessels leads in turn to an increased volume passing through the kidneys in a unit of time, and this again leads to increased elimination. That the thirst is really due in this disease to the glycaemia, is proved by the fact that when, by a proper regulation of diet, the glucose is made to diminish greatly, or even to disappear altogether, the thirst and polyuria undergo a proportionate diminution. In contrast tQ the thirst of diabetes mellitus is that of diabetes insipidus, for while we saw that in the former the thirst was primary land the polyuria secondary, here the polyuria-from renal circulatory disturbances of ner- vous origin-is primary, and the thirst is simply the ex- pression of the desire to replace the water lost by exces- sive urination. To the same category belongs the thirst accompanying hypertrophy of the left ventricle with a constant in- creased arterial pressure (as occurs with granular kid- ney). Here the increased amount of blood passing through the kidney leads to increased secretion, and this to an increased demand for water. The thirst of fevers is largely of local origin, it being caused by the catarrh of the mucous membrane of the alimentary tract. This condition, too, is the cause of the thirst accompanying many forms of dyspepsia. Finally, there is the thirst which occurs as one of the many symptoms of hysteria. It is a purely nervous phenomenon, and is of the same nature as the aberrant manifestations which lead to the eating of unnatural, and often disgusting substances, to a fondness for repulsive odors, etc. Treatment.-For allaying thirst, nothing is so uni- versally grateful as pure water, of a temperature not so cold as to be chilling. As a rule, the ingestion of water, in some form, should be free, as it promotes metabolism and removes the nitrogeneous excrementitious matters from the tissues. Those engaged in bodily exercise should drink frequently, slowly, and but little at a time. For frequent small draughts, while supplying the water lost by evaporation, do not, as large quantities would, so augment the blood-volume as to throw undue work upon the heart. Kronecker and Melzer have shown that the act of swallowing has reflexly a stimulating effect upon 60 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Thirst. Thomasville. the heart. Hence (a fact to which T. Lauder Brunton has called attention) slowly sipping a fluid has a much more refreshing effect than quickly gulping it down. Sweet drinks are apt to increase rather than allay thirst. Weak vegetable acids, on the other hand, have the opposite effect. Alcoholic beverages, especially the fermented ones, like beer, ale, etc., are liable to increase thirst when taken in considerable quantities, owing to the gastric derangement which is apt to ensue, more par- ticularly in hot weather, when the temptation to drink copiously is greatest. Small quantities of diluted spirits, on the contrary, by their stimulating effects, tend to al- lay the thirst that accompanies great fatigue. In the thirst that accompanies diarrhoea, haemorrhage, or any great loss of the body-fluids, water should be freely administered, preferably in small quantities and fre- quently. In cases where water is rejected by the stom- ach, rectal injections may be used with equally good effect. In sunstroke, where the necessity of introducing water into the system is imperative, and where, owing to the spasmodic closure of the jaws and the unconscious- ness of the patient, drinking is out of the question, my treatment at the New York Hospital consisted, in con- junction with the cold bath, in frequently injecting into the rectum a pint or more of ice-water. In this way, not only was the high fever reduced, but surprisingly large quantities of water were quickly absorbed, with the hap- piest results. In fever the thirst, as a rule, is due to local causes; hence, generally, more relief is obtained by carefully cleansing the mouth and swabbing with a hygroscopic substance like glycerine in which some borax has been dissolved, than from drinking large quantities of water or other fluids. Bibi.iogbapht. Beaumont, William : Experiments and Observations on the Gastric Juice and the Physiology of Digestion. Plattsburg. 1833. Brunton, T. Lauder: Pharmacology, Therapeutics, and Materia Medica. London, 1885. Brunton, T. Lauder: Disorders of Digestion. London, 1886. Cohnheim, J.: Allgemeine Pathologie, second edition. Berlin, 1882. Dallas, W. S.: Natural History of the Animal Kingdom. London. Flint, A., Jr. : Text-book of Human Physiology. New York, 1877. Landois, L. : Manual of Human Phjsiology. Philadelphia. 1885. Munk and Uffelmann : Die Erniihrung des gesunden und kranken Men- schen. Vienna and Leipzig, 1887. Walter Mendelson. THISTLE, BLESSED (Herba Cardui Benedicta, Ph. G. ; Chardon benit, Codex Med.). Cnicus benedictus Linn. ; Order, Composita. {Centaurea benedicta, Care- nia benedicta Benthand Hook, etc.) This much-named plant has had a doubtful place in several genera of the puzzling group Ceniaurea. It is an annual herb, with stout, upright stem several feet high, large clasping pin- natifld leaves, and ovoid heads of yellow flowers. In- volucre scales coriaceous, appressed, with spreading, rigid, pinnately spiny tips. Receptacle bristly, achenia terete, with a crown of ten short teeth, and a pappus of ten short and ten long bristles. It is a native of South- ern Europe, Northern Africa, and -the East, where it is a troublesome weed. It is also cultivated in parts of Europe for medicinal uses, and is occasionally found naturalized in the warmer parts of the United States. This particular thistle is not certainly identified as a classic medicine, but has been well known and used in Germany for three or four hundred years. Blessed Thistle contains no remarkable constituents ; potash, lime, and magnesium salts form a considerable ash, and a crystalline bitter substance, cnicin, gives it its bitterness. The plant should be gathered in midsummer and dried. This is one of the peculiar sudorific, sometimes dis- agreeable and nauseating, bitters of the composite fam- ily, having probably no advantage in any respect over many others, e.g., Thoroughwort, which are in popular use as antipyretics, diaphoretics, " anticatarrhals," etc., that is, are given for colds, coughs, intermittent and other fevers, etc. Large doses are emetic. Dose, one, two, or three grams ; a decoction is a suit- able form. Allied Plants.-See Chamomile. Allied Drugs.-Thoroughwort and many others. IK P. Bolles. THOMASVILLE. |For detailed explanation of the ac- companying chart and suggestions as to the best method of using it, see Climate.} The village of Thomasville, situated in the southwestern portion of the State of Georgia, lies within the limits of the very extensive pine- belt of that region, and occupies the highest ground in that part of the State. The surrounding country is, neverthe- less, by no means hilly, and Thomasville's elevation above the level of the sea is but 330 feet. The soil is sandy. The hotels afford ample accommodations, and their wa- ter-supply is derived from an artesian well. Educa- tional facilities exist for the children of families desiring to make the town a place of residence for the winter months. The drives through the pine-woods are pleas- ant, and the roads are excellent. Thomasville is distant from the Atlantic Ocean about one hundred and sixty miles in a "bee line," and from the Gulf of Mexico about sixty miles, and no winds can reach it from either of these great bodies of water without first passing over many miles of pine-forest and becoming impregnated Climate of Thomasville, Ga.-Latitude 30° 50', Longitude 84° 10'.-Period of Observations, April 1, 1878, to March 31 1884.-Elevation of Place of Observation above Sea-level, 330 feet. 4 A A B C D 11 1 G H ■ -- - ■ ■ ■ ■■ - ■-- -- ■- Mean temperature of months at the hours of mean temperature de- rom Column A by the i (7 A.M. +2 P.M. + 9 P.M.). Mean temperature for period of ob- servation. maximum temperature for period. minimum temperature for period. Absolute maximum temperature for period. Absolute minimum temperature for period. number of days in any onth on which the tem- was below 68°-this lie- annual mean tempera- number of days in any onth on which the tem- was 68° and above-68° re annual mean tern- Average duced f formula P.M. +9 Average Average greatest single m perature ing the ture. Greatest single m perature being t perature - - ■■ - - • ; ---- - 7 A.M. 2 P. M. 9 P. M. Highest. Lowest. De- De- Highest. Lowest. Highest. Lowest. Degrees. Degrees. Degrees. Degrees. Degrees. Degrees. grees. grees. Degrees. Degrees. Degrees. Degrees. January.... 4(1.84 60.41 50.68 52.15 58.29 45.75 61.12 43.19 78.0 63 32 14.0 31 7 February... 50.22 66.31 54.94 56.60 60.86 51.70 66.52 49.08 82.0 69 42 28.0 28 8 March 54.87 71.83 59.75 61.55 65.36 56.42 72.03 54.00 88.0 71 50 32.0 30 15 April 62.54 76.80 65.92 67.79 70.34 66.06 77.21 61.97 91.0 72 51 36.0 17 21 May 70.27 82.68 72.16 74.31 77.56 73.50 83.38 70.11 94.0 78 65 54.0 6 29 June 76.50 87.32 77.47 79.69 83.89 78.48 88.47 76.01 100.0 83 73 63.0 0 30 July 79.86 89.61 79.97 82.35 85.64 81.13 91.03 79.14 101.5 84 75 66.0 0 31 A ugust 75.59 88.40 77.12 79.55 80.58 77.76 91.00 74.68 96.5 81 73 63.0 0 31 September.. 71.99 85.22 74.11 76.35 79.33 74.24 86.54 70.17 94.5 79 67 53.5 2 30 October .... 64.68 76.62 67.71 69.18 73.32 65.94 77.23 63.32 94.5 78 57 37.0 13 21 November.. 52.55 67.69 57.00 58.56 61.27 55.64 68.12 51.72 84.5 69 45 26.0 29 9 December.. 47.34 61.74 50.86 52.70 57.84 48.05 62.51 45.18 79.5 65 26 10.0 1 31 3 61 Thomasville. Tli oiiiso nia nism. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. K IS o R S mper- ?riod. if mber ys. infall s. 8 . ■5 s 5*2 11 3 a +3 o 5 cS • £c . Range of ature for Mean rela midity. p Average of fair Average in inc Prevailing tion of Average of wind l>er hour January.... 64.0 63.73 23 3.41 S. and N.W. 5.0 February... 54.0 62.86 22 3.36 S. and N.W. 5.0 March 56.0 62.29 24 3.92 S. 9.0 April 55.0 62.30 21 5.28 s. 8.0 May 40.0 62.75 24 3.74 s. 4.0 June 87.0 64.72 21 4.37 s. 3.0 J uly 35.5 66.00 20 4.69 s. 3.0 August 33.5 69.92 19 7.23 S. and S.E. 5.0 September.. 41.0 67.75 22 3.83 s. 6.0 October .... 57.5 68.22 24 5.19 s. 7.0 November.. • 58.5 66.64 24 2.69 S. and SAV. 8.0 December.. 69.5 64.75 24 3.85 S. and N.W. 7.0 Spring 62.0 62.44 69 12.94 S. 7.0 Summer.... 38.5 66.88 60 16.29 S. and S.E. 3.6 Autumn.... 68.5 67.53 70 11.71 s. 7 0 Winter 72.0 63.78 69 10.62 S., S.W., N.W. 5.6 Year 65.16 268 51.56^ S„ S.E.. S.W., and N. W. | 5.8 possibly be rather more common than is generally be- lieved. In 1832, Sir Charles Bell described a case which, in many particulars, bears a very close resemblance to Thomsen's disease. In 1874, Leyden reported the case of a man, aged twenty-eight, who from his childhood had suffered from what must be looked upon as a well- marked example of Thomsen's disease. Symptoms.-The most pronounced symptom of this disease is a rigidity, stiffness, or tonic spasm of the mus- cles when they are brought into action. While the patient is quiet, he is apparently free from any trouble, and it is only when he attempts movement that the stiffness comes on. The degree of rigidity varies very much. In the lighter forms it may not amount to more than a feeling of slight stiffness, while in the more se- vere cases motion for some seconds, or perhaps minutes, is absolutely impossible. The patient stands rooted to the position in which he was when he made his first at- tempt at movement. The rigidity in pronounced cases affects usually all the muscles, those of the extremities being especially affected. The muscles of the jaws fre- quently are so stiff that the patient has to make a pause before he can proceed with mastication. Usually, also, the muscles of the tongue are affected with rigidity after a period of rest. The muscles of the eyeball, in the great majority of the reported cases, have escaped. The speech is not interfered with. Swallowing may be diffi- cult. The rigidity gradually passes away, only, how- ever, to return on a second attempt at movement; but it again disappears, now more quickly than at first, and after two or three attempts the patient works as if noth- ing were wrong, all his movements being free and easy. The muscles do not suffer in nutrition. Cases are re- ported in which the muscular force has been increased, while in others it has been decreased. Muscles of in- creased volume may, on being tested, prove to be very weak. The reflex irritability is much increased, so that a sharp blow, or a pinch over a muscle, gives rise to slow tonic contractions, which last several seconds. It affects all accessible muscles. Erb reports a case where slight tapping of the tongue brought a contraction which lasted a number of seconds. Erb has made a very complete electrical examination of the muscles and nerves in two cases of this disease. He found that the excitability of the nerves to the induced current and to galvanism was not materially changed. There was no change in the electrical formula, with perhaps the exception that the opening contractions (A.O.Z. and K.O.Z.) were brought out more easily than they usually are, and that the tonic contractions, from closure of the cathode, appeared rela- tively late. All contractions were found to be energetic and short. The faradization of the muscles showed some curious ab- normalities. The muscles reacted readily in a normal way, even to moderately weak currents, but to strong currents the contraction was found to be prolonged even after the current was withdrawn. The stronger the cur- rent, the more prolonged was the contraction. It was found that in the case of the deltoid it lasted twenty sec- onds with a strength of current obtained when the sec- ondary was removed from the primary spiral, a distance of 120 mm. Erb found still more important changes in the response to galvanization of the muscles. They all responded read- ily, currents of from one-fourth to two milliamperes be- ing sufficient to produce contraction in most of the super- ficial muscles. The qualitative changes were found to be of an unusual character. The contractions were slow and of long duration, and they persisted even for some seconds after the opening of the current. This peculiar effect was especially well seen in the calf muscles. The depression caused by the contraction of the muscles re- mained for some seconds after the electrode was with- drawn, not unlike, except on a much larger scale, the depression which follows firm pressure in an oedematous limb. The reaction bore some resemblance to the reac- tion of degeneration. Diagnosis.-There is a certain, but only a verysupcr- NOTE.-Thomasville being a voluntary station of the United States Sig- nal Service, the hours of the tri-daily observations of temperature differ from those observed at the regular stations. The standard of comparison adopted in columns G and H differs also from that adopted in other charts to be found in this book. The term "fair," in column N. is manifestly equivalent in value to " fair and clear" in these other charts. with the balsamic odor and health-giving volatile princi- ples exhaled by these trees. As will be seen from an inspection of the accompany- in chart (for the filling out of which the writer is in- debted to Professor L. 8. MacSwain, Voluntary Observer of the United States Signal Service), the climate of Thom- asville is a very dry one ; its winters are warm ; it is to a marked degree exempt from severe winds ; and there is always a great preponderance of sunshine and of days which admit of out-of-door exercise on the part of the in- valid. Taken in connection with the excellence of its hotel accommodations, the great climatological advan- tages of Thomasville doubtless render it one of the most desirable places of winter residence to be found in the United States, particularly for those who suffer from any form of catarrhal affection of the respiratory passages or from pulmonary phthisis. Hotels.-The two largest hotels are the Piney Woods Hotel, situated close to the pine-grove, and the Mitchell House, situated in the town itself. Both are under ex- cellent management. The Waverley House and the Gulf House are smaller than the two first mentioned. There are also many boarding-houses in the village. For more detailed information concerning Thomasville the reader may be referred to " Thomasville as a Winter Home for Invalids," an interesting pamphlet published by Dr. T. S. Hopkins, a resident of, and for twenty years past a practitioner of medicine in, that town. Huntington Richards. THOMSEN'S DISEASE. Syn. : Myotonia congenita. Definition.-This is an affection chiefly characterized by a marked rigidity in certain groups of muscles when they are brought into action after a period of rest. History.-The first true description of the disease was given by Dr. Thomsen,1 a physician of Schleswig-Hol- stein, who is himself a sufferer from it. He described the affection, which he had studied in himself and in his four sons, as consisting of tonic contractions in the vol- untary muscles in consequence of an irritable psychical disposition. He said that evidences of a similar trouble had been noted in more than twenty members of his fam- ily scattered through four generations. Since Thomsen published his description of the disease, a number of cases have been reported, principally in Germany. Many of these, however, do not correspond clinically with the description given by Thomsen. It would appear that some cases of chronic rheumatism have been diagnosed as Thomsen's disease ; while, on the other hand, the lighter forms of the affection may 62 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Thomasville. Thomsoniauism. ficial resemblance between Thomsen's disease and tetany. The latter is for the most part an acute disease, which usually passes off in a few days or weeks, and when chronic (it may last many years) it is intermittent, while Thomsen's disease is characterized by its constancy. The mechanical, faradic, and galvanic irritability of the nerves in tetany is greatly increased, wdiile in Thomsen's disease we find these different forms of irritability either normal or diminished. Cases are recorded in which Thomsen's disease has been diagnosed as pseudo-hypertrophic muscular paraly- sis. In both we have the marked hereditary influence, the appearance in early life, with increase in the volume of some of the muscles; but the peculiar gait and position of the patient in walking and assuming the erect position in pseudo-hypertrophy are characteristic. In addition, we have some muscles atrophied, while others are hy- pertrophied in pseudo-hypertrophic paralysis. Muscular atrophy is never seen in Thomsen's disease. Erb proposes the terra "myotonic reaction" for the peculiar behavior of the muscles to electricity in this dis- ease. He points out the difference between the myotonic reaction and the reaction of degeneration. There is a somewhat close resemblance between these two reactions, especially as brought out in the small muscles of the hand, but they may be distinguished by attention to the following points : 1. The myotonic reaction can be made out in all the voluntary muscles of the body, while the reaction of de- generation is essentially a local affair, being confined to certain definite nerve-areas at most. 2. The myotonic reaction is always the same, and never changes as does the reaction of degeneration. 3. Myotonic reaction appears in normal muscles or in those that are only slightly weakened. The reaction of degeneration is never seen except in muscles which are, or have been, in a decidedly paretic state. In the former the muscles are either normal or increased in size. In the latter they are always atrophied. In both we have a slow contraction, with the A. S. Z. occurring before the K. S. Z. Pathological Anatomy.-Erb in two of his cases removed pieces of various muscles, and found changes in them of a very marked character. There was great hy- pertrophy of all the fibres, and marked increase in the muscle-cells, together with slight increase in the inter- stitial connective tissue, in the meshes of which a gelati- nous-looking substance was found. Course.-Beginning in early life, it probably lasts during the patient's lifetime. As far as is at present known, it is not directly fatal. The symptoms vary in severity from time to time. Nature.-We know nothing about the essential nat- ure of the disease. The changes described in the mus- cles by Erb may be primarily myopathic or neuropathic. The evidently marked hereditary influence in the disease has received as yet no explanation. Treatment.-No method has as yet been discovered by which the disease may be favorably modified. Gal- vanism and massage have been tried without benefit. Thomsen considers regular exercise beneficial. Erb, on theoretical grounds, recommends curare hypodermically in small doses. This drug, according to Rossbach, shortens the period of muscular contraction. James Stewart. 1 Arch. f. Psych, und Nerv., 1876, vi., 8. 702. THOMSONIANISM AND PERKINISM. I. Thomsoni- anism.-The history of Samuel Thomson or Thompson, the founder of this so-called system, is tolerably complete, but the principal materials for this paper are derived from the narrative of his life and medical discoveries which is prefixed to his book called " The New Guide to Health, or Botanic Family Physician, Containing a Complete System of Practice on a Plan entirely New ; with a Description of the Vegetables Made Use of, and Directions for Preparing and Administering them to Cure Disease." This book ran through many editions, some published in Boston, others in Albany, New York, and elsewhere. Some are embellished with a hard, but evidently very carefully cut, steel engraving of himself, which gives him a very large head, a forehead both high and broad, and most determined, almost bull-dog-like features, which are softened somewhat by a very big white cravat, tied into an enormous bow, a magnificently frilled shirt, and a very fine dress-coat, with a large rolling collar, as was the fashion in those times. He probably got his great vigor of face and character from his father, Farmer John, who worked so incessantly and was so severe to his fam- ily and in his religion, that Samuel often wished most earnestly, but not reverently, that there were no such things as fathers, farms, field-labors, or religions. He was born February 9, 1769, in the thick woods of New Hampshire, in the township of Alstead and county of Cheshire. There was no other house within three miles ; the only doctors were ten miles off, and they were only root and herb doctors, Fuller and Kitteredge, and old Widow Benton. There were very few regularly edu- cated physicians anywhere in the country, and only two medical schools, that of Philadelphia, which passed its first graduate in 1768, and that of New York, in 1770. Harvard did not begin till 1782 ; and Dartmouth, N. H., only in 1797, when Thomson was already twenty-eight years of age. Foreign drugs were always dear and scarce in the wdlds of New Hampshire, and became still more so when the War of the Revolution broke out in 1776. Necessity, patriotism, and national pride urged everybody to try and find out the virtues of our indigenous plants. Old Widow Benton employed Samuel to gather roots and herbs for her, and he soon took quite a fancy to lobelia, as he chewed and tasted every plant, and found that it warmed up his stomach quite nicely and made him vomit in a wonderful way. He then gave it on the sly to his play- mates and farm hands, some of whom got very angry ; but others thought it cleared out their stomachs so thoroughly that he must have "a natural gift of healing." Then " he had the measles bad," and the canker-rash or scarlet fever and diphtheria, followed by small-pox and spotted fever, or cerebro-spinal meningitis. He treasured up all the doctors' and nurses' directions, as well as he could, and began to practise on others with great confidence before he was sixteen years of age. First he followed Widow Benton's practice, who always gave hot drinks to cause perspiration, and if one herb did not relieve or cure, she quickly tried another until the patient got well or died. But soon he always commenced with lobelia, and continued to do this for thirty or more years. If some patients complained of his "Emetic Herb," he quietly told them to say no more about " that little puke," as he knew all that. Then he married and had eight children, all of whom had the measles, scarlet fever, diphtheria, itch, and whooping-cough, and some of them small-pox and spotted fever. His wife, too, was so frequently sick that he persuaded young Dr. Bliss to live rent free on his farm for seven years, attend to all the sickness of his family, and give him instruction in medicine. Thus Samuel was taught in the then orthodox way, for stu- dents did not then attend medical schools, but studied in the offices of practising physicians for three years, more or less, when they were dismissed with a certificate of competence. During all this time Samuel was attending a great many sick people as boarders in his own house, or else he went and boarded in their houses. He believed in constant attention upon the sick, for his severe treat- ment generally made this necessary, but he still con- tinued to cultivate his farm profitably. Finally, in 1805, when he was thirty-six years of age, he determined "to make a business of doctoring," and depend solely upon that natural gift of healing which he and his neighbors thought nature or nature's God had given him. He quaintly tells us that it was now neces- sary for him to devise a system of medicine, and block out a universal routine of treatment for all cases of sick- ness. The great Boerhaave's advice to all was " to keep the head cool, the feet warm, and the bowels open ; " the lesser Thomson taught us to keep the stomach warm and 63 Tliomsonianism. Tlio in son tail is m. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. empty, and the skin sweating. He decreed that all seri- ous diseases were caused by "canker in the stomach." One degree of canker caused measles; another, canker- rash or scarlet fever ; a third, malignant sore throat; a fourth, small-pox ; a fifth, spotted, bilious, and yellow fevers ; another, erysipelas; and so on. This canker should be brought out of the stomach by No. 1, or lobe- lia. If the inside of the stomach was left cold, it must be warmed up by No. 2, or cayenne pepper; for cold was the cause of all disease and death, while heat was the origin of all life and health ; for the same reasons the skin should be kept hot and sweating by steam baths. His favorite steaming was done by putting large hot stones in a hot iron shallow dish, filled with hot water, and then pouring hot vinegar on the tops of the hot stones ; the naked patient was usually seated on an open-bottomed cane-chair and covered close with thick blankets. Samuel sometimes went into the sweat-bath himself, to encour- age timid patients. If anyone became nervous, or was thrown into "cramp-convulsion-fits," No. 3, or nerve- root, or skunk-cabbage, was relied on. He even put his practice into rhymes, thus: " The emetic, No. 1's designed A general medicine for mankind, Of every country, clime or place, Wide as the circle of our race. " In every case and state and stage, Whatever malady may rage. In male or female, young or old, Half its value can't be told. " Let No. 2 be used bold, To clear the stomach of the cold. Next take the coffee, No. 3, And keep as warm as you can be. " When sweat enough, as we suppose, In spirit wash and change your clothes. Then get in bed, both clean and white, And sleep "in comfort all the night. *' Now take your bitters," etc. He also says that nature taught him there were four elements ; viz., earth or minerals, fire or heat, water or steam, and air or life. Experience told him that earth was dull, heavy, motionless, and dead, and that minerals, which came out of the earth, had a tendency to drag down all who took them into the earth or universal grave. On the other hand, vegetables were full of life, heat, and water, and sprang up from the earth or grave toward heaven, and thus upheld mankind from the tomb. It was true that roots struck down deep into the earth or grave, and the branches of trees spread far up toward heaven, where some dead people went; but these were trifling objections to the general theory. Now he went from town to town, all over the New England States, staying days, or weeks, or months, ac- cording to his success. In the course of a few years he was imprisoned several times, tried eight times for mal- practice, poisoning, manslaughter, and even murder, but was always acquitted. The case of Ezra Lovett, Jr.,is a fair sample of the whole. In December, 1809, Thomson came into Beverly, Mass., where Lovett lived, announced himself as a physician who could "cure all fevers, whether black, gray, spotted, scarlet, green, or yellow; and declared fill other physicians were wrong while he was right." He gave singular names to his medicines: Lobelia he called ram-cats; cayenne pepper, bull-dogs; marsh rosemary and bay-berry bark, coffee ; another he called his screw auger, and some unknown herb, perhaps wake-robin, or witch-hazel, lie called belly-my-guzzle or well-my-gristle. Lovett had been sick several days with a cold, and Thomson steamed and sweat him in the usual way ; while still under the blankets he gave a teaspoon- ful of lobelia, which caused vomiting. In three minutes the dose was repeated, which again operated violently ; then a third dose was given, which acted with still more vehemence ; all these doses were given within one half- hour. Then the so-called coffee was poured down freely and the patient put in a warm bed, sweating profusely. The next day poor Lovett was able to sit up and was comfortable, only weak ; but two more lobelia powders were given to get out all the canker, and coffee (?) was ad- ministered freely. On the third day the patient was washed over with rum and ordered to walk about out- doors, on a cold January day, as air was life. Then he got two more powders and more coffee. On the fourth day Lovett was again comfortable, but very weak, and was steamed again, and got more lobelia or ram-cats. The debility increased, and although the patient was still comfortable he got two more powders on the sixth day, within twenty minutes. As they did not cause vomiting, pearlash and water was given, and more lobelia. The man now appeared to be dying, but as he said the med- icine seemed to have got down to his navel, where there was great pain, Thomson said he would "unscrew his navel" and make the lobelia operate downward. Then convulsions set in, but two strong men held Lovett while Thomson forced down two more doses of lobelia ; now he said Lovett had the hyps like the devil, and gave him skunk-cabbage. On the eighth day Lovett died, but Thomson was acquitted. See Sixth Massachusetts Re- ports, 134. In 1806 he went from Boston to New York on a sail- ing-vessel, to cure yellow fever. He was eight days on the voyage, got cold in his stomach, and landed, as he says, with yellow fever already in or upon him ; as his eyes were yellow, his tongue coated, his passages like tar, and he had great noises in his head, he took one- half pint of salt, one pint of vinegar, and full doses of No. 2, cayenne pepper, No. 3, bay-berry coffee, and No. 4 or nerve-powder, and went home again. He took no lobelia. In 1812 he went to Washington to take out a patent for the use of lobelia in fevers, colics, dysenteries, etc., and for his steam-sweating. Dr. Thornton and the celebrated Dr. Samuel L. Mitchill were very patient with him, as were Drs. Rush and Barton in Philadelphia. He came back with some sort of a patent, and refused to treat any person who did not join his Friendly Medical Society, take out a family right to practise his system, and pay $20 therefor. Next he published his book, which seems to be written in the frankest and most savagely truthful way. It is remarkable for its terseness, clearness, and vigor of lan- guage, and it is very hard to believe that it proceeded from an uneducated man, although he tells us that he only went to school for one month when he was ten years of age; but as he learned all he knew of midwifery in twenty minutes, he evidently was an apt scholar. When Thomson was in his prime, Dr. Samuel Henry published his "New and Complete American Medical Herbal, displaying the true properties and medicinal vir- tues of the plants indigenous to the United States of America." Dr. Henry was a member of the College of Physicians and Surgeons, and of the Medical Society of the County of New York ; his book is still a valuable one. Shortly after, Dr. Jacob Bigelow published his "American Medical Botany," which is still more valu- able. All primitive medicine is necessarily herbal or botanic, as it is easy for the common man to pick up plants ami make some or many trials with them ; and it is equally easy to exaggerate all their virtues. Hippocrates, b.c. 450, used three hundred vegetable remedies. Dioscorides used seven hundred ; and 30,000 copies of his work were sold in seven years, from 1554 to 1561. Pliny the Elder wrote five books on the medicinal use of plants, a.d. 23. In the eleventh century it was complained that the great difficulty in therapeutics came from the multiplicity of vegetable remedies. Caius Plinius wrote fifteen large volumes on botanic materia medica. In Alexander the Great's time not even the smallest sore could be treated except by some herb brought from beyond the Red Sea. The discovery of America was followed by a long roll of new vegetable remedies. Now the herbalists are more active than ever .before. Thomsonianism was introduced into England by Coffin and the Coffinites. Its theory was: Heat is life, and want of heat disease ; its practice was cayenne pepper and lobelia given with no cautious hand, as they asserted 64 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Thoinsonianisni. Thomsonianisni, over and over again that lobelia could not kill ; but Dr. Letheby reported thirteen cases of manslaughter caused by it. Samuel Thomson, we have seen, was born in 1769 ; Samuel Hahnemann came into the world six years later, or in 1775, and became one of the most learned and well- read medical men of his time. He too founded a sys- tem of medicine, which must be regarded as the exact opposite of Thomson's, as regards doses, but not as re- gards principles ; for the botanic doctors gave cayenne pepper, hot drops, lobelia, and other violent irritants in fevers and inflammations. Thomson lived in the times of great epidemics of scar- let and typhoid fevers, diphtheria, and cerebro-spinal men- ingitis. His book is crowded with cases of severe dis- ease, imperfectly reported, it is true, but still of some historical, if of no scientific, value. Compared to gentle Culpepper, he was a rude and unwelcome figure among homely herbalists, and never can be regarded with com- placency by kindly physicians of any school, although his practice was probably not more destructive than that of Broussais or Rasori. Dr. Eneas Munson, born in New Haven, Conn., in 1734, and the first professor of materia medica and bot- any in Yale Medical College, introduced more indigenous vegetable remedies into practice than any other physician. His successor, Dr. Eli Ives, born in New Haven in 1778, established a "Botanic physike Garden" and a green- house for less hardy plants. The good doctor often led a patient into his garden and dispensed his medicine to him with a spade. But the writings of these great and good men never became as popular as those of Thomson. II. Perkinism takes its name from its promulgator, Elisha Perkins, the inventor of the so-called "Metallic Tractors," who was born in Norwich, Conn., January 16, 1741, and died in New York, of yellow fever, September 6, 1799, fifty-eight years of age. As there were no med- ical schools in the United States until Elisha was thirty years of age, he was educated for the profession of medi- cine by his father, Dr. Benjamin Douglass Perkins, who was a respectable man in fairly prosperous circumstances. One of his descendants whom 1 knew long ago was in- tensely enthusiastic on several subjects. Elisha com- menced practice in Plainfield, Conn., where he is said to have been quite successful and to have shown decided intellectual ability. He invented his " Tractors," or " Pullers-out of Disease," in 1796, when he was fifty-five years of age. The world was then quite ripe for a delu- sion of this kind ; faith in the " Royal Touch" had not yet died out, as the celebrated Dr. Johnson was touched for " King's evil " in 1784. Benjamin Franklin had just discovered some of the great wonders of electricity; Gal- vani commenced his surprising career in 1784, and the whole civilized world was overwhelmed with enthusiasm about galvanism. Du Bois Reymond says, wherever frogs were to be found and two kinds of metal could be procured, everybody was trying to see a dead frog's legs brought to life again. All believed that the "vital fluid and power" had at last been discovered, and physicians not only thought they could explain all nervous func- tions and disorders, but could cure the most formidable nervous diseases, even lockjaw, epilepsy, neuralgia, etc., with electricity and galvanism. In 1788 Dr. Marmaduc was taking in nearly £10,000 for magnetizing credulous dukes, duchesses, marchionesses, countesses, earls, bar- ons, bishops, members of parliament, and even some phy- sicians and surgeons, besides multitudes of right honor- able men and most respectable women. Father Hell was curing disease by the application of metallic plates, and Mesmer, Swedenborg, and Hahnemann were becoming famous. Even poetry was invoked, thus : " Behold Galvani's fierce, but viewless flame, Bid new life resuscitate the feeble frame, And in man deceased the vital lamp to burn With glorious glow in death's cold urn." I am quite familiar with the metallic tractors, as I long had a pair in my possession. They consisted of two small pieces of metal, one made of bright brass to resem- ble gold, the other of polished steel to simulate silver. They had no electrical power whatever, but Perkins gave out that they were made up of a peculiar and wonderful combination of metals of great intrinsic value and extra- ordinary virtue. They were sold for $25, but Dr. Worth- ington Hooker tells us they were made in a small village near New Haven for 12£ cents a pair. Yet my set was enclosed in a very neat and showy tortoise-shell case, in- laid with fine gilt brass rings which must have been quite expensive and greatly resembled gold. The casket was far more' precious than the contents, and doubtless equally valuable in the treatment and even cure of dis- ease. The tractors were about 3i inches long, shaped like very pretty spikes, thus : Fig. 3!K)0. They were flat on the inside and rounded on the out- side, so that when fitted together they seemed to make one apparatus. They were supposed to develop elec- tricity or galvanism by contact, as the whole world was daft about voltaic piles, galvanic batteries, and electri- cal machines, not only vastly large, but also almost in- finitesimally small. The tractors were said to be so powerful that it was not necessary to apply them to the naked skin, for they worked through the thickest cloth- ing, which was a great recommendation to the modest Quakers, of whom Perkins was one. The tractors were eulogized by the faculties of three colleges in the United States, but Elisha soon went to London, as a larger and probably a more lucrative field. He was warmly received by the Quakers and others as a countryman of the great Franklin. A Perkinian Institute was soon started, under the presidency of Lord Rivers, with a large proportion of its members from the titled, learned, and reverend. No less than eight professors, forty physicians and surgeons, and fifty clergymen soon joined it. It was ostensibly established chiefly for the benefit of the poor, and Elisha encouraged his friends to buy tractors not only for them- selves, but also for all their poor relatives and depend- ents. The Perkinian committee published reports of cures from time to time, which soon mounted up to five thousand in number. Some of the certificates wTere from the highest sources and of the most positive character. This is not to be wondered at, for twenty-five years later, viz., in 1823, Professors Chapman, Gibson, Dewees, and Mott gave scarcely less enthusiastic endorsements of Swaim's Panacea. The press groaned with pamphlets vaunting the curative effects of the tractors, and Elisha soon was in possession of £5,000. The Archbishop of Canterbury was implored to compose a new prayer, to be used in all the churches, that no evil powers might be allowed to impede the magic workings of the inestimable gifts of Perkins. In Copenhagen twelve physicians and surgeons of the Royal Frederick Hospital declared in favor of the tractors, and Fessenden roared out : " See pointed metals blest with power to appease The ruthless rage of merciless disease. O'er the weak part a subtile fluid pour Drenched with invisible galvanic power, Till the palsied, staff and crutch forgo, And leap exulting like the bounding roe." To prove that the cures were not mere faithrcures, the tractors were tried on sick horses, cows, sheep, dogs, infants, and idiots, and it was decided that fools and animals could be cured by them, as well as wise men and rational creatures. The exposure of this delusion was one of the neatest and most complete things that has ever been done in medicine. Drs. Haygarth and Falconer made wooden tractors painted to resemble the metallic ones, and quick- ly cured chronic rheumatism, gout, neuralgia, and many nervous disorders with them. Thermometers were grave- ly put in the mouths of credulous patients, who said they were greatly helped. Some were cured by the applica- 65 Tiiomsonianisin. Thorax. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tion of stethoscopes, which drew so strongly on some as to make them faint away, but more by the wooden trac- tors. Some were relieved immediately, others more slow- ly ; the weak and paralyzed began to use their limbs, and the improvement was sedately noted from minute to min- ute, watch in hand; while little Mary Hills exclaimed: " Bless me, who would have thought those little things could pull all the pain out of one." Drs. Haygarth and Falconer persuaded some of their patients to give public thanks in the churches and chapels for their recovery, and then published a volume filled with cures effected by the fictitious instruments. The overthrow of Perkins was sudden and complete, and the management of the whole disclosure was masterly. Then Elisha invented an antiseptic medicine, which he used with great success against low fevers, dysenteries, and ulcerated sore throat, or diphtheria. He became anxious to try its efficacy against yellow fever, and re- turned to New York in 1799, where he worked very hard and unselfishly for four weeks among the yellow-fever sick ; then he con- tracted the disease himself and died, in spite of his specific. The tractors were sup- posed to bring all the virtues of the royal touch to those who had five guineas to spare. The kings of England and France had for cen- turies been touching, and it is said curing, hundreds of thousands of per- sons each year, who were afflict- ed with scrofu- la, hence called "King's Evil." Few are aware of the slender be- ginning and basis of this delusion. The origin was stupid enough. In the time of Edward the Confessor, a pret- ty young noblewoman, af- fected with a lump on her neck, dreamed that she would be cured if the diseased part could be washed by the king's own hand. This Edward did, using quite warm water, and as suppuration had far advanced, the softened tumor broke and discharged its pus, followed by recovery ; espe- cially as the sign of the cross was made over the whole. The cure was regarded as miraculous, and in one year Edward touched eight thou- sand five hundred and seventy-seven cases. One person was convicted of high treason and executed for speifking contemptuously of this new divine power of the pious English king. John C. Peters. THORAX, MEDICAL AND SURGICAL APPLIED ANATOMY OF THE. Bones of the Thorax.-The bony framework of the thorax consists of the twelve dor- sal vertebrae behind, the sternum in front, and the ribs laterally. The clavicle, though belonging to the upper extremity, forms a protecting arch for the apices of the lungs and the large blood-vessels which cross the first rib, while the scapula protects a portion of the back of the thorax covering a space extending from the second to the seventh rib. The dorsal region of the spine is re- markable for its fixity, and for this reason is less subject to sprains than either the cervical or the lumbar portions of the column ; but the upper part of the dorsal spine shares with the cervical a special liability to fracture and dislocation. The spines of the dorsal vertebra} being large and more projecting than those of any other part of the cord, are most liable to separation by a sharp cutting blow. The sternum in some cases is indented at its lower end, or in others is divided for a greater or less extent, forming the fissura sternalis. This fissure may be incomplete, forming a longitudinal opening in the bone, the foramen sternale, an anomaly which in some instances has been found in connection with ectopia cordis. The sternum, being of a soft and spongy formation and supported by yielding structures, is rarefy fractured ex- cept by direct violence, such as a gunshot wound. The fracture, when occurring by indirect violence, is usually situated at the junction of the first with the second piece and is transverse in direction. There is a record of but one case of fractured sternum at the Hotel Dieu of Paris during eleven years (M. Ferrier), and Lons- dale cites but one example out of 1,901 cases of fracture treated in the Mid- dlesex Hospital. The Ribs.-On the first rib is the scalene tubercle, which marks the attach- ment of the scale- nus anticus mus- cle and forms a boundary line be- tween the subcla- vian artery and vein, and is of important use in finding the third part of the sub- clavian artery in the operation for ligature of that vessel. Fracture of a rib generally takes place just externally to the angle, and is most commonly the re- sult of indirect violence, as for example, when a person is squeezed between two bodies. The results of fracture from direbt, differ greatly from those from indirect, violence ; in the former case the broken and jagged ends of the ribs are forced inward, causing in- jury of pleura and lung, and rendering the prognosis very grave ; while, on the other hand,indirect violence forces the fractured ends outward and no injury to internal parts results. Fractures of the ribs have been caused by violent cough and by the efforts of parturition. Holmes mentions a case of recovery in a young woman, where, as far as could be ascertained, every rib in the body was broken and extensive injury inflicted on the brachial plexus of one side. The ribs which commonly escape fracture in a general crush of the chest are the first and second above, owing to their protected position, and the floating ribs, owing to their mobility. The fourth to eighth ribs are most frequently broken. When ribs are fractured absolute rest is not possible, consequently union by provisional callus is more frequently met with in them than in any other bones of the body. The intercostal arteries run in a groove on the under surface of each rib. This groove is deepest and affords the greatest amount of protection in the middle third of a rib, the part most exposed to injury. Fig. 3901.-Copied from "Dwight's Frozen Sections of a Child," by permission. 66 TIiomsonlaniMm. Thorax. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Posteriorly, tiie dorsal muscles cover the artery, while in front the artery having become small, protection is no longer necessary. The ribs are plentifully supplied with blood, hence the rapidity of their union after fracture. Superficial Anatomy of the Chest.-The thorax, when viewed in a hanging skeleton, is much longer behind than in front. The anterior wall is inclined at an angle of 20° to 25° with the vertical. In expiration the upper border of the first piece of the sternum is on a level with the disk between the second and third dorsal vertebrae, and barely two inches from it; the junction of the man- ubrium and gladiolus is opposite the body of the fifth dorsal vertebra; and the xiphi-sternal articulation is about on a level with the interspace between the ninth and tenth dorsal vertebrae. The superior aperture of the thorax, viewed from above, is reniform, the vertebral column projecting into it. The inferior aperture is irregular, its margins as- cending so as to form the subcostal angle in front. The antero-posterior diameter of the thora- cic cavity is shortened by the projection of the dorsal vertebrae. In a vertical frozen section of the chest the vertebral column will be seen to occupy more than half the antero-posterior di- ameter. (For Deformities of the Chest, see Vol. II., p. 80.) On the surface the spines of the dorsal vertebrae do not correspond di- rectly with the lev- el of the bodies of the vertebrae or with the costo- vertebral articula- tions. The spine of the second dor- sal, for example, is on a level with the head of the third rib; the spine of the third dorsal vertebra with the head of fourth rib, and so on, but in a less degree, down to the lower end of the dorsal vertebrae. At the elev- enth and twelfth dorsal vertebrae the spines lie upon the same level with the ribs. The spines of the vertebrae may be rendered evident for surface marking by brisk rubbing, but in fat subjects they are not so easily made manifest. A few landmarks may be depended upon as aids in counting the dorsal vertebrae. The spine of the scapula lies on a level witli the spine of the third dorsal vertebra, while the seventh spine corresponds with the line of the angle of the scapula. The twelfth dorsal spine is on a level with the head of the last rib. The oesophagus and the trachea begin their course downward at a point cor- responding to the interval between the sixth and seventh cervical spines. The apex of the lung reaches as high as the vertebra prominens, and corresponds to the neck of the first rib. The oesophagus inclines somewhat to the left, and at the ninth dorsal spine joins the cardiac end of the stomach. The vena cava perforates the diaphragm at the same level. At the fourth dorsal spine the arch of the aorta reaches the left side of the vertebral column ; the bifurcation of the trachea takes place at the same level. The fourth, fifth, sixth, seventh, and eighth spines correspond to the heart. The lower edge of the lung lies upon a level with the tenth dorsal spine, ami the lowest part of the pleura on a level with the twelfth dor- sal spine. The cartilage of the second rib corresponds to the trans- verse ridge which marks the boundary between the first and second pieces of the sternum. The prominent lower border of the pectoralis major corresponds to the fifth rib. The lower ribs can be felt through the latissimus dorsi outside the edge of the erector spinae. The twelfth is very short, and often cannot be felt extending beyond the border of the erector spinae. The ribs should always be counted from above downward. The pectoralis major, by its lower border which over- lies the fifth rib, forms the anterior axillary fold. Ex- ternally to the pectoralis major the chest-wall is covered by the serratus magnus, whose first visible serration cor- responds with the sixth rib. At the upper border of the pectoralis major, where it runs alongside the deltoid, there lie the cephalic vein and the descending branch of the acromial thoracic artery. Just under the clavicle in this furrow the coracoid process of the scapula can be felt. The nipple is, in most subjects, found in the fourth interspace, four inches from midline, but its position varies. Behind the first piece of the sternum lie the remains of the thymus gland, the origins of the ster- no-hyoid and ster- no-thyroid m u s- cles, and the left vena innominata, which crosses the middle line just behind the epister- nal notch. The innominate artery begins its course at the middle of the junction of the manubrium with the gladiolus, and ends behind the s t e r n o-clavicular articulation. The trachea bifurcates opposite the junc- tion of the pre- with the meso-ster- num, and one inch below the upper border of the sternum the arch of the aorta reaches its highest part. The Lungs.-The apex of the lung projects into the neck to a variable extent, usually from one-half inch to one inch and a half above the level of the clavicle, where it lies between the sternal and clavicular origins of the sterno-mastoid muscle. The lungs then converge from the apices toward the midline in front, almost meeting at a point opposite the junction of the manubrium with the gladiolus, so that from this point as far down as the junction of the fourth costal cartilage with the sternum, the thin anterior edges of the lungs come together, the edge of the right lung extending over the middle line; but behind the manu- brium there is little or no lung. In a vertical section made by the writer through the midline of the chest from before backward, a thin slice of the right lung, one-half inch wide, appeared on the left half of the section. The edge of the left lung abruptly passes outward and downward in a direction represented by a line drawn from the centre of the sternum opposite the fourth costo- sternal articulation, to a point corresponding to the apex of the heart. The edge of the right lung continues down- ward in a straight line as far as the sixth costo-sternal articulation, when it follows the direction of the carti- lage of the sixth rib. At the lower part of the chest- wall the inferior margin of the lung corresponds with the Fig. 3902.-(After Dwight.) 67 Thorax. Thorax. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES sixth rib in the mammary line, with the eighth rib in the axillary line, and with the tenth rib in the vertical line let fall from the angle of the scapula. The wThole lower limit of the lung is represented on the right side by a line drawn from the junction of the sixth costal cartilage with the sternum to the tenth dor- sal spine. The lower border of the lungs ascends with lee). But the level of the pleura is lower than that of the lung, its lower limit behind corresponding most fre- quently with the head of the twelfth rib or even lower, and from this point it ascends and passes around the chest behind the seventh costal cartilage to the sternum. On the left side the edge of the pleura extends over the peri- cardium considerably beyond the corresponding lung. Heart Limits. - The writer has verified by cross-section of a frozen body the statement that the upper limit of the heart corresponds to the upper edge of the third costal cartilage at its junction with the gladi- olus. Laterally, the heart extends on this level one-half inch to the right and one inch to the left of the ster- num. To map out the heart limits the apex must be looked for at a point two inches below the nipple and one inch to its sternal side, that is, at the fifth inter- space. The right ex- tremity of the base line must be joined to the lower end of the gladi- olus, the joining line being made to curve outward. Next, t h e line at the lower end of the gladiolus should be made to join the apex point, and, lastly, the apex is joined to the left base extremity by an outwardly curved line. The outline thus formed on the chest- wall is known as the area of deep cardiac, dulness, and must be distinguished from the area of superficial or ab- solute cardiac dulness. This latter term is ap- plied merely to the area of chest-wall with which the heart is in apposition, and over which a dull note is elicited on percussion. Beginning above at the centre of the ster- num, opposite the fourth costo-sternal ar- ticulation, a line is drawn downward with an outward curve to the apex of the heart and another to the lower end of the gladiolus. These two lines limit cardiac dulness on either side ; below it is continuous with that of the liver. At the bedside the ex- tent of cardiac dulness is measured in inches, beginning at the point in the middle of the sternum for vertical dul- ness, and for the breadth of the dull area measurements are taken right and left of the lower end of the sternum and expressed in inches. Position of the Valves of the Heart.-The pulmonary semilunar valves lie in front of those of the aorta and Comes nerve , p/erenict art. TnHmammarr/ art. \ J Fig. 3903.-The Thoracic Contents as Seen on Removal of the Chest wall. (From F. Weisse's Practical Human Anat- omy, by permission.) expiration and descends with inspiration to the extent of one inch or even more. ' ' The position of the great fissure in each lung may be ascertained approximately by drawing a line from the second dorsal spine to the sixth rib in the nipple line ; and the smaller fissure of the right lung ex- tends from the middle of the foregoing to the junction of the fourth costal cartilage with the sternum " (R. J. God- 68 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tliorax. Thorax. behind the upper edge of the third left costal cartilage, close to the sternum, the pulmonary artery itself proceeding upward to bifurcate opposite the second left costal carti- lage. The aortic valves are on a lower level, correspond- ing to a point on the left border of the sternum, close to the lower edge of the third costal cartilage. The aortic trunk ascends from this point to get behind the second right costal cartilage, close to the sternum. The mitral valves lie further out in the third interspace, one inch from the sternum. The tricuspid valve is found in the centre of the chest, opposite the fourth chondro-sternal articulation. These points, it must be re- membered, are but the anatomical positions of the valves ; clinically, we are more interested in the localities where the sounds at the orifices are loudest. We mean, therefore, by the area of a valve, that portion of the chest-walls in which morbid sounds gener- ated by that valve are heard with greatest in- tensity (see Chest, Vol. II., p. 88). The aortic arch leaves the situation of the valves to pass upward and to the right, in the direction of the right edge of the sternum op- posite the second costal cartilage. The trans- verse arch, starting from this point, crosses the midline of the body about an inch from the supra-sternal notch. The innominate artery is given off opposite the middle of the junction of the manubrium with the gladiolus, and bi- furcates behind the sterno-clavicular articu- lation. The superior vena cava lies partly behind the right border of the sternum, being formed behind the junction of the first costal cartilage of the right side with the sternum, and descend- ing nearly vertically to the base of the heart, where it ends just be- hind the upper border of the third costal car- tilage. The left innominate vein crosses the middle line behind the upper part of the manubrium, being separated from the bone by the lower ends of the sterno-hyoid and sterno-thyroid muscles, and by the thymus gland or its remains. The internal mammary artery lies at first behind the cartilages of the first rib, whence it descends vertically behind the costal cartilages about half an inch from the border of the sternum, as low down as the interval between the sixth and seventh cartilages, where it ends by dividing into two branches. The Back.-The most prominent spine is that of the first dorsal, but the first to appear is the seventh cervical, or in some cases the sixth cervical. The upper angle of the scapula corresponds with the second rib, or with the interval between the first and second dorsal spines, the Fig. 3904,-The Pericardium and the Arch of the Aorta, with their Relations. (From F. Weisse's Practical Anat- omy, by permission.) lower angle of the scapula being at the level of the sev- enth intercostal space, when the arms are hanging by the side. The root of the spine of the scapula is on a level with the interval between the third and fourth dorsal spines. Nerve-supply of the Skin of the Thorax.-1The skin of the front of the thorax is supplied by the anterior cuta- 69 TIi orax, Tliorax. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. neous branches of the upper intercostal nerves, while the sides derive their sensation from the lateral cutaneous offsets of the same nerves. The course of an intercostal nerve lies at first between the pleura and the external in- tercostal muscles, then between the internal and external intercostal muscles, then between the internal intercostal muscle and the pleura. Lastly, the nerve pierces the in- ternal intercostal and the pectoralis major close to the sternum, and ends as an anterior cutaneous nerve of the thorax. (Fig 17, Vol. I.) The lateral cutaneous branches are given off half-way between the spine and the sternum, perforate the external intercostal muscle, and on coming to the surface divide into an anterior and a posterior branch. The area of skin between this posterior branch of the lateral cutaneous and the spine is supplied by the posterior primary division of the corresponding inter- vertebral nerve. Thus, there are three sets of branches (counting the posterior) wdiich make their way to the sur- face, and in some cases of intercostal neuralgia pain may be elicited on pressure at these points. " In long stand- ing cases acutely tender points are developed in one or more of these situations ; not infrequently the most de- cided of these spots is where it gets overlooked, namely, opposite the intervertebral foramen " (Anstie). The nerves most frequently involved are the sixth, seventh, eighth, and ninth. Pain situated between the shoulders is usually con- nected with cardiac disease, aortic disease, or malignant disease of the oesophagus, and is strongly suggestive of pressure upon the structures in the posterior mediastinum. Pain lower down, between the middle of the scapula and the lumbar region of the spine, suggests disease of the digestive apparatus, the pain being carried to the surface probably by means of the splanchnic nerves. The intercostal spaces are wider as they approach the sternum. The widest space is the third, the last four are the narrowest. The index-finger can be passed through the first five. The Pericardium.-The normal outline of the pericar- dium is pyriform, with the small end uppermost, the base resting upon the diaphragm. Above it is extended over the great vessels of the heart as high as two inches from their origin, and is there connected with the deep cervical fascia. In pericarditis with effusion, the outline of the percussion dulness becomes that of a truncated pyramid, with its apex in some cases as high as the clav- icle or above it, and the base extending beyond the point of apex beat to the left, especially if the patient be made to lie upon the left side. The outline of dulness, pro- vided there be no pleurisy on either side, is mobile, and when the patient returns to the right side the line is again altered. Paracentesis Pericardii.-In this operation the aspirator needle is passed at a spot from two to two and one-third inches beyond the left edge of the sternum, in the fourth or fifth interspace. Relations of the Pericardium.-The pericardium rests upon the diaphragm, which separates it from the liver. Hepatic abscess has been known to have caused death by bursting into the pericardium, and the writer has known death to have occurred from malignant ulceration of the stomach, which allowed the food to pass into the sac of the pericardium. When fully distended, the pericardium has not been observed to produce many pressure-effects on neighboring organs. Of the contents of the posterior mediastinum, those which lie nearest the pericardium are the oesophagus and the left vagus nerve. Dysphagia, though it has been noted (Stokes) as a result, has been found absent when even as many as thirty-six ounces of fluid have been in the sac. But the pericardium is not easily distended, ten ounces of fluid being the largest amount it can be made to hold on post-mortem injection, when the heart is in situ (Holden), so that any irruption of blood or stomach contents causes immediate death by pressure upon the heart. An abdominal hernia has been known to work its way into the pericardium. In puru- lent pericarditis the pus may make an opening in the vicinity of the ensiform appendix. The ^ediastina. - The superior mediastinum is the space formed by the divergence of the pleurae above, and is limited below by an imaginary line drawn from the junction of the manubrium with the gladiolus to the lower part of the body of the fourth dorsal vertebra. The upper limit is represented by the superior aperture of the thorax. In front, this mediastinum is bounded by the upper piece of the sternum and the origins of the sterno-hyoid and sterno-thyroid muscles, and behind-by the upper four dorsal vertebrae and the lower part of the longus colli muscle. Structures important in their rela- tion to thoracic aneurism are found in this mediastinum- the trachea, the oesophagus, the thoracic duct, the trans- verse portion of the aorta, the innominate artery, the thoracic portions of the left common carotid and sub- clavian arteries, the innominate veins and superior vena cava, the phrenic, pneumogastric, the left recurrent and cardiac nerves, the lymphatic glands, and the remains of the thymus gland. The anterior mediastinum, narrow above, where the two pleurae come almost or actually in contact behind the up- per part of the gladiolus, is broader below by reason or the recedence of the left pleura from the right. In front, the mediastinum is bounded by the sternum with the fifth, sixth, and a small portion of the seventh, left costal car- tilages, and by the triangularis sterni muscle ; the peri- cardium lies behind. The anterior mediastinal glands, whose efferent ducts empty into the right and left lymphatic trunks, together with some areolar tissue, are the only contents. The middle mediastinum contains the pericardium and its contents, the phrenic nerves and accompanying ves- sels, the arch of the vena azygos major, the roots of the lungs, and the bronchial lymphatic glands. The posterior mediastinum is the space bounded in front by the pericardium, behind by the vertebral col- umn, and on either side by the pleura. Its contents are the descending part of the arch of the aorta, and the thoracic aorta ; the oesophagus and pneumogastric nerves, the azygos veins, the thoracic duct, and the posterior mediastinal glands. The Heart and Great Vessels.-The Heart.-The right auricle is hidden by the anterior margin of the right lung, and it is only in pericardial effusion, when the right lung is pushed aside, that it comes into contact with the sternum and costal cartilages and can be recog- nized clinically. The right auricle is the most variable in size of all the cavities of the heart. A penetrating wound to the right of the sternum, passing through the sternal ends of the third, fourth, and fifth costal carti- lages, or the intervening intercostal spaces, would involve the right auricle. The point of the auricular appendix is exactly behind the middle line, on a level with the upper border of the third costal cartilage. The right ventricle, occupying the chief part of the front of the heart, is the cavity most frequently wounded by stabs or gunshot wounds, and "extends from above down from the third to the sixth cartilages on the left side. The conus arteriosus is the most projecting part, being uncovered by lung " (Quain). The left auricle is the only cavity not seen from the front, though its auricular appendix may be seen at the side of the pulmonary artery ; posteriorly, it is in relation with the oesophagus and the contents of the posterior mediastinum, while the pulmonary artery lies in front of it. On the surface, the left auricle " extends vertically from the level of the lower border of the second left car- tilage to the upper border of the fourth ; and in breadth corresponds to the body of the eighth dorsal vertebra and the head of the adjoining rib. The apex of its ap- pendage is in the lower part of the second intercostal space, or behind the third costal cartilage, about an inch and a quarter from the left of the sternum." Left Ventricle.-The rounded margin formed by the left ventricle extends on the left side from the third car- tilage to a point in the fifth space, two inches vertically below the nipple. The sharp margin formed by the right ventricle passes from the sternal end of the sixth cartilage on the right and passes behind the seventh right cartilage, the ensiform (at its upper third), and the 70 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Thorax. Thorax. seventh left cartilage, to meet the other margin at the apex. The auriculo-ventricular sulcus corresponds with a line drawn obliquely upward from near the sternal end of the sixth costal cartilage of the right side to the third cartilage on the left. Size of the Heart.-The heart has been said (by Laennec) to be about equal in size to the shut list. Usually the di- mensions are, live inches long, three inches wide at its widest part, two and a half inches thick from before backward. The mean weight is from nine to ten ounces. Pulmonary Artery.-The main trunk of the pulmonary artery, nearly two inches long, takes a course upward and backward, bifurcating under the arch of the aorta, and is situated behind the upper portion of the third left cartilage on a level with the body of the seventh dorsal vertebra. " As the artery ascends to the left of the ascend- ing aorta, it occupies the second left space and cartilage for four-fifths of its breadth, and is covered by the left border of the sternum for the remaining fifth " (Sibson). The pulmonary artery in the beginning of its course lies middle lobe, and the lower branch the lower lobe. The left branch of the pulmonary artery, shorter and smaller, crosses the descending aorta to divide into two branches, one for each lobe of the left lung. The right and left branches of the pulmonary artery lie in front of the body of the sixth dorsal vertebra and on a level with the sec- ond intercostal space. The intimate relation of the branches of the pulmonary artery with the other struct- ures in the root of the lung, is well illustrated by a case occurring in the Montreal General Hospital, where an ul- cer of the left bronchus perforated the neighboring pul- monary artery and caused death by haemoptysis. Pulmonary Veins.-Of the two pulmonary veins those of the left side are usually higher than those of the right, and enter the auricle at a point more nearly opposite the centre of the spine. The right pulmonary veins are on a level with the spines of the fifth and sixth dorsal verte- brae, and the two left pulmonary veins, holding a higher position, are respectively just above the level of these two spines. Tice Aorta.-The ascending portion of the arch of the Fig. 3905.-Parts Seen on Opening the Pericardium. (From F. Weisse's Practical Human Anatomy, by permission.) in front of the root of the aorta, with the auricular ap- pendages and the right and left coronary arteries on either side of it, whence it passes to the left of the ascending aorta. Both these large vessels are enclosed in a single sheath of the pericardium and are connected by loose areolar tissue. The ductus arteriosus, which in foetal life connected the pulmonary artery with the aorta, now exists merely as a fibrous cord passing from the pulmo- nary artery, to the left of its bifurcation, to the under surface of the aortic arch. The trunk of the pulmonary artery is likely to be influ- enced by pressure from without. Thus, on the right side, an aneurism of the ascending aorta may press against, or even burst into, either the trunk of the artery itself or one of its branches. Posteriorly, the pulmonary artery lies upon the left auricle of the heart. The right branch lies behind the ascending aorta and superior vena cava, pass- ing into the root of the right lung and dividing into two branches, of which the upper supplies the upper and aorta begins at the upper part of the left ventricle, oppo- site the middle of the sternum, on a level with the third costal cartilage, whence it passes obliquely upward and to the right as high as the upper border of the second right costal cartilage. The right border of this part of the aorta is situated behind or a little to the left of the right edge of the sternum, and the left border, partially cov- ered by the right border of the pulmonary artery, is about one-fourth of an inch to the right of the left edge of the sternum. The pulmonary artery lies to the front and left side of the ascending aorta, while on the right side there lie the superior vena cava, the right auricle, and the right auric- ular appendix. Behind, the aorta lies upon the right pulmonary artery and the root of the right lung. An an- eurism of the ascending aorta pushes toward the front, and not uncommonly produces a bulging of the front of the chest. Such aneurisms, too, have been known to burst into the right auricle, into the bronchus, or into the peri- 71 Thorax. Thorax. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. cardium, covering the first part of the aorta ; but the most common direction of the rupture is either externally or into the right pleural sac. Injurious pressure may be exerted upon the superior vena cava or on the innominate veins. Transverse Arch.-The transverse part of the arch ex- tends from the upper border of the second costal cartilage of the right side, close to the sternum, to the left side of the body of the fourth dorsal vertebra, its course being almost directly backward. The sections represented in Figs. 3904 and 3905 pass through the transverse aorta and serve to illustrate its relations. The left pleura lies against its anterior surface, or, more truly, lies to the left of it. A tumor of the arch would compress the left lung and seri- ously interfere with respiratory action. The left phrenic nerve crosses the arch on its way to the diaphragm, lying between the aorta and the anterior margin of the left pleura. At a much deeper level the left vagus crosses the aorta, giving off around it the recurrent laryngeal branch. The cardiac branches of the left sympathetic nerve also cross the left surface of the arch on their way to join the cardiac plexuses. Pressure upon any of these structures produces distinc- tive symptoms. The cardiac nerves, when subjected to pressure, give rise to severe pain, which in some cases re- sembles that of angina pectoris. The recurrent laryngeal nerve on the left side, as it winds around the arch, be- comes subject to pressure from an enlargement of the arch. This nerve is the motor nerve of the muscles of the left side of the larynx ; consequently, when it is irri- tated by pressure, spasm of the left vocal cord is pro- duced and paralysis of the cord follows. These changes may be watched by means of the laryngoscope. Dyspep- tic symptoms are said to be produced by similar pressure upon the pneumogastric. The effects of interference with the phrenic nerve are not commonly observed, but cases in which hiccough and unilateral paralysis of the diaphragm have been set up by interference with it, have been placed upon record. The parts behind the arch of the aorta are : (1) The left recurrent laryngeal nerve, which winds around it from below in order to get into its position between the oesophagus and the trachea ; the relation of this nerve to the great vessel renders it specially liable to pressure, since it is in relation with it in front, behind, and be- neath. (2) The oesophagus, which lies against the verte- bral column almost in the middle line of the body, and near the left extremity of the transverse arch. Refer- ence to Fig. 3906 will explain the infrequency of dyspha- gia from pressure by aneurism of the arch, for the gullet is placed in such a position that an enlarged arch has no neighboring solid body against which pressure can be made. (3) The trachea is in close relation with the pos- terior half of the transverse arch, and is often subject to a varying degree of pressure, giving rise to hoarseness and stridor of breathing. Aneurisms not uncommonly open into the windpipe and cause a fatal haemoptysis. (4) At the point where the thoracic aorta reaches the spine, i.e., between the body of the fourth dorsal vertebra and the aorta, lies the thoracic duct, which is rarely inter- fered with by morbid growths. (5) The deep cardiac plexus is placed behind the arch of the aorta, between it and the trachea, above the bifurcation of the pulmonary artery. The anginal attacks met with in cases of aortic aneurism are attributed to pressure upon this plexus of nerves. The top of the arch is crossed by the left innominate vein, and from its summit are given off the innominate, left carotid, and left subclavian veins. Beneath the arch are found the left bronchus, the right pulmonary artery, the left recurrent laryngeal nerve, and the remains of the ductus arteriosus. Compression of the left bronchus not uncommonly occurs in aneurism, and rupture of the sac into this tube has been recorded. The descending part of the arch of the aorta extends from the left side of the body of the fourth dorsal ver- tebra to the lower border of that of the fifth dorsal ver- tebra, when it becomes the thoracic aorta. Here the artery lies between the pleura and the vertebral column, with the root of the left lung in front of it, and the oesopha- gus and thoracic duct to its right. Of these relations, that to the vertebral column is the most important. The common tendency of aneurism in this situation is to grow in a backward direction and produce erosion of the bodies of the vertebrae. Owing to their deep position in the chest, such tumors are not readily detected, and the neighboring structures not being in such intimate rela- tion as in the other parts of the arch, pressure symptoms are usually absent; nevertheless the heart may be pushed forward or the tumor may interfere with the circulation in the intercostal vessels. In a case of aneurism of the descending aorta, where there existed a tumor opposite the spine of the scapula on the left side of the vertebral column, and which was under the observation of the writer for some eighteen months, localized sweating was observed over the region of the fifth and sixth ribs on the left side, the result of pressure upon the intercostal nerves. The innominate artery has in front of it the manu- brium, the thymic remains, and the origin of the sterno- hyoid and sterno-thyroid muscles, and is crossed by the leftbrachio-cephalic vein, and by the right inferior thyroid vein. The artery may press forward when it is enlarged and erode the sternum, or may even dislocate the sternal end of the clavicle. The trachea lies behind the innomi- nate artery, while to the right side are found the right pneumogastric nerve, the right innominate vein, and the right phrenic nerve, and to its left the origin of the com- mon carotid artery and the trachea. The proximity of the innominate artery to the superior vena cava, enables an aneurism of the artery to shut off completely the current in the vein. In a patient of the writer's, the innominate aneurism interfered with the blood-current in the left subclavian artery, as was shown by sphyginographic tracings, while the current through the aneurism re- mained uninterrupted. The relations of the common carotid artery in the thorax are similar to those of the innominate artery ; but, owing to its deeper situation, it comes into relation with the oesophagus and thoracic duct. The subclavian artery of the left side, inside the thorax, lies upon the oesophagus and thoracic duct, and after- ward upon the pleura, a relation which renders opera- tions upon the subclavian artery dangerous, since pleurisy often follows upon ligature of the subclavian, even in its third part, and it was owing partly to this complication that the operation in the second part of the artery had to be abandoned. Internal Mammary Artery.-The inosculations of the internal mammary artery are very numerous, and play an important part in many of the obstructions of the cir- culation in the upper part of the trunk. At first the ar- tery lies between the sac of the pleura and the cartilage of the first rib ; from this point it descends vertically along the chest-wall half an inch from the border of the sternum, and at the interval between the sixth and seventh cartilages it divides into terminal branches-the musculo- phrenic and the superior epigastric. The superior phrenic branch affords means of communication with the phrenic branches of the abdominal aorta as well as with the mus- culo-phrenic branches of the internal mammary itself. The mediastinal, pericardiac, and sternal branches, to- gether with the superior phrenic, bronchial, and inter- costal arteries, form beneath the pleura a network called the subpleural mediastinal plexus. The internal mam- mary communicates with the aorta by the anterior inter- costal branches, which, in the chest-wall, communicate with the intercostal arteries. The mammary gland re- ceives a blood-supply from both the intercostal and the perforating branches of the internal mammary, and in the substance of the gland anastomosis takes place with the superior and long thoracic branches of the axillary. The superior epigastric is the most important branch ; being the continuation of the main trunk it descends be- tween the sternal and costal portions of the diaphragm into the wall of the abdomen, where it lies at first behind the rectus between the muscle itself and its sheath ; then entering the muscular tissue it communicates directly 72 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Thorax. Thorax. with the termination of the deep epigastric ; thus a complete by-path is formed, enabling the circulation to be carried on whenever an obstruction occurs in the course of blood through the abdominal aorta. Wounds of the internal mammary artery are rare. The danger arises from slow haemorrhage into the an- terior mediastinum or into the pleura. In the upper and larger intercostal spaces the vessel may easily be secured, but with greater difficulty in the lower ones. The opera- tion is most easily per- formed in the second space, but below the fifth space the ar- tery cannot be se- cured. An ab- normal arrange- ment of the internal mam- mary artery, described by seve- ral an- ria interna of Henle) which came off from the second part of the subclavian artery, on both sides, running downward on the inner surface of the chest-wall beneath the pleura, midway between the sternum and the vertebral col- umn, but rather closer to the former. At each intercostal space anterior and posterior branches were given off, taking the place of the intercostal ar- teries. Pleura. - The apex of the pleura is in rela- tion with the first and second parts of the subclavian artery, and on the right side with the innominata, and it extends from a half to one and a half inch above the clavicle. Ligature of the sub- clavian artery has been followed by inflamma- tion of the pleura, ow- ing to this relation. At the level of the junc- Fig. 3906.-A Section through the Chest (from Dwight's Frozen Sections of a Child) passing through the Third Dorsal Vertebra, and cut- ting the Transverse Portion of the Aorta. This Figure, which Dr. Dwight has kindly permitted us to use, is introduced to illustrate the course of the aorta, to show that it is almost directly from before backward, and that the structures, the phrenic and pneumogastric nerves, commonly described as lying in front of it, really lie to the left side of it. atomists, and in one i n- stance met with by the writer in the dissecting room of Mc- Gill College, might embarrass the surgeon in the performance of paracentesis thora- cis. The normal in- ternal mammary was very small, and its place taken by a large branch (arteria mamma- 73 Thorax. Thorax. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tion of the second costal cartilage with the sternum the pleura on the left side comes into relation with the arch of the aorta and with the phrenic and pneumogastric nerves lying between them. Rupture of the pleurae is a not uncommon result of aneurism of the arch, and the softness and elasticity of the lung explains the infre- quency of interference with these nerves when the arch is enlarged. Behind the manubrium the two pleurae are separated by a considerable interval containing cellular tissue, and in young children the thymus gland. The two pleurae do not touch one another until they arrive at a point opposite the second costal cartilage. Thence the right pleura descends in the line of the middle of the sternum, while the left leaves the middle line at the fourth costal cartilage, to make room for the front of the heart. The right pleura extends nearer the median line, so as to include the internal inarqmary artery between it and the chest-wall. The internal mammary is not in re- lation with the pleura on the left side. At a lower level, about opposite the sixth costal carti- lage, the inferior cava comes into relation with the right pleura as well as the right auricle, the pericardium inter- vening, and on the left side the descending aorta lies against the vertebral column and the left pleura. The oesophagus is in relation with the posterior and internal edge of the right pleura, lying between it and the aorta. Hence the extension of disease to the right pleura in cases of carcinoma of the oesophagus. It must be borne in mind that the pleura extends downward lower than the lung, reaching as low as the seventh costo-sternal artic- ulation in front, and corresponding to the eleventh dorsal spine behind, and at the sides to a point two and a half inches above the lower margin of the thorax. Wounds of the pleura and diaphragm may occur without involve- ment of the substance of the lung. The under surface of each pleura is in relation with the diaphragm (see Dia- phragm, Vol. II.). The arteries of the pleura are derived from the inter- costal, internal mammary, phrenic, inferior thyroid, thy- mic, pericardiac, and bronchial. The phrenic and the sympathetic nerves afford the nerve-supply. The supply to the pleura by the intercostal nerves rep- resents, according to Hilton, an analogy between the pleura and one of the joints, the same nerve supplying a joint supplies the muscles moving the joint and the skin over the joint. The pain felt in the skin of the chest when acute pleurisy is present is thus explained, and, moreover, when, in the same disease, pain passes into the axilla, it must be remembered that intercostal nerves also pass to that region, notably the nerve of Wrisberg. For similar reasons pain is in other cases felt beneath the clavicle, or along the sternum to the hypo- chondrium, so that a mistaken diagnosis of hepatitis has been made, or to the loins, simulating lumbago. Fagge mentions a case where the pain was complained of in one crista ilii. Empyema.-When pus fills the pleural cavity, perfora- tion may take place at any of several points, but that at which escape is most likely to occur is situated in the fifth interspace. " The external intercostal muscle terminates, as usual, near the costalcartilages, to the outer side of the spot in question, and beyond which, toward the sternum, only a thin fascia covers the internal intercostal muscle. The pectoralis minor is altogether above the fifth space. The rectus abdominis limits the spot on its inner side. Superficially the pectoralis major overlies the spot. The pleural sac in this situation is covered by but few struct- ures, and those not over-strong, the internal intercostal muscles, the thin intercostal fascia, the weakest part of the pectoralis major, and the external oblique, together with the common fascia and the skin. On the surface this spot is represented in the fifth interspace in the mammary line ; it also corresponds nearly with the mid- dle of the pleural cavity when that is much distended. An empyema may be regarded as a great pleural abscess, and, as we know, abscesses often point opposite their centre. It is further true that the fifth intercostal space is wider than those below it, and its limiting ribs being held to the sternum, give firmness to its borders, conditions which may help the thinness of the chest-wall here in determining the place of perforation. The spaces above are still wider and equally wrell supported by the ribs, and there is an interfascicular part of the great pec- toral over the second space, where it is said often to take place in children." 1 But it must not be thought that this is the only point of discharge ; openings have been found as high as the second intercostal space, or the diaphragm may be per- forated and pus escape into the peritoneum (Fagge). The pus of an empyema may travel under fasciae and open in the loins or even in the popliteal space. Paracentesis thoracis is commonly performed in the sixth or seventh interspace between the digitations of the serratus magnus, the trocar being made to pass near the lower border of the space, so as to avoid the inter- costal artery, which runs along the groove in the ridge above. At a lower point in the chest-wall there may be danger in wounding the diaphragm, more especially on the right side. Cases have been reported ("Archives Generales de Medecine," 1886) where this accident has followed the puncture of the chest in the seventh inter- costal space, and one instance is recorded of the dia- phragm rising as high as the sixth interspace. It is, however, a common practice to open the pleural cavity lower than the seventh, even as low as the eighth or ninth interval. The lower the opening the better the drainage, and when foreign bodies make their way into the pleura, a low opening is indispensable for their re- moval. " In wounds of the chest-walls the intercostal arteries usually seem to escape.; or at least they do not often bleed in a troublesome way" (Erichsen). The Phrenic Nerves (see Phrenic Nerve).-The main origin of the phrenic nerve is from the fourth cervical nerve, but usually an extra root is derived from the third or fifth nerve. At the upper part of the thorax the nerve lies between the subclavian artery and vein, then crosses the root of the lung, and lying between the pleura and the pericardium, reaches the diaphragm, where it divides into filaments which perforate that muscle and are dis- tributed on its under surface. In the living subject the course of the phrenic is represented by a line drawn from a point taken at the level of the cricoid, midway between the anterior and posterior margin of the sterno- mastoid, to another point just behind the sternal end of the clavicle. Roots of the Lungs.-The roots of the lungs are each formed of the pulmonary artery of that side, two pul- monary veins, a bronchus, the bronchial branches of the aorta, the pulmonary plexus of the vagus, and some lym- phatics. These structures will now be considered as a whole. Afterward the medical anatomy of each will be dealt with separately. The root of the right lung has in front of it the supe- rior vena cava, the ascending aorta and the phrenic nerve. Aneurism of the ascending part of the arch is accompa- nied by such pressure signs as pain, dyspnoea, and cough, with alterations of the right lung from pressure either directly upon it or upon the right bronchus. The vena azygos major winds around the top of the root of the right lung from behind, and is enlarged when the vena cava superior is in any way interfered with. Posteriorly the right root of the lung is in relation with the pleura and the vertebral column. The root of the left lung lies in front of the aorta, and suffers from pressure when an aneurism is situated on the descending aorta. The pulmonary nervous plexus lies in front of and behind the root, and beneath it is in relation with the pleura. The Coronary Arteries.-The first branches of the aorta supply the substance of the walls of the heart. Atheroma, thrombosis, and aneurism are met with in these arteries as in those of the rest of the body. Obstruction of the coronaries, as experimentally performed in the rabbit by Gmenhagen and Samuelson, caused retardation of the rhythmical action of the heart, especially of the left ven- tricle, while the contractions of the right ventricle were at first more active and then became slowly retarded. 74 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Thorax. Thorax. Compression of the left coronary artery caused a gradual swelling of the left auricle. " This phenomenon consti- tutes a striking illustration of the mechanism by which obstruction at the mitral orifice, or weakness of the left ventricle, leads to auricular dilatation, and to oedema of the lungs."2 The superior vena cava extends from behind the junc- tion of the first costal cartilage with the sternum almost in a vertical line to the heart, opening into the right auri- cle opposite the upper border of the third costal cartilage. From a clinical point of view the relations of the superior vena cava are of the greatest importance. The innomi- nate artery is placed on the right side, and rather behind it, so that an aneurism of that trunk is likely to press upon the superior vena cava and bring about its partial, or finally its complete, occlusion. The result of the gradual cutting off of the blood-flow in this large trunk would be, in the first instance, to produce an oedema of the structures at the base of the neck, the " fleshy collar " aneurism was found to have completely occluded the su- perior vena cava. In front and externally the superior vena cava is cov- ered by the pleura. The right phrenic nerve lies upon its outer side, and at about one inch and a half from its termination it enters the pericardium, from which it de- rives a serous covering in front and at the sides, but be- hind it has no covering where it is in contact with the right pulmonary artery and the upper right pulmonary vein. The relation by its inner side .with the ascending part of the arch of the aorta again renders it liable to oc- clusion by pressure. The Lungs.-The relations of the lungs are identical with those of the pleura above named, except in front and below, where from time to time they vary. In expi- ration the thin edge of the lung retires from the space between the two layers of the pleura in front. So, too, at the inferior margins the lungs descend during inspira- tion in the costo-diaphragmatic sinus, though in neither • Bronchial arc azyyas maj&r ®1 uZmcrrzary ?i.^ Ductus, arrcriosus Dulmanary n?' Apperraije o/ te/rauricle of the clinical observers. Next the blood would find new channels and enlarge old ones, so that the swelling might subside. The blood from the head and upper extremi- ties would pass into the vena azygos major, thence to the intercostal veins, which communicate with the veins in the lumbar region, and the blood would thus find its way into the inferior vena cava and to the right auricle. The superficial veins in the thorax would be thus put into a condition of varicosity, the blood running downward to get to the external iliac vein, and so to the right auricle. Such was the state of the venous system superficially in the case of J. L. (Fig. 1, Vol. I.), and since then another somewhat similar case has come under the notice of the writer, that of one Miller, who was under treatment at the Montreal General Hospital for some eighteen months. He complained of occipital neuralgia at first, as those with innominate aneurism often do; then of swollen neck, which did not long remain large. The thoracic veins became enormously dilated, and the patient eventually died exhausted. At the autopsy a large innominate Fig. 3907.-The Roots of the Lung as seen from Behind. (From F. Weisse's Practical Human Anatomy, by permission.) case do they at any time ever reach quite to the line of inflexion between the two layers of the pleura. The Heart.-Dimensions. The healthy heart weighs in men nine ounces, in women eight.' The anterior surface, formed almost entirely by the right ventricle and auricu- lar appendage, together with the left auricular appendix which appears to the left of the pulmonary artery, is in relation above with the lung and below with the chest- wall. The heart rests upon the diaphragm, which sepa- rates it from the upper surface of the liver and.from the stomach, and lies between the inner surfaces of the two lungs, which are hollowed out to receive it. The poste- rior surface, formed by part of the right auricle, left au- ricle, and left ventricle, is in relation with the contents of the posterior mediastinum. The broader end, or base, of the lieart is directed upward, backward, and to the right, extending from the level of the fifth to the eighth dorsal vertebra (sixth to ninth, Heath), while the apex beat is felt between the cartilages of the fifth and sixth ribs, a little below and to the inner side of the left nipple (three 75 Thorax. Thorax. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. and one-fourth inches from the middle line of the sternum, and one inch and a half below the nipple, according to Quain). The position of the heart is affected by posture, by leaning forward, for instance, when more of the or^an comes into contact with the chest-walls, while in inspiration, when the diaphragm is depressed, the heart recedes from the chest-walls. Owing to the encroachment of the margin of the lung but a small part of the heart is quite uncovered; that area, part of the right ventricle, is triangular in out- line and not more than two inches square in extent. Displacements of the Heart.-A study of the anatomical relations of the heart will enable the reader readily to understand the conditions which bring about its displacements. Tiius, fluid or air in the peritoneum will push the heart upward as well as the diaphragm, but this displace- ment is more real than apparent, since the ster- num and cartilages in front of the heart are simultaneously up- raised. When the stom- ach is full of either gas or food, inasmuch as the heart rests partly upon it, an upward pressure is ex- erted which gives rise to palpitation and cardiac distress, of- ten wrongly attrib- uted to disease of the heart. A dia- phragmatic hernia may squeeze its way into the thorax and push the heart to the right or left. Conditions, too, of the lung, bring about a dislocation ; thus, in cirrhosis, shrink- age may take place to- ward one or the other side, and the heart may be drawn in that direc- tion. Pleuritic effusion is the most common cause of displacement. There is usually more fluid when the right side is attacked. In one case in which the disease was on the left side, the heart's impulse was per- ceived just below the left clavicle (Bastian). In emphysema the unusual de- scent of the diaphragm induces a downward displacement of the heart. The lower boundary of the left ventricle is brought down- ward into the epigastrium, so that it becomes situated behind and to each side of the ensiform carti- lage. Displacement into the epi gastrium may also follow upon the growth of an aortic aneurism. The Deep Cardiac Plexus.-The right half of the plexus receives all the cardiac nerves of that side ; namely, a cardiac branch from each of the three cervical ganglia of the sympathetic, the three cardiac branches of the vagus, and the cardiac branch of the recurrent laryn- geal nerve. On the left side the plexus receives the same nerves, with the excep- tion of the superior car- diac nerve of the sympa- thetic and the inferior cardiac branch of the Fig. 3908.-A Section through the upper part of the Chest, passing through the First Dorsal Vertebra, showing the relations of the trachea, oesophagus, apices of the lungs, to the great vessels. (From Dwight's Frozen Sections of a Child, by permission.) pneumogastnc, both of which go to form the su- perficial cardiac plexus. The deep cardiac plexus lies behind the transverse portion of the aorta, be- tween it and the trachea and above the bifurcation of the pulmonary artery. The superficial plexus lies on the concavity of the arch. The causation of any symptoms in cardiac disease. 76 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Thorax. Thorax. apparently unconnected with the heart, lies in the numer- ous and wide-spreading communications of the cardiac plexus. Thus, in disease of the valves, the pain is often referred to the distant branches of the cervical and bra- chial plexuses. Moreover, the urgent dyspnoea of intra- thoracic tumor is most probably the result of pressure upon the cardiac plexus itself. The Trachea.-The trachea extends from the level of the fifth cervical vertebra to the level of the fourth dorsal vertebra, where it bifurcates; this point corresponding upon the back to the fourth dorsal spine. The wind- pipe lies in the middle line in front of the oesophagus and the vertebral column in the posterior mediastinum. The sternum, the remains of the thymus gland, the aortic arch, the innominate and left carotid arteries, the left in- nominate veins, and the deep cardiac plexus, all lie in front of it. The trachea occupies the interspace between the pleurae, with the vagus nerve on either side. The right bron- chus enters the lung opposite the fourth dorsal vertebra. From behind, the vena azygos major arches over it; the right pulmo- nary artery lies below, and after- wards in front. The right bron- chus is wider, shorter, and more horizontal in direction than the left; added to this, the septum between the two bronchi lies much to the left of the middle line, so that a foreign body dropping into the trachea would naturally be directed toward the right bronchus (see Tracheot- omy). Tice oesophagus begins opposite the body of the fifth cervical ver- tebra, and descends along the front of the spine in the posterior mediastinum to end opposite the body of the ninth dorsal vertebra. In the thorax the gullet lies a little to the left as it enters, gradually passes to the middle line, and again inclines to the left as it makes its way to the (esophageal opening in the dia- phragm. The trachea, the trans- verse arch of the aorta, and the left bronchus, the posterior sur- face of the pericardium, lie in front of the oesophagus ; behind it rest, upon the vertebral col- umn, the longus colli, the thora- cic duct, and the third, fourth, and fifth intercostal arteries. At the side the pleura encloses the gullet; the vena azygos ma- jor lies on the right, the descend- ing aorta on the left side. The vagus is in close relation with it, the left nerve being in front, the right behind. The most important relation of the oesophagus is the arch of the aorta to its right front. Enlargement of the arch gives rise to the dysphagia met with in cases of thoracic aneurism. A pericardium distended with fluid has been known to cause a difficulty in swallowing, while, on the other hand, cancer of the oesophagus may extend to the pericardium. The vascular supply of the oesophagus is derived from the oesophageal branches of the descending aorta and the oesophageal branches of the gastric artery. The pneumo- gastric and sympathetic nerves form plexuses between the two layers of the muscular coat, as in other parts of the alimentary canal. The thoracic duct takes its origin, by fine radicles, op- posite the right side of the body of the second lumbar vertebra behind the aorta. Passing through the aortic opening of the diaphragm to the right side of the thora- cic aorta, it takes its course in the posterior mediasti- num, lying between the aorta and the vena azygos ma- jor and upon the front of the dorsal vertebrae, then between the oesophagus and the left subclavian artery as high as the seventh cervical vertebra, resting upon the longus colli, whence it changes its direction and turns outward, describing a curve over the apex of the pleura, and terminates on the outer side of the internal jugular vein at the point where it joins the subclavian vein. The thoracic duct receives the absorbents from many sources, from both the lower extremities, from the in- testinal canal and abdominal walls, from all the viscera except part of the upper surface of the liver, from the left side of the thorax, left lung, left heart, left upper extremities, and the left side of the head and neck. Oc- Fig. 3909.-The Tarts seen on the Posterior Wall of the Thorax. (By permission, from F. Weisse's Prac- tical Human Anatomy.) clusion of the thoracic duct has been recorded. M. An- dral fils, in the dissection of a phthisical patient, found the duct occluded at a point corresponding to the third, fourth, and fifth dorsal vertebrae ; but from the third to its termination in the vein, the canal regained its former size and transparency and seemed to be full of lymph. A large lymphatic vessel was found arising from the principal duct a little below the point at which it was obliterated, and, passing obliquely upward behind the azygos vein, entered into the proper canal just above the point of obliteration. The ductus lymphaticus dexter is from a quarter to half an inch long. It receives the absorbents of the right up- per limb, the right side of the chest, the right lung and the right half of the heart, and part of those of the upper surface of the liver, and empties itself into the angle 77 Thorax. [ence. Thouglit^Trausfer- REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. formed by the union of the right subclavian and jugular veins, where a valve guards its orifice. The, vena azygos major enters the thorax through the aortic orifice of the diaphragm, lying to the right of the thoracic duct, superficial to the intercostal arteries of the right side, receiving the right intercostal veins, ex- cept the first and second. The vena azygos minor joins the vena azygos major at about the sixth dorsal verte- bra, passing behind the aorta. The vena azygos major, after passing behind the aorta, arches over the right bronchus, to open into the superior vena cava before it enters the pericardium. The vena azygos major forms an important communi- cation between the superior and inferior cava in the event of obstruction from tumor or other cause. The venous blood maks its way down the vena azygos major into the inferior cava, thence joins the up-current from the lower extremities and to a certain extent restores the equilibri- um of the circulation. H. L. MacDonnell. 1 John Marshall: Lecture on Disease of the Chest Cavity, requiring Surgical Treatment, Lancet, March 4, 1882. 2 Lancet, June 19, 1880. THORAX, JOINTS OF THE. The separate skeletal elements of the thorax are the twelve thoracic vertebrae behind ; the sternum, often composed of three or more segments, in front; and twelve ribs, with the intercostal cartilages, upon each side. By the union of these parts with each other are constituted the joints. The entire sys- tem resembles a cage or basket, open below and extending much farther downward on the sides and back than in front. The movements of these parts with reference to each other are occasioned by the action of the respiratory muscles, which raise and depress the ribs, these latter act- ing like a series of curved bars, approximately transverse, with hinged attachments at the ends. Motions of eleva- tion and depression cause them to lift out laterally and, bracing against the spine, push forward the more mov- able sternum, thus expanding the thorax. The motions arc necessarily of a very limited character, and the articulations are therefore of a very simple type, being merely examples of arthrodial or gliding joints, slightly varied according to the forces, acting upon the particular joint in question. The joints between the verte- bra take no part in the movements of the thorax, except those of forced respiration. They will, therefore, not be considered in this connection. A classification and enumeration of these joints may be made as follows : Costo-central 24 Costo-transverse 20 Chondro-sternal 14 Interchondral 6 to 8 Costo-chondral 24 Intersternal 2 Of these joints, those of the ribs with the vertebra (costo-central and costo-transverse) are much the best developed. The costo-central joints, between the heads of the ribs and the bodies of the vertebra, are essentially the same in superficial extent throughout the series, although their situation varies slightly, the middle members of the series being situated upon the bodies of two vertebra and the intervening fibro-cartilage, while at the ends of the series (first, tenth, eleventh, and twelfth) they have been slightly displaced, so as to set entirely upon the vertebra below. Variations in this are, however, very frequent. When- ever the so-called cervical ribs are found, the first thoracic rib abuts upon two vertebra. The writer has noted cases where this abutment, and a somewhat large and flattened processus costarius to the seventh cervical vertebra, were present as the last vestiges of a cervical rib. The motion here is merely a slight lifting and falling for the upper and lower joints, with a slight twisting at the middle joints. At the same time, considerable strength is re- quired to make the walls of the thorax firm and prevent the ribs sliding toward each other when pulled upon by the intercostal muscles or by the great muscular masses that take their origin from them, such as the pectoralis major, serratus magnus, latissimus dorsi, and the abdom- inal muscles. In order to effect-this, there is a fibro-car- tilage within the joint, which may be considered as a vestige of the original fibrous tissue in which the rib was laid down, and which connects the head of the rib with the intervertebral cartilage. There is usually discernible upon the head of the rib a transverse ridge (crista capituli), which serves as the point of attachment for the interartic- ular cartilage. The entire arrangement is not dissimilar to that of a rod attached to a post by a leathern hinge (see Fig. 3910). It is wanting in the joints of the first, ninth, tenth, and elev- enth ribs. Each of these joints is encap- suled by a liga- m e n t w h i c h blends with the periosteum o f the head of the rib and surrounds the eminence on the dorsal vertebra upon which the articular facet is situated. That emi- nence is known to comparative anatomists as the capitular process, and is more marked in some lower vertebrates than in man. The process is a little more prominent on the superior of the two vertebrae, in order to counteract the upward push which the rib necessarily makes, and when there is but one vertebra involved in the articulation it will be seen that the upper lip of the articular facet slightly overhangs. The capsular ligament is strength- ened in front by a series of radiating bands, which are known collectively as the stellate or costo-central liga- ment. There are usually three distinct bands, in the di- rections in which the strain is necessarily the greatest; viz., one to the vertebra above, one to the vertebra below, and one to the interarticular cartilage. This ligament is particularly of use in preventing the head of the rib from slipping forward in inspiration, and in strengthening the whole apparatus. Two synovial cavities exist in the joint, by reason of its division by the interarticular cartilage, and these rarely or never communicate with each other. The costo-transverse joints are those between the tu- bercles of the ribs and the transverse processes of the vertebrae. The eminence which bears the facet on the transverse process is known as the tubercular process, and the facet itself is called the fossa transvcrsalis. The joints are wanting upon the two lowest whs, owing to the reduction of the transverse processes and the disap- pearance of the tubercles. Each joint is provided with a thin capsule strength- ened by a number of bands, which are not directly con- nected with it but pass from the rib to the transverse processes. These are called the costo-transverse liga- ments. They are three in number, distinguished by their position as the posterior, extending from the tuber- cle of the rib to the tip of the transverse process with which it articulates ; the middle or interosseous, uniting the neck of the rib to the same transverse process ; and the superior, anterior, or long costo-transverse ligament, passing from the neck of the rib to the edge of the trans- verse process above it. Toward the ends of the series of ribs these ligaments undergo a corresponding reduction. Thus, there is no superior costo-transverse ligament for the first rib, and no posterior costo-transverse ligaments for the eleventh and twelfth ribs. There are, however, traces of the middle costo-transverse ligament through- out. The chondro-sternal joints are at the other extremity of the costal bar, uniting the costal cartilages with the sternum. They resemble in some degree the costo-cen- tral joints, being usually so situated that they abut against two of the originally separate sternal elements (haemal spines of Owen). As, however, the union be- tween the lower of these takes place very early, there is Inter-articu lar fibro-car- tilage. Vertebra. Intervertebral disk. Rib. Vertebra. Articular cavities. Fig. 3910.-Attachment of Rib to Spinal Column. 78 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Thorax. [ence. Thought-Transfer- a partial obliteration and crowding together at the lower end of the sternum, so that this arrangement is not very distinctly made out, especially in the case of the sixth cartilage. The xiphoid appendage itself is, properly speaking, merely the remains of ribs which have become aborted except as to their sternal ends, the joints between them and the sternum having become obliterated. In several cases the w'riter has found traces of these joints still apparent in subjects of fifteen years of age. The cartilages fit into the impressions known as the costal notches on the side of the sternum. All the joints except the first possess an articular cavity. The second one, between the manubrium and the body, is much the largest, and there is usually developed within its cavity a cartilage like that in the costo-central articulation, and which unites in a similar manner with the fibro-cartilage which exists until late in life between these two segments of the sternum. Interarticular cartilages are occasion- ally found in some of the other joints also. These joints are encapsuled, and are, besides, invested in front and behind with a strong fascial covering, derived from the aponeuroses of the outer and inner thoracic muscles. Strengthening bands also extend over the capsule above and below. The interchondral articulations are those which take place between the costal cartilages themselves. Owing to the various modifications acting upon the rib elements of the vertebrate body, they have gradually been reduced in the abdominal and lower thoracic regions till the elev- enth and twelfth ribs no longer have any anterior attach- ment, and the eighth, ninth, and tenth do not usually reach the sternum. The eighth does occasionally do this, but in an experience of some years the writer has seen but two cases of the kind. The cartilages of the lower ribs usually unite with those of the rib above, within a short distance of the distal end, the joint being one of simple apposition and admitting only a very slight gliding movement as the ribs twist outward and inward during the movements of respiration. These joints are protected by the fascia, wdiich is derived in front from the abdominal muscles, behind from the triangularis sterni. There are usually four such articulations on either side, from the sixth to the ninth rib, inclusive. The costo-chondral joints are those which exist be- tween the ribs and their cartilages. Many anatomists do not consider these as joints, properly speaking, but rather such a union as occurs between the shaft of a bone and its epiphysis. It seems probable, however, from embry- ological data and from comparative anatomy, that the separation between rib and cartilage takes place before ossification commences. If that is the case, the costal cartilage ought to be considered as a separate ossific inte- ger (haemapophysis of Owen). Luschka reports finding a true synovial cavity between the first rib and its carti- lage, in the body of a man aged fifty-five. The intersternal joints are two in number, the first be- tween the manubrium and the body, the second between the body and the xiphoid cartilage. The bond of union is by fibro-cartilage, wdiich may ossify late in life. The upper joint has frequently a synovial cavity, and this may occur also in the lower joint, when it is to be re- garded as a persistence of the foetal condition, the xiphoid appendage clearly showing at that time that it is the ster- nal extremity of a series of aborted ribs. These joints are also covered by the fascia which invests the sternum be- fore and behind. All the joints of the thorax enjoy a singular immunity from disease. This is apparently for the reason that no great strain or shock is usually put upon them, the ac- tion of the component parts being regular and persistent; the conditions of nutrition are therefore of the most stable character possible. Frank Baker. THOROUGHWORT (Eupatorium. U. S. Ph., Boneset). Eupatorium perfoliatum Linn. ; order, Composita. A handsome, large, perennial herb, with a hairy, rather simple stem, growing from two to four or more feet high, large, dark green, opposite, and completely connate, pu- bescent leaves, and rounded, complex, cymose clusters of small heads of minute, creamy-white flowers. The leaves are lanceolate, or narrow-halberd shaped, with long, slender points ; the bases of the opposite leaves are united, with a vein running along the line of union, and prolonged to a point on each side. Flower heads small, from ten- to fifteen-flowered, in very large corymbs. Scales of the involucre few, linear-lanceolate. Corollas tubular, bell-shaped, bluntly five-lobed. Anthers five, not "tailed;" achenia slender, bluntly five-angled. Pappus in a single row, consisting of slender, roughish hairs. This is a widely spread species, growing about the borders of ponds and brooks, and in wet places gener- ally, from Canada to Florida, and from the east to the western side of this country. It is very abundant, and frequently accompanied by one or two other species of Eupatorium, as E. teucrifolium and purpureum. Boneset has been long used in the United States as a tonic and antiperiodic, and even as an emetic, but always more a family medicine than one prescribed by physi- cians. Since the beginning of the present century it has fallen very much into disuse. Its composition is not very definitely known, but in common with most Composita, it contains volatile oil (a trace), resin, and one or more bitter principles, no fur- ther studied than to class them as extracts. Tannin, col- oring matter, and common plant constituents are also present. The medicinal properties are extracted by wa- ter. Use.-In small doses, Thoroughwort is a bitter tonic, like the chamomiles and others in the same family, but with less aromatic character than most of them. It is also a good deal like horehound in the Labiata. In larger doses, especially in hot infusion, it is diaphoretic, possibly diuretic, and is still occasionally used, followed by a sweat under blankets, to abort colds, and in the be- ginning of most acute diseases. In very large doses (an infusion of an ounce or so) it is a nauseating emetic. Doses as large as can be borne by the stomach, repeated for some days, have considerable reputation in the coun- try, and a little real value in the treatment of intermit- tent fever and other malarial manifestations. Quinine is, however, so much superior in these cases, that Thor- oughwort is but rarely to be recommended. As a siipple bitter tonic it is far inferior to Gentian. Dose, as a tonic, one or two grains, two or three times a day ; as an antiperiodic, six or eight times as much daily ; as an emetic, fifteen to thirty grains. There is a Fluid Extract (Extractum Eupatorii Fluidurn, U. 8. Ph.; strength, j) having all the medicinal properties of the herb, but for most purposes the hot infusion is the best preparation. Allied Plants.-The genus is a large one, compris- ing more than four hundred species, including a score or more which are natives of this country. Most of them have about the same properties. Still another, E. tri- plinerta, is officinal in France (Ayapana, Codex Med.), and there are several others in use in other countries. Numerous plants belonging to other related genera, Mi- kania, Solidago, etc., are also bitter and resinous. Allied Drugs.-Besides the above, see Gentian. W. P. Holies. THOUGHT-TRANSFERENCE, OR TELEPATHY. Thought-transference, or telepathy, is the direct action of one mind upon another, by which the thoughts, sen- sations, etc., of one person are communicated to the mind of another without making use of the channels of sense -of sight, touch, hearing, taste, or smell; that is, it is the direct communication of ideas without the use of written or spoken language, or any code of signals of any kind whatsoever. As our knowledge of the existence of such a faculty, if indeed, it really exists, is of recent date, and as the subject is still sub judice, a brief summary of the evidence thus far collected will best give the reader an idea of the nature as well as the limitations and extent of the alleged faculty. For most of our knowledge of thought-transference we are indebted to the English So- 79 Thought- Transference. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ciety for Psychical Research, which, through its commit- tee, consisting of Professor W. F. Barrett, Mr. Edmund Gurney, and Mr. F. W. II. Myers, together with Professor Balfour Stewart, Professor Alfred Hopkinson, and Mr. and Mrs. Henry Sidgwick, originated and carried out the first systematic experimental investigation of the subject. The reports of these experiments are to be found in the " Proceedings of the Society." 1 The committee were led to carry on their investigations by the results frequently reported to have been obtained in the well-known " will- ing game," which at one time attracted much popular interest. The principle of this game is that one or more people will that another person shall do something-such as touch some object in the room, or take something from a given place and put it in another place. The willers are usually in contact or in close contiguity to the one who is willed. It is well known that most of these performances are done by voluntary or involuntary push- ing on the part of the willers. Still there remains over a small residue of phenomena, which it was thought seemed to point to something more, and to be sufficiently well attested and important to become the legitimate ob- ject of serious scientific investigation. That which was the direct inducement to serious in- vestigation appears to have been the phenomena mani- fested by the now celebrated Creery children, daughters of a Rev. Mr. A. M. Creery, of Buxton. It seems that Mr. Creery, having heard of the reported extraordinary results exhibited in the willing game, determined to try it with his own family, employing for the purpose four of his children, between the ages of ten and sixteen, and a maid-servant about twenty years of age. This was in 1880. The success of the children in guessing was so re- markable, even when no contact was allowed, that Mr. Creery communicated the facts to Professor Barrett, who was known to be interested in the subject. The children and maid-servant were then still further made the sub- jects of more systematic experiment during 1881 and 1882 by Professors Barrett, Hopkinson, and Stewart. In the latter year, on the formation of the Society for Psychical Research, they were investigated by the special committee of that society. The results of these experi- ments were very successful and attracted wide-spread notice. For reasons that will shortly appear these earlier experiments will be passed over here for the present, till later ones with other subjects have been described. But first a few words on the method of conducting experi- ments. The ideas to be conveyed may be various, but always of a simple nature. Those usually employed as most convenient are : 1, mental images of playing cards ; 2, of objects ; 3, names of places and fictitious persons ; 4, sensations of taste, smell, pain, etc.; 5, diagrams and drawings. The person whose idea is to be transferred is called the agent, the one to whom it is to be transferred, i.e., who is to perceive it, the percipient. If the diagram, object, or card tests are used it is well to have a stand or screen placed behind the percipient and directly in front of the agent, on which the diagram or other test can be placed. The agent then concentrates his attention on the card, drawn at random from a pack, or on the object placed before him, etc. Every precaution should be taken to prevent fraud. No one should be allowed in the room during the experi- ments besides the agent and percipient, excepting the other experimenters, if there be any. Not a word should be spoken, excepting such laconic expressions as may be absolutely necessary. The percipient should be seated with his back to the agent and at little distance. Precautions should be taken to insure the impossibility of giving information by such means as coughing, sneezing, audible breathing, etc. There is reason to believe that the possibility of signal codes, so subtle as to elude de- tection, is greater than was supposed at the time of the earlier experiments. One ingenious code, for example, consists in the percipient so crossing his knees that a slight pulsation will be given to his foot by every beat of the artery at the knee, while at the same time he takes his pulse at the wrist. The agent watches the pulsations of the percipient's foot, and taking a faintly audible breath or making some other slight noise, as a signal, counts the pulsations, and at the end of the given number, say seven, makes another faint noise or movement, such as would be likely to escape observation. The percipient has also counted from the first signal, and therefore knows the number is seven. The numbers thus obtained could be used in the number and card tests, or as ciphers for more varied information. All the sources of fallacy cannot be discussed here, though many will become apparent as we proceed. Soon after the experiments with the Creery children were made known, the attention of the committee was called to a Mr. Smith, a young mesmerist, living at Brighton, who, in conjunction with a Mr. Blackburn, editor of the Brightonian, had given evidence of thought- transference. A series of experiments was accordingly undertaken, some of which-the later ones-are among the most valuable recorded. In the earlier series experi- ments were made in guessing colors, numbers, names, sensations of pain, and diagrams, with marked success, but as contact was allowed, they are not admissible as evidence. In the later trials with diagrams, the condi- tions were made more stringent, and no contact whatso- ever was allowed. The modus operandi is described as follows: " The percipient, Mr. Smith, is seated blindfolded at a table in our own room ; a paper and pencil are within Original. Reproduction. No. 4. No. 8. No. 10, Mr. Smith had no idea that the original was not a geometrical diagram. No. 18. Mr. Blackburn forgot the eyes. Fig. 3911. his reach, and a member of the committee is seated by his side. Another member of the committee leaves the room, and outside the closed door draws some figure at random. Mr. Blackburn, who so far has remained in the room with Mr. Smith, is now called out, and the door closed ; the drawing is then held before him for a few seconds, till its impression is stamped upon his mind. Then, closing his eyes, Mr. Blackburn is led back into 80 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. TllOUglit- Transference. the room and placed, standing or sitting, behind Mr. Smith at a distance of some two feet from him. A brief period of intense mental concentration on Mr. Blackburn's part now follows. Presently, Mr. Smith takes up the pencil amidst the unbroken and absolute silence of all present and attempts to reproduce on paper the impression he has gained. He is allowed to do as he pleases as regards the bandage round his eyes ; sometimes he pulls it down before he begins to draw, but if the figures be not dis- tinctly present to his mind, he prefers to let it remain on, and draws fragments of the figure as they are per- ceived. During all this time Mr. Blackburn's eyes are generally firmly closed (sometimes he requests us to bandage his eyes tightly as an aid to concentration), and, except when it is distinctly recorded, he has not touched Mr. Smith, and has not gone in front of him, or in any way within his possible field of vision since he re-entered the room. "When Mr. Smith has drawn wThat he can, the orig- inal drawing, which has so far remained outside the room, is brought in, and compared with the reproduc- tion. Both are marked by the committee and put away in a secure place. The drawings and reproductions, given at the end of the report, are in every case fac-similes of the untouched originals, from which they have been photo- graphed on the wood blocks." Fac-similes of a few examples of these drawings, with the reproductions, are given here (reduced in size). The numbers are as in the originals. It is difficult to criticize these experiments with any degree of profit or satisfaction, as any criticism must be entirely based, on the data furnished by the report itself -that is, on the conditions which the experimenters be- lieve to have been observed-without means of verifica- tion. It is well known that self-deception in matters of this kind is one of the easiest things in the world, and, unless we can "go behind the returns," there must al- ways be a greater or less element of doubt as to whether the imposed conditions were maintained as rigorously as was supposed. If they were maintained, the case must be regarded as a strong one. Though a study of the re- port cannot determine this, a brief consideration of cer- tain possible fallacies may not be out of place, especially as there is reason to believe, from later developments, that the possibilities of subtle signal-codes in expert hands are far greater than originally believed by the committee. Most criticisms on this diagrammatic evidence assume the possible use of codes. Unfortunately, this cannot be met by specific observations on the part of the commit- tee made with the intent of recording the character and rates of breathing of agent and percipient, all (apparent- ly involuntary) movements of the head and feet, and all sounds, etc., though seemingly accidental. The commit- tee merely contents itself'with asserting the impossibility of the use of an adequate code. While arguments based upon the supposed impossible are very fallacious, there is still considerable force in this opinion. No code thus far suggested is sufficient to ex- plain all the drawings. One can understand how infor- mation concerning simple diagrams and lines, like tri- angles, squares, etc., could be thus communicated, but it is much more difficult to imagine how, as the commit- tee claim, without contact, and, if the report is to be be- lieved, without the use of visual sensations, sufficient information could be conveyed by auditory signals to enable a person to draw complicated and unconventional figures, which even to describe by the use of verbal lan- guage would require a lengthy circumlocution. On the few occasions that the writer has attempted to test this reasoning, he has not found it possible to describe some of the unconventional figures given in the reports in rea- sonably condensed verbal language with sufficient clear- ness to allow of a reproduction as successful as that ob- tained by Mr. Smith. Undoubtedly constant practice between the same persons would do much to develop a facility in description as well as interpretation, but it still remains to be shown how far this could be carried. And what is true of the difficulties of oral description, must be so in even greater measure when a code is limited to visual signs and auditory signals. Further- more, though much has been claimed in the reproduc- tion of drawings for subtle codes invented by different critics, no one, so far as the writer knowTs, has furnished any published demonstration of these claims, like the di- agrams offered by the advocates of thought-transference. Still, it is a possibility which must be met, especially in view of the fact that we are not definitely told if any conversation was allowed with the agent outside the door. Nor do we know of the non-occurrence of any noises at this time, such as shuffling of the feet. If con- versation took place, it may be that by a series of deftly put questions audible to Smith inside the room, general information regarding the character of the drawings may have been given. It is knowm that Heller, Bishop and others in this way give most accurate information to their confederates in-double-sight performances. Or it may be that the same information could have been given by shuf- fling the feet, coughing, blowing the nose, etc. It must be remembered that a large number of the trials were fail- ures, and it was only necessary to occasionally succeed. If these diagrams were produced by fraud, fully as plaus- ible, if not more plausible, an explanation, it seems to the writer, would be the supposition, not of a code, but of self- deception on the part of the experimenters ; or, perhaps better, of a combination of the two. The report states distinctly that the percipient and agent both remained in the room, while one of the committee left the room and outside drew some figure at random. Not until this had been done was the agent called out and shown the draw- ing. Now, may not the simpler diagrams, as No. 4, and those least well reproduced, as Nos. 15* and 19* of Fig. 3911, have been signalled in some way to Mr. Smith, and then Mr. Blackburn, when outside the room, have induced the experimenter to withdraw any particular drawing on the ground, perhaps, that it was too complicated to hold in his memory, and then by subtle suggestion have man- aged that he should draw some figure previously ar- ranged between Blackburn and Smith ? In the absence, as has been said, of any knowledge of the occurrence of conversation, we do not know what subtle hints may have been instilled in the committee- man's mind, to bear fruit, not perhaps at once, but in the next few minutes. The presence of a stenographer, un- der such circumstances, would not have been amiss. In view of the experimental evidence furnished by S. el. Davey in " The Possibility of Mal-observation and Lapse of Memory," published in the Psychical Society's own reports,2 the plausibility of this suggestion must be ad- mitted. A perusal of this paper will afford food for re- flection to anyone who thinks he is competent, in the presence of an expert conjurer, to observe correctly what passes before him, or to do what he intends to do, and describe, much more remember, what he actually did. Whether or not the genuine character of these experi- ments is confirmed by investigations with other subjects, the reader must now judge. Shortly after the experiments with Messrs. Smith and Blackburn, the attention of Mr. Malcolm Guthrie, of Liverpool, was called to two young ladies in his employ,! known as Miss R and Miss E , who were reported to have the power of mind reading. These young ladies were accordingly made the subjects of numerous experiments by Mr. Guthrie, ■with the co- operation of Mr. Steel, President of the Liverpool Liter- ary and Philosophical Society, Mr. James Birchall, Sec- retary of the same, Mr. Hughes, of St. John's College, and later, of Dr. Oliver J. Lodge, Professor of Physics in University College, Liverpool. Mr. Gurney and Mr. Myers, for the committee on thought-transference, also paid a visit to Liverpool and conducted a series of exper- iments. As to the young ladies concerned, it is fair to them to * Not reproduced here. + Mr. Guthrie is proprietor of a large drapery establishment in Liver- pool. He is described as being a Justice of the Peace, and an active member of the governing bodies of several public institutions, among others of the new University College ; he is a severe student of philoso- phy. and the author of several works bearing on the particular doctrines of Herbert Spencer, 81 Tliought- Transferenee. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. quote the following words of Mr. Guthrie : "I have known them all for many years, and am able to speak in the highest terms of their probity and intelligence. I know, also, that they have a high regard for me, and would not willingly lead me into any error." Mr. Guthrie made a large variety of experiments, the most important consisting in guessing objects and repro- ducing diagrams. His report states that "almost all the experiments with objects were performed under strict conditions, the ' subjects' being blindfolded, and the ob- jects placed out of the range of their vision, even had they been not thus incapacitated for observation, and silence being preserved during the progress of the exper- iments. In other cases the precautions were not so strict; but as the rule has been to record every incident, the full record is presented." In the earlier experiments contact was allowed, that is, the agent and percipient either clasped or touched hands. Later, no contact was allowed. In this case all present acted collectively as agents, concentrating their attention on the object. Al- together, a very large number of experiments were made on a number of different occasions. A number of people were usually present and participated at each sitting. Space will only allow a few of these to be quoted here, only those where no contact was allowed being made use of. 20, 1883. Present: Mr. Guthrie, Mr. Steel, Mr. Birchall, Miss R., Miss R-d, Miss J., Miss E., and Miss C. Percipient. Object. Result. Miss R. A gilt cross hold by Mr. G. be- hind the per- cipient. Is it a cross ? Asked which way it was held the percipient replied. The right way, which was cor- rect. Miss R. A yellow paper knife. Yellow . . . is it a feather ? . . . It looks more like a knife with a thin handle. Miss R. Mr. Steel's ex- change pass ticket (similar to a first-class railway con- tract ticket), maroon - color- ed leather cover. Is it square ? . . . longer one way than the other ... a dark reddish color. Miss R. A pair of scissors standing open and upright. Is it silver? . . . No, it is steel. . . . It is a pair of scissors standing upright. October 3, 1883. Present: Mr. Guthrie, Mr. Birch- all, Mr. R. C. Johnson, Miss R-d, Miss R., and Miss E. Percipient. Object. Result. Miss R. Mr. G.'s gold watch sus- pended by a hair or silk guard on the face of some white ground -the back of the watch fronting. I still see a lot of white . . . and something hanging . . . looks like a letter . . . some- thing of the shape of an A . . . looks like a locket or a watch. N. B. The guard of the watch and the watch itself hung against the white surface. Miss R. Letter L. Is is a letter ? L. Miss R. Letter Q. It is either an O or a Q. Miss R. A knife with the three blades open. Is it something this way? (tracing horizontally) . . . Is it a knife ? Open . . . pointing up ... three blades. Miss R. One of the fram- ed and glazed fashion pict- ures. A lady in full cos- tume. Frame, black and gold. Can't see . . . something white . . . something in the middle . . . with a lot of colors . . . Is there anything dark all round the edge ? . . . Seems like a black line . . . and then a white . . . with something in the middle . . . Can't see distinctly what is in the middle. There's more than one color . . . seems to be a lot down at the bottom . . . then seems to go up narrower. . . . No ... I don't see it a bit distinctly. (Mr. G. now placed himself in contact.) Is there anything written at the top ? .' . . Looks to me something like a picture, but I can't tell what it is. Miss E. * Letter B. A letter, is it? I see B. N. B. Was not at all aware what object would be presented, i.e., the kind of object. She asked, but was not informed. Miss E. Letters S 0. Are there two letters? . . . One looks like an O . . . an- other T (this last only suggestive- ly, as if she were thinking aloud). I see the 0, but the other is not so distinct . . . Is it S? I think the S is first. April 7, 1883. Present: Miss R., Miss R-d, Miss J., Miss E., and Miss C. {First Experiments without Con- tact, reported by Miss C.) Percipient. Object. Result. Miss R. A half-crown. Like a flat button . . . bright . . . no particular color. Miss R. Four of spades. A card . . . four of clubs. Said she did not know the difference between spades and clubs after- ward. Miss R. An egg. Looks remarkably like an egg. Miss R. A penholder, with a thimble inverted on the end. A column, with something bell- shaped turned down on it. Miss R. A small gold ear- drop. Round and bright . . . yellow . . . with loop to hang it by. April 9, 1883. Present: Mr. Guthrie, Mr. Birchall, Miss R., Miss R-d, Miss J., Miss E., and Miss C. Percipient. Object. Result. Miss R. A gold cross. It is yellow . . . it is a cross. Miss R. A red ivory chess knight. It is red . . . broad at the bot- tom . . . then very narrow . . . then broad again at the top. . . . It is a chessman. Asked to name the piece, said she did not know the names of the pieces. Miss R. Mr. B. A half-c r o w n It is round . . . bright . . . in this experi- held up by Mr. no particular color .... sil- ment turned B. and taken ver . . . it is a piece of money the percipi- out of his . . . larger than a shilling, but ent's face to pocket after not as large as . . . The per- the wall, and away from the rest. he had placed the percipient as described. cipient was unable to say more. Miss R. A d i a in o n d of pink silk on black satin. Light pink . . . cannot make out the shape . . . seems moving about. N. B. The object was held somewhat unsteadily by Mr. G. April 13, 1883. Present: Miss R., Miss R-d, and Miss C. {Reported by Miss C.) It is to be regretted that the details given of the con- ditions under which these experiments were made are so meagre. As has been said, Mr. Guthrie merely con- tents himself with stating that the conditions were "almost" always strict, the subjects blindfolded, and the object so placed as not to be seen, even if this precaution had not been taken. It would be well to know to how many experiments and what the word "almost" applies. Nor does Mr. Guthrie, perhaps because relying on the good faith of the young women, give any hint that he was aware of the possibilities of signal codes. As it is, these experiments, interesting as they are, must be considered worthless, not only on account of the im- Percipient. Object. Result. Miss R. A leaf out of a Bright yellow square. Miss R. 1 ittle book, paper. A key. square yellow A little tiny thing with a ring at one end and a little flag at the other like a toy flag Urged to name it she replied, It is very like a key. 82 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tlioii"ht- Tr austere nee. perfect way in which they are reported, but because of the looseness with which, by the experimenters' own showing, they were conducted. Two or more of the subjects were allowed in the room at the same time, and those not actually acting as percip- ient permitted to know the test object, and to act with the others present as agent. It does not appear that any par- ticular attention was paid to the possibility of such audi- tory signals as might be given through audible breathing, rustling of the dress, scraping of the chair upon the floor, striking the object so as to produce resonance, etc., by which it is possible that much information can be con- veyed. The experimenters did not seem to realize that any pre- cautions were necessary beyond those calculated to ex- clude the senses of sight and touch, and seemed to con- sider it a very simple matter to eliminate all possibility of fraud. We cannot say, of course, that any code was made use of in these experiments ; very possibly it wras not. But to render them of any scientific value, specific statements should have been offered showing, not only that all the above-mentioned sources of fallacy were not overlooked, but giving details of the observations made upon each, the rhythm and character of the breathing, whether suspicious or not; all noises such as coughing, rustling, etc. It will be noticed that "all present" acted collectively as agent, i.e., simultaneously concentrated their attention on the object. Now, it is very questionable whether it is possible, under such conditions, to observe whether any subtle signals are being used or not. If such are being watched for, then the collective agents could not con- centrate their attention on something else, and vice versa. More valuable are the diagram tests, which impress the writer as being more convincing than any yet obtained ; for it is expressly stated that, with the exception of two (numbers seven and eight), the only persons present were the " agent " (Mr. Guthrie, Mr. Birchall, Mr. Steel, or Mr. Hughes) and the "percipient," either Miss E., or Miss R. As the impeachability of any of these gentlemen is above question, by no possibility could a code have been used. There only remains the possibility of the percipient having caught a glimpse of the original drawing, either directly or indirectly from some reflecting surface. Mr. Guthrie makes the following statement regarding this point: " The originals of the following diagrams were for the most part drawn in another room from that in which the ' subject ' wras placed. The few executed in the same room were drawn while the ' subject ' was blindfolded, at a distance from her, and in such a way that the pro- cess would have been wholly invisible to her or anyone else, even had an attempt been made to observe it. During the process of transference, the ' agent ' looked steadily and in perfect silence at the original drawing, which was placed upon an intervening wooden stand ; the ' subject ' She could not have done so, in fact, without rising from her scat and advancing her head several feet; and as she was almost in the same line of sight as the drawing, and so almost in the centre of the agent's field of observation, the slightest approach to such a movement must have been instantly detected. The reproductions were made in per- fect silence, and without the 'agent' even following the No. 5. Original at left. No. 6. Original at top. Fig. 3913. Fig. 3914. Fig. 3913.-Mr. Guthrie and Miss E. No contact. Fig. 3914.-Mr. Guthrie and Miss E. No contact. Miss E. almost di- rectly said : "Are you thinking of the bottom of the sea, with shells and fishes?" and then, "Is it a snail or a fish?"-then drew as above. actual process with his eyes, though he was, of course, able to keep the 'subject' under the closest observa- tion." It would be interesting to reproduce here all the draw- ings published in the report. Space will allow us to give only the following, which are not particularly more successful than the others (published). Series 1 to 6 of the report are especially interesting, as being the com- No. 15. plete and consecutive series of a single sitting ; 3, 5, and 6 are inserted here. Experiments were also made in the reproduction of the sensations of taste, smell, and pain. The most im- portant of these are the last fifteen in the transference of taste, conducted by Mr. Guthrie, Mr. Gurney, and Mr. Myers, when only the two percipients, Miss E. and Miss R., were present. The conditions observed are described as follows : The substances were enclosed in small bot- tles or parcels, precisely similar to one another. None of them " were allowed,even to enter the room where the percipients were. They were kept in a dark lobby out- side, and taken by the investigators at random, so that often one investigator did not even know what the other took. Still less could any spy have discerned what had been chosen, had such spy been there, ■which he cer- tainly was not." "Miss E. was unfortunately suffering from sore throat, which seemed to blunt her suscepti- bility." September 3, 1883.-Present: Messrs. Myers, E. G. Gurney, and M. G. Guthrie. No. 3. Original. Reproduction. Fig. 3912.-Mr. Guthrie and Miss E. No contact. sitting opposite to him, and behind the stand, blindfolded and quite still. The agent ceased looking at the drawing, and the blindfolding was removed only when the subject professed herself ready to make the reproduction, which happened usually in times varying from half a minute to two or three minutes. Her position rendered it abso- lutely impossible that she should glimpse at the original. 2 c * 2 H s Taster. Pei ci pi- ent. Substance. Answers Given. 1 M. E. Vinegar. A sharp and nasty taste. 2 M. E. Mustard. Mustard. 3 M. R. M ustard. Ammonia. 4 M. E. Sugar. I still taste the hot taste of mus- tard. 83 Thought- Transference. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Experi- ment. Taster. Percipi- ent. Substance. Answers Given. 5 E. Ci. and M. E. Worcestershire sauce. Worcestershire sauce. 6 M. G. R. Worcestershire sauce. Vinegar. E. G. and M. E. Port wine. Between eau de cologne and beer. 8 M. G. R. Port wine. Raspberry vinegar. 9 E. G. and M. E. Bitter aloes. Horrible and bitter. 10 M. G. R. Alum. A taste of ink-of iron-of vin- egar. I feel it on my lips ; it is as if I had been eating alum. 11 M. G. E. Alum. (E. perceived that M. G. was not tasting bitter aloes, as E. G. and M. supposed, but something different. No dis- tinct perception on account of the persistence of the bitter taste.) 12 E. G. and M. E. Nutmeg. Peppermint-no-what you put in puddings-nutmeg. 13 M. G. R. Nutmeg. Nutmeg. 14 E. G. and M. E. Sugar. Nothing perceived. 15 M. G. R. Sugar. Nothing perceived. (Sugar should be tried at an earlier stage in the series, as, after the aloes, we could scarcely taste it ourselves.) 16 E. G. and M. E. Cayenne pep- per. Mustard. 17 M. G. R. Cayenne pep- per. Cayenne pepper. (After the cayenne wc were unable to taste anything further that evening.) September Mh. of the second percipient with the nutmeg was the only- occasion, throughout the series, to which it can be ap- plied." One of the principal objections to these experiments is that they do not allow for hypersesthesia on the part of the percipients. Most of the substances were strongly odorous, and it is well known that the sense of smell varies immensely among different people, and it only re- quires the development of the sense something above the average to recognize odors imperceptible to most people. Even the presence of hypersesthesia is not an extravagant supposition in view of well-known physiological facts, and the phenomena of this kind manifested by hypnotic subjects. One or the other of the young ladies might have learned of the substances in this way and signalled them to the other. Later, Mr. Guthrie has reported a very large number of additional experiments in taste, smell, and pain, which well deserve study. Many of them seem to have been much more rigidly conducted than those already cited. Yet it is to be regretted that the mode in which they were planned does not allow us to place implicit con- fidence in the results. The same objections raised to the preceding experiments of ZMr. Guthrie, and to those of Messrs. Gurney and Myers in taste, are applicable to these, so that it is hardly necessary to quote further. Very interesting are the experiments made by Profes- sor Lodge,3 at the request of Mr. Guthrie. Professor Lodge states that he " had every opportunity of examin- ing and varying the minute conditions of the phenomena, • so as to satisfy myself of their genuine and objective character, in the same way as one is accustomed to satisfy oneself as to the truth and genuineness of any ordinary physical fact." It is distinctly stated that the objects for the tests were kept in an adjoining room, and were se- lected and brought in by the experimenter after the per- cipient had been blindfolded. No reliance, however, was placed on, or care taken in, the bandaging; it was merely done because the percipient preferred it to merely shutting the eyes. "The opacity of the wooden screen on which the object was placed was the thing really de- pended on, and it was noticed that no mirrors or indis- tinct reflectors were present. The only surface at all sus- picious was the polished top of the small table on which the opaque screen usually stood. But as the screen sloped backward at a slight angle, it was impossible for the ob- ject on it to be thus mirrored. Moreover, sometimes I covered the table with paper, and very often it was not used at all, but the object was placed on a screen or a settee behind the percipient; and one very striking success was obtained with the object placed on a large drawing- board, and almost hidden by it." As regards collusion and trickery, Professor Lodge, like all others who have witnessed the experiments, is convinced of the honesty and sincerity of the subjects. He admits, however, that this is not evidence to others, but to the best of his scien- tific belief no collusion or trickery was possible under the varied circumstances of the experiments. But in only one series of these experiments was collusion rendered impossible by the conditions imposed, as in all but the first set, and in the one experiment with Dr. Shears, both percipients were in the room, and in the latter case, as indeed in many of the others, contact was allowed. It is to be regretted also that contact was allowed in this first set between Miss R. as percipient and Mr. Birchall as agent. For though I should be the last to question Mr. Birchall's honesty, still the question of unconscious com- munication will present itself." The following is the record of the one series alluded to ; no one present but Professor Lodge, Mr. Birchall, and Miss R. (everything said by the experimenters is printed in parentheses, and everything by the percipient with inverted commas). Mr. Birchall holding Miss R.'s hand.. Next object: a key on a black ground. (It's an object.) In a few seconds she said, " It's bright. ... It looks like a key." Told to draw it, she drew it just inverted. Next object: three gold studs in morocco case. " Is it yellow ? . . . Something gold. . . . Something Experi- ment. Taster. Percipi- ent' Substance. Answers Given. 18 E. G. and M. E. Carbonate of soda. Nothing perceived. 19 M. G. R. Carraway seeds. It feels like meal-like a seed loaf-carraway seeds. (The substance of the seeds seems to be perceived before their taste.) 20 E. G. and M. E. Cloves. Cloves. 21 E. G. and M. E. Citric acid. Nothing felt. 22 M. G. R. Citric acid. Salt. 23 E. G. and M. E. Licorice. Cloves. 24 M. G. R. Cloves. Cinnamon. 25 E. G. and M. E. Acid jujube. Pear drop. 26 M. G. R. Acid jujube. Something hard, which is giv- ing way-acid jujube. 27 E. G. and M. E. Candied ginger. Something sweet and hot. 28 M. G. R. Candied ginger. Almond taffy. (M. G. took this ginger in the dark, and it was some time before he realized that it was ginger.) 29 E. G. and M. E. Home- made noyau. Salt. 30 M. G. R. Home- made noyau. Port wine. (This was by far the most strongly smelling of the substances tried, the scent of kernels being hard to conceal. Yet it was named by E. as salt.) 31 E. G. and M. E. Bitter aloes. Bitter. 32 M. G. B. Bitter aloes. Nothing felt. September 5th. The experimenters remark that, "in some cases two ex- periments were carried on simultaneously with the same substance, and when this w'as done the first percipient was, of course, not told whether her answer was right or wrong. But it will, perhaps, be maintained that when her answer was right, her agent unconsciously gave her an intimation of the fact by a pressure of his hand ; and that she then coughed or made some audible signal to her companion, who followed suit. Whatever the theory may be worth, it will, we think, be seen that the success 84 Thought- Transference. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. round. ... A locket or a watch perhaps." (Do you see more than one round ?) " Yes, there seem to be more than one. . . . Are there three rounds ? Three rings." (What do they seem to be set in ?) " Something bright, like beads." (Evidently not understanding or attending to the question.) Told to unblindfold herself and draw, she drew the three rounds in a row quite cor- rectly, and then sketched round them absently the out- line of the case, which seemed, therefore, to have been apparent to her, though she had not consciously attended to it. It was an interesting and striking experiment. Next object: a pair of scissors standing partly open with their points down. "Is it a bright object?" . . . . Something long ways (indicating verticality). . . . A pair of scissors standing up. ... A. little bit open." Time, about a minute altogether. She then drew her impression, and it was correct in every particu- lar. The object in this experiment was on a settee be- hind her, but its position had to be pointed out to her, when, after the experiment, she wanted to see it. Next object: a drawing of a right-angle triangle on its side. (It's a drawing.) She drew an isosceles triangle on its side. Next: a circle with a cord across it. She drew two de- tached ovals, one with a cutting line across it. Next: a drawing of a Union jack pattern. As usual in drawing experiments, Miss R. remained silent for perhaps a minute, then she said, " Now I am ready." I hid the object; she took off the handkerchief, and proceeded to draw on paper placed ready in front of her. She this time drew all the lines of the figure except the horizontal middle one. She was obviously much tempted to draw this, and indeed, began it two or three times faintly, but ultimately said, "No, I'm not sure," and stopped. The remainder of Professor Lodge's experiments are very striking, but unfortunately they lose their value for reasons stated above. This is to be regretted for the cause of thought-transference, as many of the results were very brilliant. In connection with the possibility of collusion by means of a code, one experiment has a most suspicious flavor, though more cannot be argued from it. When experiments were made with both Miss E. and Miss R. acting together simultaneously as percip- ients, i.e., under conditions that prevented one of them from knowing the object, the results were failures. This concludes the most valuable of the experiments with the Liverpool subjects. Since those last made (1884), for one reason or another, it has not been found practicable to continue the experiments. A careful study of the reports of these subjects shows one thing clearly, and that is, that the experimenters were, one and all, thoroughly convinced of the good faith of the subjects, and in consequence of this confidence failed to take precautions to prevent or detect trickery. Even contact was often allowed, without an apparent sus- picion that it might be made use of. Furthermore, it was not known at that time to what perfection a code system could be brought. But whatever be the cause of the negligence on the part of the experimenters, their failure to enjoin proper conditions is fatal to the value of their results. Reports of experiments with a number of other sub- jects by different observers have been published, notably those of J. W. and Kate Smith, Max Dessoir, Richet, and A. Schmoll. They are not, however, sufficiently valuable to necessitate their consideration here. Later still, in the December number of the Journal of the So- ciety for Psychical liesearch, 1887, is an account of experi- ments by a number of different persons, in particular Mrs. Shield, and Mr. Henry G. Rawson. They are not of a character to add much to the strength of the evidence. It will be remembered that the possibility of thought- transference was first suggested by the phenomena ex- hibited by the Creery children, and that the considera- tion of this evidence was temporarily postponed. We have now to take this up. These early experiments are characterized by their conspicuously successful results, and have been given great prominence, not only from this fact, but also because the experimenters were no less than the committee of the Psychical Society, as well as Mr. and Mrs. Sedgwick, Professor Balfour Stewart, and Professor Alfred Hopkinson. The experiments were lim- ited to guessing cards, numbers, names of objects, names of places, and of fictitious persons. The card tests pre- dominated, it being thought at that time that they were the most valuable, on account, I suppose, of the ease with which the possibility of pure chance as a factor can be calculated. After the experiments had been continued some time, it became obvious that the power of guessing correctly was gradually leaving the children. The last experiments recorded were made in 1882. More recently they have been heard from again, but not in a reassuring way. In some experiments recently undertaken in Cambridge by Mr. Gurney and others, two of the children were detected using a code of signals, and a third confessed, on being interviewed at Manches- ter before any communication could reach her from the others, to having occasionally used the code in the earlier experiments at Buxton. The code used was very simple. A look upward on the part of the agent meant hearts ; downward, diamonds; to the right, spades ; and to the left, clubs. Right hand to face meant king ; left hand to face, queen ; and arms crossed, knave. There were probably also signs for the ten and ace, consisting of movements of the hands. It does not appear that there were any signs for the other numbers. When a screen was interposed so that the children could not see one another, a scrape of the foot meant hearts, while diamonds were indicated by sighing, yawning, coughing, and blowing the nose. Spades and clubs were probably distinguished by general movements for one and complete stillness for the other. Of course, the first effect of this exposure is to destroy all faith in the value of the earlier experiments, and yet, if we look at the matter impartially, something may still be said for them. The father, while admitting the fraud, still claims that the earlier results were bona fide, and that the signals were only lately used, as the mind-read- ing faculty deteriorated. It is not much matter what anyone claims ; the evi- dence must be weighed on its merits. Nor are any ex- periments of any value that are not conducted on the principle that any subject, no matter what his or her reputation, will cheat if the opportunity be given. It can hardly be questioned that the average person, to draw it mildly, even if he demonstrably possessed the faculty, would help out his powers by fraud if the oc- casion offered. Common experience shows this. De- tection of the fraud under such circumstances would not invalidate the existence of the faculty, which had been proven by other means. It behooves us, then, as impartial critics, to review from this point of view the evidence of the Creery chil- dren, and see if thought-transference is proven by any of the experiments, in spite of the confession that "codes were used in some. A study of the evidence shows that it may be divided into two groups: One including those experiments in which, besides the percipient, one or more children were present and knew the test-object; the second including only those in which the experimenters alone were sup- posed to know the test-object. To the former group belong the series reported under Easter, 1881 ; April 17, 1882 ; November 12, 1881 ; Feb- ruary 18, 1882; the Cambridge experiments reported under August 2, 1882, and the Dublin experiments with cards. All these may accordingly be eliminated as worth- less, so far as concerns their value as evidence, inasmuch as not only collusion was possible, but is known to have been resorted to in some instances. We have left, belonging.to the second group, the series reported under date of April 13, 1882 ; most of the Cam- bridge experiments, and those of the Dublin* experi- * It is impossible to form any opinion regarding the conditions of the Dublin card experiments, as the report says. In the large majority of these trials the second sister did not know the card selected, but in the table the committee admit only 30 out of 109. 85 Thrombo81s?^nce* REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ments made with words and figures. It may fairly be claimed that these should be considered on their merits, as the test cards, etc., being supposed to be known to the experimenters alone, a code of signals was out of the ques- tion. The committee themselves have, in the original report, tabulated as follows the results of these cases, in order that they may be compared with what would be expected if pure chance was the determining factor : Table showing Success obtained when the selected Object was known to one or more of the Committee only, to test Hypothesis of Collusion. Place of trial. Things chosen. Number of trials. Number right on Total right. If first guess only is counted, experiment gave The chance of suc- cess by accident was First guess. Second guess. Buxton experiments Playing cards... Numbers, etc... . Cards ... 14 15 ' 216 64 30 108 50 9 4 17 5 3 32 25 18 6 ii 10 10 5 38 11 3 43 35 1 right guess in 1 1 " " 3% 1 " " 13 1 " " 12^ 1 " " 10 1 " " 3X 1 " " 2 1 right in 52 trials. 1 " 90 " 1 " 52 " 1 " 90 " 1 " 52 " 1 " 12 " 1 « 4 u Cambridge experiments it li Numbers ... Dublin experiments Cards ,.. Numbers, etc .. Words.... it 44 Totals 497 95 45 145 1 right guess in 5% 1 right in 43 trials. They add : " Excluding the Dublin trials, which were made before one member of one committee only, and where the odds against success by accident also were smaller, and confining our estimate to the first answer alone, the experiments show that where the committee alone knew the card or number selected there were : "260 experiments made with playing-cards; the first responses gave 1 quite right in 9 trials; wdiereas the re- sponses, if pure chance, would be 1 quite right in 52 trials. " 79 experiments made with numbers of two figures ; the first responses gave 1 quite right in 9 trials ; whereas the responses, if pure chance, would be 1 quite right in 90 trials." When thus reduced to pure numbers these experiments have a formidable look, but it must not be forgotten that their value depends upon whether or no the thing selected was known only to the committee, or whether or no the subject could possibly have discovered it by ordinary means. Unfortunately, from the reports themselves one can form no opinion. The details given of the method pursued are very meagre. It cannot be interpreted, espe- cially in view of recent revelations, as lacking in respect for the powers of observation of the experimenters, if the position of all the parties in the room where the card was drawn and shown to the different experimenters fs asked for; also exactly how many of the family remained in the room, etc. The report itself indicates the want of a proper appreciation of the dangers from collusion, for it is remarked of the Buxton experiments : " Collusion by a third party is avoided by the fact that none were al- lowed to enter or leave after we had selected the thing to be guessed " [as if that prevented the use of a code when the other children were in the room], " and in the second series of experiments [April 13th] by the exclusion of all members either from the room or from participation in the requisite knowledge." But we are not told if it was during the successful trials that they were excluded from the room, or only from "participation in the requisite knowledge." Anyone who has had experience in parlor juggling knows that, even with acute observers, opportu- nities of catching glimpses of selected cards unbeknown to the audience are numerous, and it is not outside the range of possibilities that some one of the sisters in the room may occasionally have caught a glimpse, directly or indirectly, of the card, and that this glimpse coincided with many of the successful guesses. After all, whether or no the experimenter alone knows the thing selected under ordinary conditions must be a matter of individual opinion, and we have no way of determining whether more than ordinary conditions were observed in the Bux- ton experiments. It is not too much to ask that, con- sidering the unusual character of such experiments, the minutest details of the conditions under which they are performed be given. Regarding the Cambridge experiments, we are told that "on several occasions the children were tested, one by one, alone," but we are not told how many of all the experiments this includes. In those of August 3d, with cards, when of ten trials (a very small number) one card was guessed right on the first guess, and one on the sec- ond guess, it is not explicitly stated whether the remain- ing children were allowed in the room. And, regarding these particular experiments as a whole, the report speaks of the Misses Creery being excluded from a " knowledge " only of the thing selected. Thirty- two experiments, in which the other children knew the card selected, are included, being considered "unexcep- tionable," they were so placed that "only the tops of their heads were visible to the guesser," thus ignoring all audible codes, which there is every reason to believe were actually used, and which enabled the guesser to name the suit fourteen times running. On reviewing the evidence thus far obtained, if we exclude all experiments in which collusion was rendered possible by the conditions, we shall have to eliminate all the Liverpool experiments, excepting those with dia- grams and one set of Professor Lodge's, all the Smith- Blackburn, and most of the Creery experiments. Those that remain to be accepted as proof of telepathy, or to be explained by other means, are the taste experiments of Messrs. Gurney and Myers with Miss E. and Miss R. ; the above-mentioned diagram tests, in which only one percipient and the experimenter were in the room ; the one set of Lodge's previously quoted, and a minority of the Creery experiments. Of these we may say that the taste experiments must be regarded as questionable from the odoriferous nature of most of the substances used, the possibility of hyperaesthesia, and the presence of two subjects in the room at the same time ; the disclosures in the case of the Creery children, in conjunction with the imperfect character of the reports, place even the most stringently conducted of these experiments in a most problematical light; while it is very unfortunate, to say the least, that Mr. Birchall should have permitted him- self to hold the hand of the percipient in Lodge's set. Of all these numerous experiments, then, there only remains one set the conditions of which will bear critical examination, namely, the diagram tests with the Liver- pool young ladies. While we have no information on which to confute them, still, standing by themselves, they are too few and too unique to establish the faculty of thought-transference. For this they need further con- firmation, and the question must still be regarded as sub judice. If, as a result of future experience, telepathy shall be proved, the probabilities in favor of the bona fide character of many other of the experiments above re- ferred to must naturally be greatly increased. In the above discussion it has been assumed that, granting the experimental facts, the theory of thought- transference is the logical inference therefrom. It should not, however, be lost sight of that the theory is only the best explanation we have as yet to offer, and that other possible modes of explanation may be found in the fut- ure. Working on this line, the American Society have discovered, largely through the labors of Dr. C. S. Minot, that there exists in many people a number habit, by which a person tends naturally to guess certain num- 86 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Thought-Transfer- Tlirombosis. [ence. bers more frequently than others ; so that in guessing cards, certain numbers will be most frequently chosen. If this habit should coincide with the habit of another person, or with the chance drawing of a limited number of cards, an apparent case of thought-transference would be found. A similar but less successful attempt has been made to show a diagram habit. The number habit is not applicable to the card tests of the English experiments, as the cards were drawn from the pack at random. It might possibly explain a few of the number tests, though it has not been shown that such a habit exists for num- bers of more than one figure. The probabilities, at the present moment, are, that it may be a long time before thought-transference is satisfactorily proved or disproved. If it exists, experience shows that it is a very rare faculty, very limited in its possibilities, and perhaps hampered by the very conditions requisite for an experimental demonstration. It may be that the very mental effort necessary to put the mind in a recep- tive state may inhibit the reception of the transferred thought. Thoughts may be constantly transferred spon- taneously from mind to mind, and yet we may never be able to demonstrate the fact. As yet, though consider- able search has been made, few persons supposed to Have the faculty have been found in England, and none in America. Consequently, the cases being so few, it is not likely that the faculty will be demonstrated to the satis- faction of everyone. The foregoing discussion of the evidence has been based largely on the possible use of codes. It would be interesting, if space permitted, to consider in detail some of these codes, a large number of which have been invented. There is no doubt that by their use informa- tion can be conveyed in a way almost to defy detection. This may better be appreciated when it is remembered that Heller, Bishop, and others have been able, merely by subtle modes of putting questions, to give sufficient information to enable a confederate to describe correctly a bank-check, giving the date, name of the bank, amount, the name of payee, and the drawer of check-in fact, by such means, to describe correctly with minutest details any object whatever. It is not difficult, then, to understand that, even with- out spoken language, the comparatively simple descrip- tions necessary for thought-tranference could easily be signalled under lax conditions. Furthermore, many of the results may be explained by accidental opportunities of learning the object, unconscious suggestions, and the like. Accepting the principle of thought transference as proven, the authors of " Phantasms of the Living" have sought to explain many of the currently reported hallu- cinations which are said to have occurred to people at the time of death of a distant relative or friend, or at a time when such person had incurred a great danger, etc. Accounts of many such experiences have long been cir- culated, and the authors have collected about eight hun- dred of them, of greater or less authenticity. They ex- plain the hallucination by supposing that a transference of the mental state of the dying person, for example, has taken place from a distance to the person who has the experience. We cannot further enter here into this phase of telepathy, for, until the experimental variety has been established, it is hardly profitable to discuss this even more speculative aspect. Morton Prince. 1 See also Phantasms of the Living, by Edmund Gurney, F. W. H. Myers, and Frank Rodman ; and Proceedings of the American Society. 2 Part, xi., p. 405. 3 Reports, vi., p. 189. THROMBOSIS (Greek, ^poy^os, a clot). Thrombosis is the formation, during lise, of a clot of blood in the heart, an artery, vein, or capillary ; or of lymph in a lymphatic vessel. Physiology of Coagulation.-The fact that blood which had in any way escaped from the vessels which naturally carry it, would quickly coagulate, has been known from time immemorial. By the older theories this occurrence was attributed to lowering of temperature, exposure to the air, and loss of motion. Experiments, however, proved the fallacy of these theories. It was easily determined that a freezing temperature prevented coagulation ; that, if healthy blood was transferred from healthy vessels directly into a vacuum, coming into con- tact with no air whatever, coagulation was not interfered with ; that, if a segment of a large vein, filled with blood, was removed from one of the lower animals, and the blood remained perfectly motionless in this normal re- ceptacle, it retained its fluidity for a long time. More- over, if this segment of a vein were suspended vertically, and the upper end were left open so as to permit free ac- cess of air ; or if the blood were slowly poured in a small stream into another similar segment of a vein, coagula- tion was not thereby markedly hastened. If, however, during the progress of this experiment, a portion of the blood were removed from the vein, and placed in any ordinary vessel, it would quickly solidify. Burdon San- derson compressed the jugular vein of a rabbit at two points, in such way as not to wound the vessel walls, and found that the blood thus confined retained its fluidity for two days. Nevertheless, it is universally admitted that retardation or stoppage of the flow of blood, in liv- ing vessels even, does tend to slowly produce coagulation. It became evident that the vascular system possessed some peculiar power by virtue of which blood remaining in it retained its fluid state under conditions which would elsewhere result in its coagulation. Dennis' theory that, when blood was removed from the receptacles normally containing it, there occurred the decomposition of some previously existing constituent of the plasma, increased the confusion by introducing a new unknown factor. Schmidt's idea, that the paraglobuline and fibrinogen united to form the fibrine of the clot, was not verified by tests ; and was followed by the discovery of the fibrine- ferment, under the catalytic action of which fibrinogen has been found to be transformed into fibrine. The very minute proportions in which this ferment is present ren- der extremely difficult any investigations into its charac- ter and exact mode of action. It has been supposed by some to exist in the vascular coats and interstitial tissues beyond ; by others in the white blood-corpuscles. The probabilities seem to be in favor of the latter theory. At any rate its elimination, or its power to act, are clearly restrained by the presence of a healthy and uninjured tunica intima. As Briicke has stated, blood will not co- agulate as long as it is in contact with the healthy lining membrane of the blood-vessels. As healthy blood is necessary to the structural integrity of the vessels, the summing up of Michael Foster seems sufficiently to explain the phenomena of coagulation. He says : " All the facts known to us point to the con- clusion that, when blood is contained in healthy living vessels, a certain relation or equilibrium exists between the blood and the containing vessels, of such nature that, so long as the equilibrium is maintained, the blood re- mains fluid ; but when this equilibrium is disturbed by events in the blood, or in the blood-vessels, or by the re- moval of the blood, the blood undergoes changes which result in coagulation." A number of articles appeared in the Fortschritte der Medicin during 1885, 1886, and 1887, written by various observers, setting forth the composition and mode of for- mation of thrombi in animals, both warm- and cold- blooded. From these it may be inferred that it is not entirely safe to conclude that results which will follow after certain operations or conditions in one class of the animal kingdom, will certainly do so in the other. Aberth and Schimmelbusch conclude that there is an essential difference between the coagulation of blood out- side of the body and the formation of a thrombus in a vessel in which the circulation is still maintained. They name the former coagulation, the latter conglutination. For them coagulum is a mass of fibrine, embracing in its thread-like meshes red and white blood-corpuscles in about their usual proportion to each other. In the for- mation of a thrombus the white blood-disks undergo a viscous metamorphosis causing them to adhere to any prominence on the wall of the vessel and to each other, and little or no fibrine is present. The red corpuscles, 87 Thrombosis. Thrombosis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. possessing no power of becoming viscous, and being of greater specific gravity than the white ones, are carried along in the axis of the vessel, only a few of them becom- ing entangled mechanically, and hence a thrombus is at first white or n'early so. When a thrombus has reached such a size as to occlude the lumen of the vessel it occu- pies, then stagnation of the current takes place and co- agulation begins. " Conglutination is the characteristic mode of thrombus formation in circulating blood, just as coagulation is in blood at rest.'' At the same time they admit that the dividing line between the two processes is not. at all times, a sharply defined one. They found also that the destruction of all the coats of a vessel, either by the actual cautery or by escha- rotics, did not in all cases result in the formation of a thrombus, even after the lapse of many hours. They are of the opinion that "the lesion of a vessel causes throm- bosis only when it has first caused some mechanical dis- turbance of the circulation." If the inner coat remains smooth, even though it be entirely necrosed to the ex- tent of one or twro centimetres, no thrombus will form. For them coagulation is a chemical process ; conglutina- tion a mechanical one. Hanau, on the other hand, concludes, from the obser- vation of cases and from experiments, that coagulation and thrombosis have physiologically the same antece- dents and are only different morphological processes ; and that the theory which ascribes to the usual fermen- tative processes in the blood the production of thrombi, is correct. Etiology.-To the clot formed in living vessels Vir- chow gave the name of thrombus ; and it has been found, as stated above, that a very slight disturbance of the re- lation normally existing between the circulating fluid and the circulatory system may cause the formation of thrombi. Among the causes of such disturbance the fol- lowing may be mentioned : 1. Atheromatous or calcare- ous degeneration of the lining membrane of the vessels. Arterial degenerations of this character, resulting in se- nile gangrene, are of every-day occurrence, and are also frequently observed in the brain. 2. Foreign bodies, penetrating the arteries, veins, or heart, form a suitable nucleus for thrombosis. 3. Emboli, obtaining a lodg- ment at any point in a vessel and occluding it, are very frequent causes of secondary thrombosis, and the latter is usually of much more serious importance than the em- bolism itself, because the collateral circulation is thereby cut off, and gangrene must follow. This point is fully brought out in the article on Embolism. 4. The enlarge- ment in diameter of an artery or vein favors the forma- tion of a clot, partly by the retardation of the current; but it must be remembered that enlarged vessels are usu- ally also diseased vessels; and the disease of the wyalls often exerts more influence than the mere mechanical changes in the rapidity of the current. Nutritive changes are produced in the vessel-walls by retardation of the current, even if they be not the subject of primary dis- ease ; and these changes may be sufficient to produce coagulation. The formation of clots in aneurismal sacs, and in connection with varicose veins, may be cited as in- stances of this. The writer has within the past year seen two cases of well-marked thrombosis of the internal sa- phenous vein in the thigh, extending up to the groin, in persons otherwise in perfect health, for the occurrence of which no cause could be assigned other than the pre- vious existence of a well-marked varicose condition of this vessel below the knee. 5. Certain conditions of the blood itself, in which coagulation occurs with unusual facility, are sometimes the cause of thrombosis, Hyper- inosis, in which fibrinogen is present in excess, is one of these, and the chemistry of some of the others is not yet very definitely determined. Among the diseases in -which this condition appears to present itself may be mentioned rheumatism, measles, scarlet fever, diphtheria, the essen- tial fevers, the puerperal state, pneumonia, phthisis, can- cer, nephritis, constitutional syphilis, septicaemia, and pyaemia. 6. Heart-weakness, causing the blood to cir- culate under too low tension and at too slow a rate, is a frequent cause of thrombosis. This usually depends upon organic disease of the central organ, such as hy- pertrophy with dilatation, atrophy, or fatty degeneration, or upon some lesion of the valves. In this case the orig- inal thrombus often forms in the heart itself, is washed away in the blood-current, lodges as an embolus in the pulmonary or general circulation, as the case may be, and there forms the starting point of a secondary throm- bosis. 7. Inflammation of the lining membrane of the heart or vessels. The older authorities gave great prom- inence to phlebitis and endarteritis as causes of throm- bosis ; but there is now no doubt that in many of these cases the thrombosis was the first step in the pathological process, and the inflamed condition of the vessel wall the result of a conservative effort on the part of nature. It is also doubtful whether inflammation of the vessel or lining membrane of the heart ever causes thrombosis un- til after it has first resulted in some mechanical roughen- ing. But in so many cases does endocarditis, both simple and ulcerative, ultimately cause thrombosis, that atten- tion should be called to this fact; and there is equally no doubt that clotting in an artery or vein sometimes results from the extension inward of an inflammation of sur- rounding parts. 8. Mechanical injury to the lining mem- brane of the heart or a blood-vessel. This is taken ad- vantage of by the surgeon, who takes good care to draw his ligature so tight as to cut through the internal and middle coats of the vessel he is ligating, whether for the arrest of haemorrhage or the cure of aneurism. For those who believe that the fibrin-ferment exists in the walls of the vessels, its escape and activity under these circum- stances account for the coagulation which ensues. The etiology of thrombosis of the lymphatic vessels is not yet well ascertained. The condition has been ob- served mainly in the lymphatics of the uterus and in those extending upward from these. It is probably con- nected with some change in the lymph, possibly also in the walls of the vessels. One choosing to generalize on the etiology of throm- bosis might say that, in one class of cases, the result seemed to depend upon a retardation of the flow of blood or upon its complete arrest; in a second class, upon some structural change in the wall of the vessel; in a third class, upon some change in the blood itself. Pathology.-The character of the clot depends upon the manner of its formation. If it forms slowly, and is attached to the walls of the heart, or of a vessel through the centre of which the current is still maintained, it is white or light yellow. Under the microscope this white clot is seen to consist essentially of fibrine and white blood-disks, with only very few red corpuscles, if any. The proportion of fibrine and white disks varies very much ; sometimes very little of the former can be seen. If the current through a vessel has been completely arrested, then the clot has the dark-red color of blood coagulated outside of the body, or is even somewhat darker. A primitive thrombus is one which has not extended from its original site; one which has reached as far as the junction of the next vessel, the lumen of which it may involve, is termed produced, or extended. A uniform thrombus is one which is either white or red throughout. In many instances, the portion which is first formed.is white ; that which forms later, after the lumen of the vessel has become entirely obstructed, or after death, is continuous with this, but dark red in color. Many clots are laminated, the fibrine being deposited in successive layers, between which, under the microscope, the white disks will be found grouped together in large numbers. A parietal thrombus is one which forms on the wall of a vessel ; if it increases in size until it prevents the flow of blood, it is said to be obliterating. It is often very important to distinguish at an au- topsy between ante-mortem and post-mortem thrombi. Of course, no white clot can be formed after death ; doubt can exist only concerning a dark-colored clot. If this is adherent to the wall of the heart or of a blood-vessel, it was formed during life. The fibrine in post-mortem clot, true to its inherent tendency, will shrink, just as it does outside of the body ; the thrombus will lie loose in 88 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Thrombosis. Thrombosis. the heart or vessel, never filling up its entire calibre. The connecting link between the two is the clot which is so often found in the heart of a patient who has died very slowly, and which was, years ago, erroneously named polypus of the heart. The portion of this which was first formed is, as a rule, white or light yellow- sometimes likened to "chicken fat"-while continuous with it are dark prolongations, extending often many inches into the pulmonary artery and aorta. Much, if not all, of the dark portion is of post-mortem formation ; but any portion of a clot which is light yellow in color, or adherent to the wall of the heart or of a vessel, may be regarded as having been formed during life. A thrombus may be disposed of by resolution, by or- ganization, by degeneration, or by suppuration, if the patient's life is spared long enough. There is nothing special to be said about the process of resolution, as it is accurately described in all text-books on pathology. Its occurrence is rare ; but when it does happen, the func- tion of the heart or blood-vessel is completely restored. In case the clot becomes organized, the vessel, if that has been the site of the occurrence, becomes continuous with the organized clot in one firm fibrous cord, much reduced from its original diameter by atrophy, and the circulation must be maintained by collateral branches. Only when it is insignificant in size will a heart clot be- come organized, and it then constitutes a firm vegetation, the power of which for evil depends entirely upon its size and location. In a few cases calcareous degenera- tion occurs in a partially organized thrombus, and a phlebolith is the result, which often in its turn becomes the cause of an inflammatory process in the tissues sur- rounding it. Suppuration of a thrombus certainly occurs occasionally ; and it is very common, at an autopsy on a patient dead from thrombosis, to find veins filled with a thick fluid which presents to the naked eye all the ap- pearances of pus. In many of these cases, however, mi- croscopical examination will show that this fluid contains very few, if any, pus-corpuscles, but is made up almost entirely of granular and fatty debris. The entrance of this debris, or of pus, into the general circulation, is fre- quently the cause of death in cases whose progress has been, for some time after the first occurrence of throm- bosis, apparently satisfactory. Symptoms.-The effects of thrombosis are so decidedly mechanical, depending upon obstructed circulation, that the symptoms are entirely different according as we have to deal with thrombosis of the heart, of an artery, or of a vein. Of the Heart.-If the clot be small, and the symptoms not very urgent, they will closely resemble those of ad- vanced valvular disease. There will be some sense of oppression ; some dyspnoea; increased frequency of res- piration ; rapid, irregular, and intermittent pulse ; slight cyanosis ; slight fulness of the jugular veins. In the worst cases, all these symptoms are vastly increased in severity, and in addition the patient becomes restless and uneasy, rolling and tossing from side to side, or abso- lutely refusing to remain in bed, breathing hard and heavily, and begging for more air ; while the face, neck, and upper extremities are bathed in perspiration, and the facial expression is that of the utmost distress and anxi- ety. The brain soon manifests the effects of the circu- lation of impure blood by the appearance of active de- lirium or of convulsions, and profound coma is the precursor of a fatal issue. The physical signs of cardiac thrombosis cannot be said to be perfectly characteristic, and yet they are in some respects well marked, provided the coagulum be of such size and so located as to obstruct an orifice, or in- terfere with the function of a valve. Much the same signs may follow the rupture of one of the chordae ten- dineae or of a valve. The diagnosis is rendered much more probable by the known previous existence of some of the conditions which have been enumerated above as favoring the formation of a thrombus. This affection occurs more frequently on the right side of the heart than on the left. On inspection and palpation we find the labored heart-action, with irregularity and intermittence of the apex-beat. On percussion the area of dulness may be increased to the right of the sternum, but is not always so. On auscultation the irregularity as to both force and rhythm of the heart-beat is heard. If no murmurs pre- viously existed they are developed now ; if previously present, they are increased in intensity. Most commonly they are those which accompany either tricuspid or pul- monary obstruction, possibly joined with regurgitation, at one or the other, or both, of these orifices. Occasion- ally similar sounds are heard on the left side instead of on the right. Sudden, and otherwise unaccountable, shock to the heart must accompany these signs to render the diagnosis at all certain. The signs of pulmonary ap- oplexy or oedema will accompany the advent of either of these not uncommon results. The prognosis is always unfavorable, and if the clot is evidently large, and the symptoms urgent, is as bad as can be. If the thrombus is very small it may, how- ever, disappear entirely, or become organized into a simple vegetation. In the latter event, the possibility of subsequent embolism must be borne in mind. Death may occur within twelve hours, and is rarely delayed beyond the third day ; it may occur at any time, almpst instantaneously, by the detachment of a large clot from its original location and its lodgment in one of the valvu- lar openings. Of an Artery.-The symptoms which follow this are precisely those which follow embolism, save that they come on slowly instead of suddenly. The reader is, therefore, referred to the article on Embolism. The main difference is that thrombosis is accompanied by little or no pain. Of a Vein.-In this event, the return circulation being interfered with, oedema frequently becomes a prominent sign, and would always be so were it not that in many parts of the body nature has so abundantly provided against such a contingency by the freedom of the col- lateral circulation. Venous hyperaemia, dilatation, and sometimes haemorrhage, precede the watery exudation. In the case of.the superior vena cava, the head, neck, up- per extremities, and upper part of the thorax become the seat of the anasarca ; of the inferior vena cava, the lower extremities, abdominal wall, kidneys, and sometimes the other abdominal organs; of the portal vein, the chylo- poietic viscera in general; and ascites also follows sooner or later. In this last case, moreover, the function of the liver is interfered with, and the result is abscess of the liver, or a train of other symptoms directly dependent upon such interference. In the extremities we do not neces- sarily get much cedema, if only a single vein is throm- bosed, but still it is a frequent symptom. If the vein is sufficiently superficial for examination by the sense of touch, it will be found to have been converted into an elastic cord, of considerable size, and in some instances constrictions seem to mark the site of the valves. Very soon tenderness develops along the site of the vein to just the extent of the thrombosis, and motion, either active or passive-more especially the former, becomes painful. After three or four days, if the vein is quite superficial, a red band appears on the skin, which is also warmer than the surrounding surface. The tenderness, redness, and heat are due to phlebitis-nature's effort at repair. The redness and heat will both be concealed by the oedema, if it be at all extensive. The so-called milk leg is, in many cases, nothing more than this condition of the veins of the thigh, or sometimes of the inferior cava. The prognosis in case of thrombosis of the venaj cavae or of the portal vein is bad ; that of thrombosis occurring in the veins of the extremities is good. In the latter case death may result, it is true, or abscesses may require to be opened ; but the majority of cases, even though they appear serious, recover. Treatment.-One prime indication in every case is to keep the affected part at perfect rest. In the case of the heart the patient should be confined absolutely to the recumbent or semi-recumbent posture, not even being allowed to sit up for any purpose whatever. Many sud- den deaths have occurred from infraction of this rule. The same rule applies to cases in which the affection 89 Th rombosls. Thymus Gland. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. involves the venae cavae or the portal vein. In throm- bosis of the veins of an extremity the limb should be kept entirely at rest and somewhat elevated. Protecting the limb with cotton batting and oiled muslin has been rec- ommended, and usually adds much to the patient's com- fort. Bathing the extremity with warm embrocations, to which laudanum may be added if much pain is pres- ent, sometimes gives more relief than the cotton batting. After the first few days have passed, the author thinks that he has seen very good results follow the gentle inunc- tion of the skin over the affected vein with unguentuin hydrargyri, and laying on it a strip of patent lint spread with the same. The firm, careful application from be- low upward of a roller bandage of flannel is in all cases advisable. As to general treatment, it should be scarcely necessary to say that bleeding, either general, or by cups or leeches, should be studiously avoided. It is very important to quiet the patient's nervousness and restlessness, and this is best accomplished by opium or its derivatives, given either by the mouth or by the hypodermic syringe. Digitalis is indicated, and perhaps also stimulants, if the heart's action is weak and irregular. Of course any drug which would render the blood less likely to coagulate, or which, circulating in the blood, would tend to dissolve the clot which had already formed, would be of the great- est assistance, Richardson, of London, asserts that we have such aids in the alkalies, and especially in ammonium carbonate. It is recommended that the last-named drug be given in large doses, frequently repeated ; and Rich- ardson states that under its influence he has seen cases recover in which there was every evidence of the exist- ence of embolism of the heart or pulmonary artery. Samuel B. Ward. THYME (Ilerba Thymi, Ph. G.; Thym, Codex Med.; Oleum Thymi, U. 8. Ph.; Thymol, U. 8. Ph., Br. Ph.).. The herb, also the oil and camphor of Thymus vulgaris Linn.; Order, Labiates. The common Garden Thyme is a lowT, slender, much- branched shrub, a foot or less high, with brown, nearly cy- lindrical branches, minute, opposite, narrowly oval or lanceolate leaves, and blunt, interrupted, spike-like clusters of violet-colored flowers ter- minating the branches. Flow- ers small, dimorphous. Ca- lyx and corolla both labiate. Stamens four, sometimes short and equal, at other times long, exserted, and in pairs. Plant variable, more or less hairy ; a native of Southern Europe, but cultivated there and else- where for centuries. Thyme has but little history as a medicine, being mostly used as a condiment and flavor for soups, etc. It has a pecul- iar, pungent, fragrant smell, a minty taste, and contains a mixture of essential oils and stearoptenes. Of Oil of Thyme {Oleum Thymi, U. S. Ph.) there are two varieties, the crude (Red Oil), which is deep yellow or reddish, generally known as Oil of Origanum, and mostly used in liniments or in veteri- nary practice ; and the redis- tilled " White Oil," which is obtained from the other by redistillation, and the only one intended in the Pharmacopoeia. It is described as "a colorless, or pale-yellow, thin liquid, becoming darker and thicker by age and exposure to air ; having a strong odor of thyme, a warm, pungent, and afterward cooling taste, and a neutral reaction. Specific gravity about 0.880. It is readily soluble in alcohol." The Oil of Thyme is a composite liquid, consisting of two hydrocarbons named Cymene and Thymene, and a solid, crystalline, fragrant camphor, Thymol (U. S. Ph.), soluble in the hydrocarbons, but separable by long stand- ing and cold. Thymol is also found in other species of Thymus, and even in species of other genera and families, as Carum, Monarda, etc. It is obtained by refrigeration, or by treating the oil with caustic solutions and finally decomposing the thymol salt so obtained. It is a solid, crystalline, fragrant substance, with the odor of Thyme, a pungent, biting taste, and a neutral reaction. It is a little heavier than water when solid, but floats on the surface when melted. Soluble in 1,200 parts of water, in one of alcohol, and freely in the usual solvents of volatile oils and camphors. Mixed with cam- phor, Thymol, like chloral, liquefies. Action and Use.-Oil of Thyme belongs to the mod- derately rubefacient oils like Eucalyptus, Cajeput, Sage, etc., and is more employed externally than as an internal remedy. As an ingredient of liniments it adds to their stimulating character, and gives them a rather agreeable smell. Thymol, although discovered about a century ago, has been an article of commercial value only about ten or twelve years, since when it has been in consider- able demand as one of the milder antiseptics. A satu- rated solution in water, while not so reliable as carbolic acid (2| per cent.), or corrosive sublimate (-^ per cent.), is still useful, and in clean wounds or operations usually entirely safe. The same solution will prevent the forma- tion of the usual fungous growths in aqueous solutions of the alkaloids, and may be used for their preparation. Morphine and atropine solutions, for instance, made with Thymol water, will keep perfectly well indefinitely. Administration.-Neither of these articles is often given internally. Allied Drugs.-The Mint and Umbelliferous oils, and Cajeput, Eucalyptus, etc., are nearest like Thyme. Allied Plants.-Several species of Thymus, having similar properties to the above, are somewhat in local use as aromatic or external stimulants. Thymus Serpyllus is official both in France (Serpolet) and Germany {Herba Serpylli). For the Order see Peppermint. IF. P. Bolles. THYMUS GLAND (Audios). The thymus is classed with the blood vascular, or ductless glands. Synonyms : Cor- pus thymicum, Lat.; Thymusdruse, Ger.; Corps thymique, Glande thymique, Fr. Anatomy.-Situation.-The thymus gland lies princi- pally within the thorax, immediately behind the sternum in the anterior mediastinum, its upper extremity ex- tending into the neck, sometimes as high as the thyroid gland. Its relations are (at birth): anteriorly, the sternum from the level of the fourth costal cartilage upward, and the sterno-hyoid, and sterno-thyroid muscles in the neck; posteriorly, the pericardium, the roots of the great ves- sels, and in the neck the trachea (Fig. 3917, A). It forms, therefore, the most superficial object in the thorax after the sternum has been removed. Form.-It consists of two lateral lobes which are con- nected above, the anterior and posterior surfaces being flattened, the lateral edges being sharp. The lobes are sometimes long and narrow, at other times short and broad. It has a superficial resemblance to the submax- illary gland, owing to its being subdivided into small lobules. On dissecting out these lobules they are found to be continuously arranged about a central cord or axis (see Fig. 3917, B and C). Size.-The size of the thymus is normally subject to great variations ; it is only a temporary organ, and atro- phies before middle life. The average size of the gland at birth is about two and a half inches in length, and one and a half inch in width, and its weight is about thirteen grammes (3 drachms). At the age of one year it weighs twenty grammes (5 drachms); at two years it attains its Fig. 3916.-Thymus Vulgaris. Thyme. Flowering Branch, about half natural size. (Bail- Ion.) 90 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Thrombosis. Thymus Gland. The lobules resemble lymph-glands in structure, each consisting of several follicles, from which on section a more or less abundant milky juice exudes, containing finely divided fat, compound granule- cells, and a few leucocytes. Under a low power the tissue of the lobule in the main resembles that of a compound lymphatic gland, but presents the peculiarity of each follicle being di- vided into two zones : an outer, opaque portion (cortex), and an inner, translucent (medulla). The cortex consists of ordinary finely reticulated lymphoid tissue, the meshes of which are filled with leucocytes. The medulla is distinguished by the presence in varying number of peculiar, concentrically arranged bodies, the con- centric corpuscles of Hassall, which con- sist of small epithelial cells with distinct nuclei, flattened by being concentrically arranged about a homogeneous or gran- ular centre. These bodies usually range from 10 to 25 g in di- ameter. At times they are much larger, and may be so closely set as to leave very little intervening tis- sue ; at other times the centre of the fol- licle is filled with the milky fluid men- tioned above, and the concentric corpuscles are less numerous. In the human subject the interspaces be- tween these corpus- cles are filled with the dense lymphoid tissue which forms the bulk of the gland, so that the corpuscles themselves might al- most be overlooked. The occasional presence of hollow spaces within the lobules has given rise to an erroneous impression that the spaces are due to imperfectly formed acinous tubules. But these spaces were in great measure due to the somewhat rough methods of in- vestigation employed. Vessels.-The arteries consist of numerous small branches from the internal mammary, inferior and su- perior thyroid, subclavian, and caro- tid arteries. Their capillaries are distributed chiefly to the cortical portion of the follicles, but also send some loops inward to the central medullary areas. The veins empty into the left in- nominate vein. The lymphatics are large and numerous and accom- pany the vessels. Nerves.-The nerves of the thymus are very minute, and are derived from the pneumogastric and sympa- thetic. Filaments from the descendens noni and phrenic nerve are supplied to the investing capsule, but do not penetrate the gland tissue. Development.-The comparative embryology of the gland, as worked out by Stieda, Kolliker, Dohem, Maurer, and His, still leaves many points doubtful. The thymus is developed on each side from the poste- rior extremity of several branchial arches (in mammals usually from the third only), to become a solid, compact epithelial body, being soon penetrated by lymphoid tissue which separates the epithelial elements, till the latter are greatest weight, twenty-six grammes (64 drachms), and at puberty it still weighs about twenty-five grammes. After this it rapidly atrophies and becomes a mere rudi- Fig. 3917.-A. Situation, Relations, and Form of the Thymus Gland: 1, right lobe; 2, left lobe ; 3, furrow between the lobes; 4, lung; 6, thyroid body ; 7, trachea; 10, internal jugu- lar vein ; 11, common carotid artery ; 12, pericardium. B. Right Lobe of the Thymus after Removal of its Sheath. C. The Gland Unravelled, showing the lobules, 3, grouped round a central cord, 4. (After Sappey-figured in Quain's Anatomy.) ment, being scarely ever distinguishable after the twenty- fifth year. Besides these variations, due simply to the age of the subject, it has been observed to become smaller in conse- quence of active exercise, and to be again increased in size after rest and overfeeding. Structure.-The thymus is fixed in the anterior medi- astinum by means of loose areolar tissue, rich in elastic Fig. 3919.-Thymus of Embryo Rabbit at Six- teen Days, Enlarged. a, Thymus canal ; o, superior ; c, inferior extremity of the or- gan. (After Kblliker, figured in Hertwig's Lehrbuch d e r Ent- wickelungsgeschichte.) Fig. 3918.-Section of a Portion of the Thymus Gland, seen under a Low Power, a, Fibrous tissue between the lobules; b, cortex; c, medullary portion. (Klein's Elements of Histology.) fibres, which forms a sheath or envelope enclosing it {in- volucrum), at the same time sending prolongations which pass, between the lobules and which contain the vessels and lymphatics. 91 Thymus Gland. Thyroid Gland. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. only represented by the concentric corpuscles. In rep- tiles and birds the thymus persists in the form of two separate lobes, one on either side of the trachea. In mammals it consists at first of a closed tube, having a very narrow lumen lined with a thick coating of glan- dular epithelial cells. It extends toward the pericardium, and at this extremity begins to assume its characteristic branched, lobulated appearance, but is from the first solid and without a central cavity. Simultaneously its histological character changes. Lymphoid tissue and blood-vessels penetrate it, and it loses its appearance of an epithelial gland. Henceforth, any increase in size is solely due to increase in the lymphoid tissue. The cavity originally present in the upper part becomes obliterated, and any subsequent cavities formed in it are merely ir- regular spaces produced through softening of the tissue. Involution.-From the time when the thymus attains its greatest size it begins to show signs of atrophy. These are not only seen in its gradually diminishing size, but also in the color, which at birth and up to the second year is a translucent grayish-pink, but afterward becomes more opaque, mottled, and yellowish, finally yellowish- brown, this change being due to fatty degeneration. After puberty the gland becomes firmer, owing to the relatively large amount of fibrous tissue present through absorption of the fat. As before stated, however, the degeneration of the epithelium begins much earlier, go- ing on hand in hand with the development of the lymph- oid element. Anomalies.-The principal anomaly, beyond the va- riation in the shape of the lobes already mentioned, is the occurrence of small, detached, accessory thymus glands in the immediate neighborhood. This has no morphological significance. Chemical Composition. - Analyses of the thymus gland show it to be rich in coagulable albuminoids. It also contains xanthin, lactic, formic, acetic, and succinic acids, ammonium salts (?), and an amount of fat ranging from one per cent, to seventeen per cent., according to the age of the animal. Physiology.-The chemical composition of the thy- mus gives no clue as to the nature of its functions. As far as known, it acts simply as a lymphatic gland. This is shown by the fact that in animals which possess no true lymphatic gland (reptiles and amphibians) it persists as a permanent organ. Nothing is known as to any pos- sible function which the epithelial elements may per- form, nor has any light been thrown upon its functions by experiments in which the gland has been extirpated. Pathology.-But little is known of the pathology of the thymus. It seems to take little or no part in general diseases, and local pathological changes rarely occur in it. It may be abnormally enlarged, this usually occurring at birth. This condition was formerly thought to produce interference with the respiration through pressure (asth- ma thymicum), but the idea is now abandoned. It is occasionally absent, but in all wTell-authenticated cases this has only occurred in connection with other marked deformity (such as anencephalia). In congenital cyanosis the gland has been found to be dark red in color from minute haemorrhages, and in purpuric conditions haemor- rhagic areas of considerable size have been found. Inflammation was thought to be common by the older writers, this belief having probably been caused by the presence of post-mortem changes accompanied by diffu- sion of the blood pigment. It is certain, however, that inflammation and suppuration actually do occur, though rarely, either in pyaemia or in subjects of congenital syphilis ; in the latter case, possibly through degenerative changes in gummata. Enlargements of the thymus (always of the nature of lymphadeno- or lympho-sarco- mata) are sometimes met with in children, most fre- quently in connection with leukaemia. These tumors are sometimes soft and medullary, at other times hard and fibrous, and may cause obstruction to the respiration through pressure upon the trachea. No reliable case of carcinoma has ever been recorded, and this, taken as a negative fact in relation to Cohn- heim's theory of tumors, is of some interest. In the progress of degeneration the concentric corpus- cles sometimes become calcified, this condition having even been met with in the foetus. In some cases the gland, while apparently of large size, has been found to consist solely of true adipose tissue. Parasites have never been met with in the thymus. Bibliography. Henle's Anatomy. Quain's Anatomy. Hertwig, O.: Lehrbuch d. Entwickelungsgeschichte, Bd. ii. Hoppe-Seyler: Physiologische Chemie. Watney, H. : Philosophical Transactions, 1882. Orth: Lehrbuch der Speciellen Pathologischen Anatomie, 1886. Wyatt G. Johnston. THYROID GLAND (&vpe6s etSos). This organ belongs to the class of ductless, or blood vascular glands. Synonyms: Corpus Thyroideum, Glandula Thyroidea (Lat.) ; Schilddriise (Ger.); Corps Thyroide, Glande Thy- roide (Fr.). Anatomy. Position and Relations.-The thyroid gland is situated in the anterior part of the neck, and consists of two lateral lobes joined below by a transverse connecting portion called the isthmus, which lies in contact with the anterior surface of the trachea, usually from the second to the fourth ring. The late- ral lobes extend upward and backward nearly to the level of the hyoid bone, lying in contact posteri- orly with the tra- chea, larynx, and pharynx on each side, and with the sheath of the great vessels of the neck. Anteriorly the gland is cov- ered by the sterno- hyoid, sterno-thy- roid, and omo-hy- oid muscles. The average length of the late- ral lobes is from five to seven ctm. (2 to inches). The height of the is t hmus varies from five to twenty mm. (| to | inch). The weight of the whole gland is about thirty to sixty grams (one to two ounces). Its relation to the body weight is at birth, 1-300; at the age of three weeks, 1-1,000; in adult life, 1-1,800 (Krause). Its weight was formerly thought to bear an inverse ratio to that of the spleen, but this view is no longer held. Ligaments.-In the connective tissue between the thy- roid gland and the larynx and trachea, strong lateral ligaments extend from the cricoid cartilage and three upper tracheal rings to the lateral lobes, and a median ligament from the crico-thyroid aponeurosis to the pos- terior surface of the isthmus. Vessels.-The thyroid arteries are on each side the superior thyroid artery, a branch of the external, or sometimes of the common carotid ; the inferior thyroid artery, a branch of the thyroid axis in the first portion of the subclavian ; occasionally a middle thyroid artery, the thyroidea ima, is given off from the innominate artery. The thyroid veins are of large size, with free anastomoses. They form plexuses on the anterior surface of the gland and in front of the trachea, from which arise on each side the superior and middle thyroid veins emptying into the jugular, and the inferior thyroid veins emptying into the innominate veins. The lymphatics are large and numerous, and terminate in the thoracic and right lymphatic ducts. Fig. 3920.-From Henle's Anat- omy. showing the Relation of the Thyroid Gland to the Trachea. 92 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Thymus Gland. Thyroid Gland. Nerves.-The nerves are derived from the pneumogas- tric (recurrent laryngeal) and from the middle and infe- rior cervical ganglia of the sympathetic. They are of small size. Structure.-The whole gland is invested by a dense sheath of connective tissue(involucrum), which sends prolongations into the gland-substance, di- viding it into lobules; these again being similarly divided into still smaller lobules, giving it a coarse- ly granular appearance. It is grayish-red in color, slightly translucent, and sometimes mottled by yel- lowish or brownish tints. On section, a thick glairy fluid (colloid) exudes in small quantity upon the surface, making it appear moist and glistening. When examined with a low power under the mi- croscope, this fluid is seen to have come from innu- merable minute closed vesicles ranging in di- ameter from 0.015 to 0.15 mm., becoming relatively larger as age advances, and being separated from each other by tine septa of connec- tive tissue containing numer- ous nuclei. The wall of each vesicle is lined with a single layer of cubical epithelial cells, hav- ing distinct nuclei. There is no basement membrane (?); between the epithelial cells numerous plasma cells are seen. The central portion of the vesicle is filled with a homogeneous colloid substance, which is coagulated by alcohol and acetic acid without becoming turbid, and which stains faintly with nuclear semi-fluid colloid material, detached epithelial cells, leu- cocytes, and red blood-corpuscles in various stages of degeneration, are some- times seen, but are not, strictly speaking, normal- ly present, being really products of degeneration. The interstitial connective tissue between the vesicles also frequently contains plasma cells, and the areo- lar spaces are often infil- trated with colloid sub- stance similar to that found within the vesicles. Wolfler has described the gland as consisting of a cortical portion in which the development is incom- plete, the epithelial cells being arranged in solid elongated clusters or col- umns, and a medullary portion where the gland is fully developed, and all the cells are arranged to form vesicles. The exist- ence of a limited number of epithelial columns in the medullary part of the gland, regarded by Vir- chow as evidences of a true tubular racemose ar- rangement or connection between the vessels, is ac- counted for by Wolfler as the persistence of the gland- tissue in its embryonic form between the more fully de- veloped vesicles. This dis- tinction forms the basis of Wdlfler's classification of en- largements of the thyroid gland (see article Goitre; Pathological Anatomy, Vol. III., p. 352). It is in the in- terstitial tissue that the vessels and nerves ramify, and neither the vessels nor the lymphatics are in direct con- tact with the interior of the vesicles. A varying amount of true lymphoid tissue is also found here. Development.-The thyroid is developed from three centres, one for each of the lateral lobes and isthmus,. Fig. 3921.-Relations of the Thyroid Gland to the Neighboring Parts. 1, Vena cava superior: 2, trunk of left brachio-cephalic vein; 3, left subclavian vein : 4. left internal jugular vein ; 5, left external jugular vein ; 6, left inferior thyroid vein; 7, left superior thyroid vein ; 8, left facial vein ; 9, a remarkable condition of anastomoses, peculiar to this individual case, and constituting a variety of anterior jugular veins; 10, trunk of right brachio-cephalic vein; 11, right inferior thy- roidvein. (Beaunis and Bouchard.) Fig. 3923.-Section of Thyroid Gland, X 100, Showing Small Vessels Filled with Homogeneous Colloid Substance. (Henle.) Fig. 3922.-Section Showing Three Vesicles of Thyroid Gland Highly Magnified. Two of the vesicles show the single lining of cutical epi- thelium ; in the other the section has exposed the upper surface of a vesicle, showing the epithelial lining to be continuous. (Henle.) and one remaining rudimentary. This latter is in reality a diverticulum from the anterior wall of the pharynx at the root of the tongue. In fishes and amphibians this soon separates from its attachments to become a solid globular body. In birds, mammals, and man, it becomes stains, such as logwood, and often, especially in adults, stains very strongly with picric acid. Imbedded in this 93 Thyroid Gland. Thyroid Gland. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. a hollow epithelial vesicle, of which the cavity in man rapidly closes. His, from researches upon the human embryo, states that in early foetal life a duct exists (duc- tus thyreo lingualis) extending continuously from the epithelial vesicle mentioned above to the surface of the tongue. The upper part of this duct (ductus lingualis) persists as the foramen caecum, while the lower part (ductus thyroideus) becomes obliterated. He has de- tected traces of this portion in adults, and sometimes a body resembling the thyroid gland in structure remains. This has been called the supra-hyoid or the prae-hyoid gland. The symmetrical or lateral centres for the thyroid gland, formed from the last branchial clefts, soon separate from their original attachments and fuse in the middle of the neck about the trachea. In some animals {e.g., dogs and horses) this fusion does not take place, consequently the thyroid in such animals possesses no isthmus. In some reptiles the right lobe always remains rudimentary. At first the thyroid consists of very small vesicles widely separated by a large amount of embryonic connective tissue, but later the vesicles become larger and more nu- merous, while the connective tissue disappears. Anomalies.-The most common is the presence of a slender tongue-like process (see Fig. 3924) (middle lobe, site is close to the posterior edge of the right lobe, be- tween the trachea and oesophagus. In cases of goitre this supernumerary gland, when present, may cause great obstruction to respiration and swallowing. " If an oper- ation be performed upon it, the incision must be made posteriorly (see article Goitre). In dogs, Wolfler has described two small accessory thyroids, "aortic glands," situated in the fat about the origin of the aorta. Wolfler has also detected traces of striated muscle-iibre in an otherwise normal thyroid. The chemical composition of the thyroid is stated by Hoppe-Seyler to be characterized by the presence of a colloid substance, which corresponds neither with any known albumin nor with mucin ; possibly a globulin, though no satisfactory method of isolation has yet been discovered. Analyses of tlie gland have yielded formic, acetic, lac- tic, and succinic acids, xapthin and leucin. In cysts of the thyroid a highly concentrated serum, albumin, and a globulin are always found. In old standing cysts cho- lesterin, and in cysts into which haemorrhage has oc- curred the various derivatives of haemoglobin, are found. Physiology.-Of the function of the thyroid in health nothing positive is known. The only means of obtain- ing information on this point has been from observing the effects of diseases of the thyroid upon the system, or in noting the effects of its extirpation in men or animals. While the results so obtained are certainly striking enough, yet any deductions drawn from them, as to the normal functions of the gland, contain many unavoidable sources of fallacy. Gegenbauer held that in some animals very low in the scale, e.y., tunicata, the thyroid has a definite and impor- tant function in connection with digestion, and that in man and mammalia it persists without function. That it has some function, however, appears certain, owing to the uniformity with which certain pathological conditions are brought about by its removal. The results of extirpation have been carefully observed in man, chiefly by Kocher, Wolfler, J. L. Reverdin, and Kaufmann, and in animals by Schiff, Horsley, Fuhr, and many others. In man, the disturbances observed after total extirpa- tion of the thyroid set in about two or three months after the operation. They consist in general weakness, ten- dency to fatigue, sluggishness and uncertainty of move- ment, slowness of speech, and weakness of the intellect- ual powers (defective mentation), with hallucinations and delusions. In addition to these symptoms, chilliness, with cold extremities, and pains in the arms, legs, and body have been observed. Most of the cases show at some time fibrillar tremors, and some of them tetany. The patients had a dull, stupid look, which often sug- gested actual idiocy, though this was not the case, since they felt and recognized the change in themselves. This condition was accompanied by moderate anaemia, four- cases being recorded where the blood-count was under 2,800,000 red cells per cubic millimetre. The skin was pale or with a yellowish tinge, and usually harsh and dry. Usually the condition of myxcedema appeared, the skin and subcutaneous tissue becoming swollen and boggy, not pitting on pressure (see article Myxcedema, Vol. V., p. 98). The condition is not, as a rule, fatal, though the patients sometimes die in the course of one to three years, usually from some intercurrent disease or from accident. They may recover completely or in part. The above detailed symptoms are precisely identical with those characterizing cretinism in the advanced stages of goitre, and it was at first thought that they were part of the original affection for which the thyroid had been removed and which developed later. At pres- ent, however, the prevalent idea is that these symptoms, whether occurring in the course of goitre or following thyroidectomy, are directly or indirectly the result of abolishing the function of the thyroid gland, and Kocher on this account suggested the term cachexia stramipriea to describe this condition. The results of experiments upon animals are no less Fig. 3924.-Thyroid Gland with Middle Lobe Present. (Henle.) pyramid), extending upward in front of the larynx. It occurs in forty per cent, of all cases (Gruber). It is often separated from the isthmus. When present, it often has a muscular slip attached to its anterior surface (levator glandulae thyroideae, or mus- culus azygos), usually derived from the thyro-hyoid. The isthmus is sometimes situated abnormally low. This is of importance in performing tracheotomy, as it is sometimes convenient to draw down the isthmus in- stead of raising it, and perform the operation above the isthmus instead of below it. The isthmus is sometimes absent altogether in man, the gland then consisting of two lateral lobes only-which is the normal condition in many of the mammalia. The lateral lobes sometimes extend abnormally high, even above the level of the hyoid bone. Inferiorly, in man, their normal level is at the lower border of the isth- mus, but at times they may reach much lower. One case is recorded in which the left lobe extended downward to the sterno-clavicular articulation, while the right reached within the thorax to the arch of the aorta. The blood-supply in this instance was normal. An accessory or supernumerary thyroid sometimes oc- curs detached from the lateral lobes. The most frequent 94 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Thyroid Gland. Thyroid Gland, striking. Schiff, who began experimenting as early as 1856, found that when the whole gland was excised in dogs they died in from three to twenty-seven days, be- coming indifferent and melancholic shortly after the op- eration, and having twitching of the muscles with epi- leptiform convulsions, loss of excitability of the cortical motor centres and lowered blood-pressure. He found that if the gland were only partially excised and the re- mainder removed after an interval of tw'enty days, it was possible to keep the animal alive. This has been ex- plained by the supposed existence of small accessory thyroid glands within the thorax, which became hyper- plastic and discharged the functions of the parts re- moved. The most carefully recorded experiments are those of Horsley, conducted upon monkeys. The nervous symp- toms were the most striking. Tremors set in in the course of five days; they persisted after the section of the motor nerves to the part, or the removal of the corre- sponding cortical centres ; were increased by inhalation of ether, lessened by voluntary movement, and stopped by reflex stimulation. The nite of the tremors corre- sponded with that of paralysis agitans. Sensation was somewhat blunted. The centres of the lumbar cord- medulla were involved. Dyspnoea, apparently of bulbar origin, sometimes appeared suddenly. Ankle clonus was never present. There was a diminution in number of the red corpuscles, with leucocytosis. The blood contained mucin, but was otherwise normal in chemical composi- tion. The salivary glands became hypertrophied, and the parotid began to secrete mucin. The appetite be- came ravenous shortly before death. The urine was normal in quantity and contained a normal amount of mucin ; at times temporary glycosuria was noted. The temperature curve was exaggerated af- ter the tremor set in. In the late stages the animal, from being dull and stupid or irritable, became gradually coma- tose before its death, which took place in one or two months after the operation, but could be deferred for a considerable time by keeping the animal in a very warm place. At the autopsies the subcutaneous tissues were found to be swollen, jelly-like, and extremely sticky. This was most marked in the neck. The areolar tissue of the mediastinum showed the same condition, which was also seen in the course of the coronary arteries. There were no changes in the bursae or the synovial membranes. The membranes of the brain were distended with fluid. No structural changes were made but in the brain or nerve tissues. While it is generally admitted that the symptoms above described are chiefly, if not wholly, due to the removal of the thyroid gland, the inferences drawn from them as to the actual functions of the gland differ considerably. In the main the symptoms are considered as due to some in- terference with the nervous system, and hence the infer- ence that in health the function of the thyroid is in some wray associated with the nutrition of the nervous system. One or more of the following have been stated by vari- ous observers as being its functions : 1. That it acts as a regulator of the cerebral circula- tion. 2. That it secretes a something necessary for the proper nutrition of the nervous system. 3. That it excretes a something injurious to the nervous system. 4. That this substance is mucin. From the fact that anaemia so frequently follows extir- pation of the thyroid it is stated, 5. That the thyroid acts as a blood-forming organ. To examine these statements more in detail: 1. The method in which the thyroid may act as a regu- lator of the cerebral circulation has never been satisfac- torily explained. The view that it acts in a mechanical way, by preventing undue pressure of the muscles of the neck upon the great veins, and so preventing overfilling of the cerebral vessels from obstructed outflow of venous blood during exertion, does not seem to be supported by the facts, as the symptoms are those of cerebral anaemia rather than hyperaemia. Another view, that it prevents pressure of the muscles upon the carotid arteries, seems negatived by the fact, emphasized by Kocher in man and by Canalis in animals, that the preservation of only a very small portion of the gland sufficed to prevent the occur- rence of cretinism. It has been held that the incidental interference with the sympathetic fibres was the cause of these symptoms of disturbed circulation, but Schill's ex- periments, which showed that, by placing a portion of the excised thyroid of another animal (dog) within the ab- domen some weeks before the operation of complete ex- tirpation, the untoward symptoms could be averted, seems to meet this objection. 2. That the thyroid secretes some element necessary to the proper nutrition of the nervous system is not impos- sible. Some of the symptoms of cachexia strumiprira, such as the ravenous appetite, general debility, and weak- ness, suggest this explanation ; but this may possibly be only apparent, and it is certainly noteworthy that no structural degenerative changes in the nervous system have been detected to correspond with the marked loss of function. This want of anatomical proof of malnutri- tion makes it improbable that the symptoms arise entirely from this cause. 3. That the thyroid normally removes from the circu- lation some element injurious to the nervous system, ap- pears more probable than any of the foregoing theories, as more of the nervous symptoms following extirpation can be thus explained than by any of the other theories. All the mental symptoms, and still more the tremors, are perfectly explained by it. The supposition that this body is an irritant is upheld by Virchow, who has recently published the impressions made on him by a study of Mr. Horsley's preparations, and has come to the conclu- sion that the phenomenon of myxoedema is essentially one of irritation. Other observers, as Colzi, have noted what appeared to be a lepto-meningitis with secondary encephalitis, and attributed it to irritative influences. Ewald was able, by injecting an infusion of fresh thy- roid gland into the veins of dogs, to produce marked nar- cotic effects, and this observation is of positive value, and differs from the others in being direct evidence and not merely a deduction. As to the actual nature of the poison, if such exists, we are entirely ignorant. 4. That this body normally excreted is mucin, does not necessarily follow, nor does the discovery of excess of mucin in the blood and tissues of animals whose thy- roid glands have been extirpated, make this supposition justifiable, since mucin as such does not exist in the thy- roid. It is possible that some intermediate body may exist, which is converted and excreted when the thyroid is present, but only changed into mucin, wholly or par- tially, when it has been extirpated. It, of course, cannot be conjectured whether there is a single body present in excess, after the thyroid has been removed, which com- bines the properties of a narcotic with those of an irri- tant, or whether more than one body is present. The absence in certain cases of cretinism (myxoedema), when there is complete atrophy of the gland, is very dif- ficult to understand. 5. That the thyroid is a blood-forming organ, was in- ferred from the anaemia observed after its extirpation, and it was thought by some capable of supplying the place of the spleen, or being in some way correlated in function with the supra-renal capsules. J. L. Gibson, after carefully investigating the subject, has come to the conclusion that the thyroid is not, properly speaking, a blood-forming organ ; that its removal has no essential part in producing anaemia ; that it does not show any signs of hematopoiesis in animals whose spleens have been removed ; and that any blood-forming powers it may have are owing to the presence of a certain amount of lymphoid gland-tissue within it. Pathology.-The principal (and in fact the only im- portant) pathological changes occurring in the thyroid gland are described in the articles on Goitre, Exophthal- mic Goitre, and Myxoedema. Of congenital abnormalities some have been already 95 Thyroid Gland. Tinea. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. mentioned. Any of the varieties of struma (goitre) may occur congenitally. Inflammation of the thyroid gland (thyroiditis, stru- mitis) is most commonly seen as the accidental or in- tentional result of remedial measures employed in the treatment of goitre, such as setons, irritating injections, punctures, etc. But it is also met with in pyaemia, malig- nant endocarditis, measles, and diphtheria. The inflam- mation may be either simple or purulent. Purulent inflammation is rare. The abscess formed may be most extensive, and at times very considerable areas of the gland may slough. These abscesses tend to perforate into the mediastinal spaces following the planes of the deep fascia of the neck. They sometimes ulcerate into the trachea. On the other hand, they may remain circumscribed, and the contents may become inspissated or may calcify. In cases in which the inflammation does not become purulent it usually rapidly disappears, but occasionally it becomes chronic, producing a fibrous enlargement of the gland. Inflammation of the capsule (perithyroiditis) some- times occurs. The symptoms are pain, tenderness, and swelling in the front of the neck over the region of the gland, the swelling moving during deglutition. The presence of pus can be demonstrated with the aspirating needle. If the abscess has perforated into the cellular tissue the signs of severe cellulitis of the neck are present in addition. In purulent thyroiditis severe rigors and high fever may be present. Treatment.-In the simple form and early stages, leeches, anodyne fomentations, or poultices, with rest and low diet, are indicated. When suppuration occurs prompt incision and drainage are called for. Tuberculosis occurs in the thyroid in about twelve per cent, of all cases of phthisis, the miliary form being the most common. Sometimes only a portion of the gland is affected. At times large caseous masses are present. The tubercles originate in the connective tissue between the vesicles. As a rule, the gland is not enlarged and no symptoms are produced during life. Gummata have been observed, but are rare ; actinomy- cosis has never been noted. Atrophy of the gland sometimes occurs. This may arise from the pressure of tumors, or may occur after the internal administration of small doses of iodine. In this condition the epithelial elements may entirely disappear, leaving only a shrivelled mass of fibrous tissue. It is thought to be due to the direct action of iodine upon the epithelium. Hale White has recorded two cases where atrophy was thought by him to be due to pressure upon the recurrent laryngeal nerve in cases of thoracic aneurism. Myx- oedema was not present in these cases. Degeneration.-Amyloid degeneration occurs, and is specially prone to attack portions of the gland which have become hypertrophied. Both the epithelium and the vessels are involved. Fatty and calcareous degeneration occur especially in advanced life. In old persons the gland-vesicles are of large size, and may contain crystals of cholesterin or of oxalate of lime. Hyaline degeneration is also often marked in old people. Echinococcus cysts are sometimes met with iu the thy- roid. Bibliography. Henle: Anatomie des Menchen. article Thyroid Gland. Hoppe-Seyler: Phisiologische Cheinie. Kocher: Archiv f. klin. Chirurgie, xxix. Wolfler: Ueber die Entwickelung und den Ban des Kropfes, 1883. Schiff, Virchow, J. L. and A. Reverdin, Hirsch: Jahresb., 1884. Horsley, V.: Lancet, ii„ 1884. Gibson, J. L.: Journal of Anatomy and Physiology, vol. xx. Fuhr: Archiv fur Exp. Pharmakol., Bd. xxxi. Ewald: Berliner Klinische Wochenschrift, 1882, No. 11. Hale White: Brit. Med. Journal, ii., 1886. Wyatt G. Johnston. TINEA FAVOSA, or FAVUS, is a contagious, vegetable parasitic skin disease, due to the presence of the achorion Schonleinii. It is characterized by discrete or confluent pea-sized, circular, friable, pale yellow, cup-shaped crusts, each usually pierced by a hair. It may occur upon any part of the integument, but is commonly met with upon the scalp. Occasionally, also, the parasite in- vades the nails (tinea favosa unguium, onychomycosis favosa). Upon the scalp, the disease begins as a superficial in- flammation, more or less circumscribed, slightly scaly, soon followed by the formation of yellowish points about the hair-follicles, surrounding the hair-shaft. These points increase rapidly in size, becoming as large as small peas; are then cup-shaped, with the convex side press- ing down upon the papillary layer, and the concave side elevated several lines above the level of the skin ; they are friable, sulphur-colored, and usually each cup or disk is perforated by a hair. Upon removal or detachment, the underlying surface is found to be somewhat exca- vated, reddened, atrophied, or suppurating. Although at first the crusts are as above described-discrete and made up of closely-packed, concentrically arranged layers,-as the disease progresses, they become confluent and coal- esce, forming irregular masses of thick, yellowish, mor- tar-like accumulations. The hairs are involved early in the disease, become brittle, lustreless, break off, and fall Fig. 3925.-Achorion Schonleinii, the Fungus of Tinea Favosa. (X about 500.) out, and the papillae may be even permanently destroyed. In some instances, near the border of the crusts are seen pustules or suppurating points. The mass of growing fungus pressing upon the skin gives rise to atrophy, as shown by depressed, firm, shining, cicatricial-looking areas. The crusts have a peculiar, characteristic odor, that of mice or stale, damp straw. Itching, variable as to degree, is always present. Upon the non-hairy portions of the body the disease is similar to that upon the scalp in its clinical signs, modi- fied, it is true, by the anatomical differences of the parts. The nails, when affected, become yellowish, more or less thickened, brittle, and opaque. Favus is a comparatively rare disease in this country, and is observed almost exclusively among the poor. It is a contagious disease, but is much more common in children than in adults. It is also observed in the lower animals, from which it is probably often communicated to man. The affection is due solely to the presence and growth of the vegetable parasite, the achorion Schon- leinii, in the upper layers of the skin. The fungus, con- sisting of mycelium and spores, may be readily detected by examining, with a power of from three hundred to five hundred diameters, the crust, nail scrapings, or hair, moistened with liquor potassic. 96 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Thyroid Gland. Tinea. The diagnosis of favus is rarely difficult, as its clinical features are characteristic. In advanced cases, when the crusts have coalesced and form a solid mass, it may re- semble pustular eczema, but the condition of the affected hair, the atrophic areas, and the odor are distinguishing points. It should not be confounded with ringworm, for in this latter disease crusting is wanting, as is also the tendency to the formation of atrophic areas. As regards the prognosis of favus it may be stated that, when seated upon the scalp, it is extremely chronic and rebellious to treatment; in neglected cases permanent baldness, atrophy, and scarring sooner or later occur. When it involves the nails it is also apt to be obstinate. Upon non-hairy portions it yields readily. The initial step in the management of favus of the scalp is the removal of the crusts. This is easily effected by means of applications of oil and washings with soap and water. This accomplished, the hair on and around the diseased areas is to be cut short, epilation is to be practised, and a parasiticide applied. Epilation, or ex- traction of the hairs, is an essential part of the treatment. It is best done with the epilating forceps, as many hairs as practicable being extracted each day. The parasiti- cide that may be selected is to be applied thoroughly, twice daily. The following are the most efficient para- siticides : Corrosive sublimate, 0.13 to 0.26 Gm. (gr. ij. to gr. iv.) to 31 Gm. (§ j.) of alcohol and water ; carbolic acid, one part to three or more parts of glycerine ; a five or ten per cent, oleate of mercury ; ointments of tar, sulphur, ammoniated mercury, officinal strength or weak- ened ; hyposulphite of sodium, 4 Gm. (3 j.) to 31 Gm. (1 j-) of water ; sulphurous acid, pure or diluted ; and chrysarobin in ointment or as a solution in chloroform, 2 to 4 Gm. ( 3 ss. to 3 j.) to 31 Gm. ( 3 j.). This last rem- edy, if used, must be employed with caution. At the end of one or two months applications should be discon- tinued for several days, in order that the exact condition may be again determined. In an average case a cure in from three to twelve months may be considered satisfac- tory. In the treatment of favus of the non-hairy por- tions of the body, after the crusts have been removed, any of the above-mentioned parasiticides, somewhat weakened, may be employed. The duration of treat- ment is usually from a few days to several weeks. In favus of the nail frequent and close paring of the affect- ed part, and the application, twice daily, of one of the milder parasiticides, will eventually lead to a good result. henry W. Stelwagon. TINEA TRICHOPHYTINA, or ringworm, is a conta- gious disease of the skin due to the invasion of the cuta- neous structures by the vegetable parasite, the trichophy- ton. The clinical characters vary considerably, depending upon the part affected. Thus, upon the scalp, upon the general surface, and upon the bearded region, the disease presents totally different appearances. It may coexist upon two of these parts in the same patient. Although the disease is contagious, individuals differ considerably as to susceptibility. The fungus consists of spores and mycelium. In the epidermic scrapings it is never to be found in abundance, and the mycelium predominates; while in affected hairs the spores and chains of spores are almost exclusively seen, and are usually present in great profusion. For examination the scrapings or hair should be moistened with liquor potassae, and if the fungus is present it may be seen with a power of from 300 to 500 diameters. Tinea trichophytina corporis (commonly known as tinea circinata), or ringworm of the general surface, appears as one or more small, slightly elevated, sharply-limited, somewhat scaly, hyperaemic spots. Rarely, minute pap- pules, vesico-papules, or vesicles may be detected, es- pecially on the peripheral portion (hence the names herpes circinatus, and herpes circine, applied by the Ger- mans and French respectively). The patch spreads in a uniform manner peripherally and tends to clear in the centre, giving it a ring-like appearance. When clinical- ly observed, the patches are usually from one-half to one inch in diameter, the central portion being pale or pale red, and the outer portion more or less elevated, hyper- ®mic, and somewhat scaly. As a rule the scaliness, although always perceptible, is slight, but in rare in- stances this feature may be so marked as to give to the patch more or less resemblance to circinate patches of psoriasis. The number of patches varies from one to several dozen or more ; as commonly met with, however, the number rarely exceeds five or six. After reaching a certain size, they may remain stationary, or in excep- tional cases may tend to spontaneous disappearance. At times, when close together, several may merge and form a large, irregular, gyrate patch. Itching, variable as to degree, is usually present. Ringworm of the general surface does not limit itself to any age, but it is seen chiefly in children. It may occur upon any part of the surface, but is most frequently seen about the face, neck, hands, and forearms. In adults, more especially males, the inner portion of the upper part of the thighs and scro- tum may be attacked, and here the affection, favored by heat and moisture, develops rapidly and soon loses its or- dinary clinical appearances, the inflammatory symptoms becoming especially prominent. The whole of this re- gion may thus become involved in an inflammatory sheet Fig. 3926.-The Trichophyton as Found in Epidermic Scrapings in Ring- worm. (X about 500.) of eruption, always, however, with sharply defined bor- ders, and usually also with one or more outlying patches possessing the ordinary clinical type of the disease. This condition or variety, before its true nature was suspected, was described by Hebra as eczema marginatum. In ex- ceptional instances also a like condition is observed in one or both axillae. As usually met with, ringworm of the general surface is a mild affection, and yields readily to treatment; not infrequently, indeed, disappearing- spontaneously. Rarely, and more especially in tropical countries, it is of a more severe grade, and may prove obstinate. The fungus has its seat in the epidermis, es- pecially in the corneous layer. The nails are also liable to be invaded (tinea trichophytina unguium), and in con- sequence become soft or brittle, yellowish, opaque, and thickened, the changes taking place mainly about the free borders. When the above-described clinical signs are present there should be no difficulty, as a rule, in recognizing the disease. Exceptionally it may bear a resemblance to eczema, psoriasis, and seborrhoea. In all doubtful cases the scrapings should be subjected to a microscopical examination ; this should be carefully made, as the fungus in this variety of ringworm is apt to be scanty. The scrapings for this purpose should be taken from the border of the patch. Tinea trichophytina capitis (commonly known as tinea 97 Tinea. Tinnitus Aurium. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tonsurans), or ringworm of the scalp, begins in the same manner as that upon the general surface, but, as a rule, much more insidiously. It is not long, however, before the hair and follicles are invaded by the fungus. The hair, in consequence, falls out, or becomes brittle and breaks off. The follicles, except in very chronic cases, are slightly elevated and prominent, and the patch may have a puffed or goose-flesh appearance. In addition there is slight scaliness, grayish or slate colored. It is usually at this stage of the disease that the case comes under medical observation. At this time the following clinical appearances are noted: a rounded, grayish, somewhat scaly, slightly elevated patch, the follicles prominent as in goose-flesh, more or less alopecia, here and there broken, gnawed-off-looking hairs ; some broken off just at the outlet of the follicle, and appearing as black specks. One qr more such patches may coexist, and may finally become confluent, resulting in the forma- tion of a large irregular area with the same peculiar char- acters as are presented in the single patch. In some cases the patch may become almost completely bald, pre- senting a resemblance to alopecia areata. As the affec- tion becomes chronic the follicles are less prominent, and there is then, as a rule, no elevation. Scaliness, although slight, is a constant feature, as are also the loss and brit- tle condition of the hair. Occasionally a tendency to the formation of pustules is observed. The affection may also appear as small, scattered spots or points, and may be easily over- looked. Occasionally the disease may be decidedly inflammatory, involving the deeper tissues, and then, instead of the ordi- nary typical patch, there is seen a more or less bald, rounded, inflammatory, oedematous, boggy, honey- combed tumor, discharg- ing from the follicular openings a mucoid secre- tion - tinea kerion. The fungus in ringworm of the scalp invades the epider- mis, hair-shaft, root, and follicle. The disease is persistent and obstinate. It rarely, if ever, tends to spontaneous disappear- ance, except when the pa- tient reaches the age of sixteen or thereabouts-the disease (on the scalp) practically never occurring or per- sisting in those beyond this age. The affection should not be mistaken for alopecia areata, favus, eczema, seborrhoea, or psoriasis. The pe- culiar clinical features of ringworm-the slight scaliness, broken hair, and the hair-stumps, with a certain amount of baldness-serve to distinguish it from any of the above- mentioned diseases. In obscure or doubtful cases a mi- croscopical examination should be made. In favus, although the same condition of the hair is noted, the yellow, cup-shaped crusts, and the presence of the atrophic areas in that disease are pathognomonic. Tinea trichophytina barba (also called tinea sycosis, parasitic sycosis, and barber's itch), or ringworm of the bearded region, presents a different clinical picture. The disease begins in the usual meaner, as a rounded, slightly scaly, hyperaemic patch. In rare instances it may per- sist as such, with very little tendency to involve the hairs and follicles; but usually the hairy structures are soon invaded. Many of the hairs become loose and fall out, others are broken off. From involvement of the fol- licles, or for other unknown reasons, more or less subcuta- neous swelling ensues, and the parts assume a distinctly lumpy or nodular condition. The skin is usually con- siderably reddened, and is apt to have a glossy appear- ance, studded with few or numerous pustules. The nodules tend, as a rule, to break down and discharge, at one or more of the follicular openings, a glairy, glutinous, purulent material, which may dry to thick, adherent crusts. The disease may be limited to one patch, and in such instances, when swelling and discharge are promi- nent symptoms, may resemble a carbuncle. As a rule, however, a large area, even to the extent of the whole bearded region, becomes involved. The chin and sub- maxillary regions are favorite localities. The upper lip is rarely invaded. The disease is seen only in the male adult. Untreated, it is persistent and may last for years ; and in severe, neglected cases there may be more or less permanent loss of hair. The lumpiness, and brittleness and loss of hair, the history, and finally, in doubtful cases, the microscopical examination, are the essential points in differentiating from eczema and non-parasitic sycosis, diseases which it may at times resemble. The prognosis of ringworm, as already intimated, is favorable in all the different varieties, a cure finally re- sulting. It is only rarely, moreover, that there is any permanent loss of hatr. First, as to ringworm of the general surface. This variety of the disease will, as a rule, respond rapidly to any parasiticide application. The milder remedies are to be advised in these cases, such as a solution of hyposulphite of sodium, 4 Gm. ( 3 j.) to 31 Gm. ( § j.); carbolic acid, 0.3 to 1.8 Gm. (gr. v. to gr. xxx.) to 31 Gm. (§ j.); also ointments of sul- phur, mercury, and tar. The remedy should be applied two or three times daily. When occurring at the upper and inner part of the thighs (so-called eczema margina- tum), the above remedies will also be found useful, but, as a rule, it will be necessary to use them stronger. Lo- tions of carbolic acid and corrosive sublimate, the latter 0.03 to 0.26 Gm. (gr. ss. to gr. iv.) to 31 Gm. ( ? j.), will be found useful in this condition. This latter remedy, in the same proportions, may also be prescribed in the tincture of myrrh or benzoin, as recommended by Tay- lor, and painted over the parts. It acts admirably in some cases. Ringworm of the scalp, except in recent cases, often requires several months for its cure; and in rare in- stances proves exceedingly rebellious, seemingly defy- ing all applications. The scalp, fortunately, will stand positive and long-continued treatment. The various par- asiticides already mentioned are useful in this variety of the disease also. In many cases it is not so much the choice of the remedy as the thoroughness and persever- ance in its application. The parts should not be too fre- quently washed, in order that the remedies may have an opportunity to soak into the invaded structures. Epila- tion is of value and should be practised. A few remedies need special mention, viz., the oleate of mercury, corrosive sublimate, and carbolic acid. The oleate is best prescribed with lard or lanolin, in varying strength from five to twenty per cent.; carbolic acid with glycerine or oil, in the proportion of five to twenty-five per cent.; corrosive sublimate, in solution with alcohol and water, 0.065 to 0.26 Gm. (gr. j. to gr. iv.) to 31 Gm. (j.). Chrysarobin, in the form of rubber plaster, or in a solution of gutta-percha, ten to fifteen per cent, strength, may be employed, but its use requires caution. In rare cases, when the disease is limited to one or two small patches, which have failed to respond to ordinary meth- ods of treatment, croton-oil has been advised. It is ap- plied pure, or with one or two parts of olive-oil. After one or more applications a violent suppurative dermatitis results, and as a consequence the fungus is often de- stroyed or dislodged, and a cure brought about. It is a severe, as well as a somewhat dangerous, remedy, and its use requires careful supervision. Permanent loss of hair may follow this mode of treatment. In that form of ringworm of the scalp known as tinea kerion, mild applications, such as a weak solution or ointment of car- bolic acid or hyposulphite of sodium, should be employed until the inflammatory symptoms have subsided. In not a few such cases the active inflammation proves destruc- tive to the fungus, a spontaneous cure resulting. Tinea trichophytina barbae usually responds much Fig. 3927.-Free Spores and Chains of Spores of the Trichophyton, as Shown in a Hair-stump in Ring- worm of the Scalp. (X about 500.) 98 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tinea. Tinnitus Aurium, more rapidly to treatment than does ringworm of the scalp. A favorable result should be expected in from one to three months. The strength of the remedial ap- plications will depend upon the local conditions, whether slightly or markedly inflammatory. Epilation should be practised as a necessary part of the treatment. The fa- vorite parasiticides in this variety of ringworm are the oleate of mercury, corrosive sublimate, and hyposulphite of sodium, in about the same (possibly somewhat weaker) strength as used in ringworm of the scalp. The appli- cations should be thoroughly made, at least twice daily. In all forms of ringworm, especially that occurring upon the scalp, treatment should, from time to time, be intermitted for several days, in order that the progress of the disease and the effect of the therapeutic measures may be noted. After a cure has apparently resulted, the case should, for obvious reasons, be seen at intervals of a few weeks, for a period of a month or more. Henry W. Stelwagon. TINEA VERSICOLOR is a contagious, vegetable para- sitic skin disease due to the presence of the microsporon furfur. It is characterized by variously sized and shaped, slightly furfuraceous, macular patches of a yellowish or fawn color, and occurring for the most part upon the trunk. The disease begins as one or more yellowish macular points; these extend, and together with other patches that a vegetable fungus-the microsporon furfur. This con- sists of mycelium and spores, the latter showing a marked tendency to aggregate. It invades the superficial portion of the epidermis. The scrapings from a patch moistened with liquor potassae, and examined with a power of from 300 to 500 diameters, will disclose the fungus, usually in great abundance. The diagnosis of tinea versicolor is not difficult if the characters and distribution of the eruption are kept in mind. It should not be confounded with chloasma, vitiligo, and the macular syphiloderm. In doubtful cases the microscope will decide. The disease responds rapidly to treatment. Any of the wTell-known parasiticides may be employed, with usu- ally good results. The most efficacious are a lotion of the sulphite or hyposulphite of sodium, 4 Gm. ( 3 j.) to 31 Gm. (§ j.) of water ; corrosive sublimate, 0.065 to 0.26 Gm. (gr. j.-gr. iv.) to 31 Gm. ( ? i.) of water and alcohol ; of sulphurous acid, pure or diluted ; of carbolic acid, 0.65 to 1.3 Gm. (gr. x.-gr. xx.) to 31 Gm. ( 3 j.) of water and alcohol; resorcin, 0.65 to 2.0 Gm. (gr. x.-gr. xxx.) to 31 Gm. (3 j.) of alcohol and water. These remedies may also be applied in the form of ointments. The ap- plications are to be made, according to the extent and obstinacy of the eruption, once or twice daily. In all cases the parts should be washed with soap and hot water at least once a day, just previous to the remedial applica- tion ; and in obstinate cases, instead of the ordinary toilet soap, sapo viridis should be employed. After the disease is apparently cured, an occasional remedial ap- plication should be made for a few weeks or a month, in order to guard against the possibility of a relapse. Henry W. Stelwagon. TINNITUS AURIUM. In a general way, this term is understood to refer to the various noises heard by those who have more or less disease of the ear. But there are noises referred to the ears that are not caused by dis- ease of this organ, i.e., they are not attended by loss of hearing power, and some of these may even be heard by a by-stander. For example, it has long been known that a snapping or cracking noise can be voluntarily, by some persons, produced in the ear. Fabricius ab Aquapendente is said to have possessed the power of voluntarily producing such a noise in both ears at the same time, while Johannes Muller could pro- duce it in either ear at will, and felt that it was not an uncommon occurrence. He believed that it was due to the voluntary contraction of the tensor tympani muscle. Since his day a large number of observers have re- corded cases in which such noises occurred, both volun- tarily and involuntarily, and probably almost every aurist has met with at least one example. In one case of this sort, inspection of the ear showed that the membrana tympani moved ; in another, that old cicatrices in the membrane made distinct movements. This sort of noise has been found in connection with in- voluntary spasms of the pharyngeal muscles, spasm of the velum palati and sterno-cleido mastoideus, synchro- nous with spasms of the soft palate and uvula, associated with movements of the membrana tympani. Aneurismal- like bruits have been beard coming from the ear, as well as systolic murmurs. Besides contraction of the tensor tympani muscle, these cases of snapping noises have been explained by spasms of the stepedius muscle, by spasm of the palatal muscles causing a sudden drawing away of the membranous por- tion of the Eustachian tube. Undoubtedly some of these sounds are due to a catarrhal state of the nares and naso- pharynx, and are probably caused by reflex excitation of the motor nerves following irritation of the sensitive nerves, producing the twitchings perceived as both ob- jective and subjective noises. The hearing may or may not be affected in these cases. Treatment.-Undoubtedly, when there is an abnormal state of the nasal or naso pharyngeal mucous membrane, treatment should be directed toward this condition. When this is not the case, or when such treatment fails, resort must be had to some form of electricity. Fig. 3928.-Microsporon Furfur. The Fungus of Tinea Versicolor. (X about 500.) arise, may form almost a solid sheet of eruption. The upper part of the trunk, especially anteriorly, is the usual seat of the eruption, but in exceptional instances, the neck, axillae, arms, the whole trunk, and thighs may become invaded. One or two cases in which the face also has been involved have been reported. Practically, however, tinea versicolor is a disease of the upper part of the trunk. The number of patches varies; there may be but a few, or, on the other hand, a profusion. There is little, if any, elevation. The scaling is furfu- raceous, always slight, and at times, except on close in- spection, scarcely perceptible. The color of the eruption is a pale or brownish yellow ; in rare instances, in those of delicate skin, there may be more or less hyperyemia, and in consequence the patch may be of a reddish hue. The course of the disease is variable, but as a rule its progress is slow. Untreated, it is always persistent and lasts for years. Relapses are notuncommon. Slight itch- ing, especially when the parts are warm, is usually present. The disease is contagious, but apparently to a slight de- gree. The affection is tolerably common and occurs in all parts of the world. With rare exceptions it is ob- served in adults only, being most common in middle life. The cause of the disease is to be found in the presence of 99 Tinnitus Aurium. Tin. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. There are other noises, which are produced in reality in the middle ear or its vicinity-the so-called internal or en- totic sounds. When these internal noises manifest them- selves under the form of pulsations, isochronous with the pulse, they are due to the resounding of the arterial pulsations in and about the ear. Unquestionably there are many sounds produced in and about the ear of which this organ takes no cogni- zance in a healthy state, but when, from any cause, the equilibrium between noise production and escape is dis- turbed, sounds, otherwise inaudible, become annoyingly audible. In some cardiac affections and in aneurisms of the vessels of the head and neck the souffle is very much accentuated when there is an affection of the middle ear. Undoubtedly the production of the noises complained of by anaemic and chlorotic patients was correctly explained a quarter of a century ago by Bondet, who assumed the propagation of the bruit de diable in the internal jugular vein up to its superior extremity at the jugular fossa. True Subjective Tinnitus.-Under this head are included those noises which are directly associated with affections of the different portions of the auditory appa- ratus. There is a no more frequent or bitter complaint heard in the aurist's consultation-room than that in regard to noises in the ear. Wilde has truly said that the descriptions given by patients depend almost entirely upon their fancy and their surroundings, and are such as the ringing of bells, the hum of insects, murmur of trees, noises of machin- ery, rolling of vehicles on the street, escape of steam, etc. As a rule, the sounds are disagreeable, only in exception- al cases being pleasant. It is a curious fact, observed by everyone, that either these subjective noises are more rarely present in chil- dren, or the complaints are fewer because they are less annoying to them-probably the former is the case. Most frequently the tinnitus is referred to the ear, some- times to the top or back of the head, rarely to the front. Sometimes the noises are only referred to one ear, some- times to both. Sometimes the character or intensity va- ries on the two sides. Tinnitus may be intermittent or continuous. It is a curious fact that tinnitus is comparatively rarely complained of when a perforation of the membrana tym- pani exists. The intensity of the noise bears no fixed re- lation to the deafness. It may be entirely wanting in complete deafness. Again, it may be present to a very annoying degree when the hearing is normal. The noises usually diminish, but they may even increase, as the deaf- ness diminishes. In the beginning patients generally hear them only at night, when everything is still, or when they are lying down. When the patient is depressed, tired, or annoyed, the tinnitus is liable to become exaggerated. Changes in the weather, great dampness, dryness, or heat, likewise increase the noises, especially when there is chronic catarrh of the middle ear. An attempt has been made to localize these subjective noises in some particu- lar portion of the basilar membrane of the cochlea ; an attempt, it is needless to say, which could not but fail in the present state of our knowledge. In a general way, we may say that those violent noises that suddenly appear are usually due to a lesion of the labyrinth, or some central affection ; now and then, per- haps, to a very rapid and abundant exudation into the cavity of the tympanum (Levi). The subjective noises heard by the insane are occasionally dependent upon demonstrable lesions in the ear, but are usually due to central disturbances of the acoustic nerve. Halluciha- tions of hearing, such as cries, voices, etc., are not infre- quently the precursors of mental disease, but they have sometimes disappeared on the cure of an external or mid- dle-ear trouble. On this general subject, Schwartze says : "Subjective aural sensations, which are caused by de- monstrable affections of the ear, may, in predisposed per- sons, especially when there is any hereditary tendency to mental disease, become the direct cause of aural hallu- cinations, that may accelerate the outbreak of mental disease " (Roosa's Troltsch). However, more recent in- vestigation of the relation between tinnitus and mental diseases would not seem to indicate any very important connection. Tinnitus aurium is met with in affections of the ex- ternal auditory meatus, and of the middle and internal ear. Undoubtedly chronic troubles of the cavity of the drum are the cause of the large majority of noises in the ear. A plug of cerumen in the external ear frequently excites tinnitus. Tinnitus may also be caused by furun- cles in the meatus. Foreign bodies of all sorts, resting upon the membrana tympani, give rise to noises in the ear. Inflammations of the membrana tympani are ac- companied by very annoying tinnitus. The tinnitus here, like that due to furuncles and for- eign bodies in the external meatus, is very largely to be explained by the re-enforcement of the heightened vascu- lar sounds, owing to the thickening of the membrana tympani in the first case, and, in the latter, to the plug- ging of the external meatus, interfering with, and pre- venting the escape of the sounds. Troltsch claims that any kind of poisoning or intoxica- tion, especially that due to quinine (also salicylate of soda and antipyrine), gives rise to subjective sounds; also such conditions of the blood (as already alluded to) as are found in anaemia and chlorosis ; and temporary and per- manent obstructions to the circulation. Affections of different portions of the internal ear give rise to tinnitus. One of the most striking examples is found in the com- plex of symptoms called Meniere's disease, which is no- toriously accompanied by the most annoying tinnitus aurium. Tinnitus aurium has been met with after injuries of the head in which little or no deafness resulted. In such cases we might imagine that small haemorrhages had occurred in the vestibule or cochlea, or that an act- ual disturbance of the terminal expansion of the nerve had taken place ; this disturbance may subsequently sub- side and the noise disappear. Explanation of True Tinnitus Aurium.-While we are really ignorant of the way in which noises in" the ears are produced, there are not lacking theories, and a widely ac- cepted view is that these subjective sounds must always be regarded as an expression of an irritation of the audi- tory nerve, whether of its trunk or its terminal expansion in the labyrinth (Troltsch). Again, disturbances of the "pressure equilibrium" have been invoked to explain tinnitus (Field). In the same line, tinnitus has been looked upon as a symptom indicating pressure upon the vessels of the tympanum and labyrinth (Roosa). These noises have also been regarded as due to " morbid vibra- tions originating in the various parts of the organ of hear- ing, i.e., they have truly an objective existence in the subject " (Burnett). A vascular theory has been advanced to account for tinnitus, which assumes that tinnitus has a real existence due to morbid vibrations produced in the vessels of the internal ear, and then communicated to the nerve (Theo- bald). Prognosis.-Undoubtedly those noises that are continu- ous and have lasted for a long time are practically incur- able, as are likewise those existing with little or no per- ceptible disease of the organ of hearing; while those dependent upon external causes, and the more acute cases of middle-ear trouble, are the favorable ones. In general, in regard to those noises connected with middle-ear affec- tions (the by far most frequent cause), it may be said that usually the tinnitus and deafness diminish pari passu. However, candor compels the statement that the prog- nosis of tinnitus aurium is very unfavorable, and that, after a noise is once thoroughly established in the ear, it usually remains. Often the relief of the aural trouble takes place and the hearing is improved, while the tinni- tus even becomes aggravated. Treatment.-Undoubtedly nearly all of the cases of tin- nitus aurium occur in connection with middle-ear affec- tions, and, as these are also the chief cause of deafness, we have to deal with two distressing evils at the same time. Patients often fancy that the noises prevent their hearing, and only care for treatment of this symptom. 100 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tinnitus Aurium. Tin. Before entering specifically upon the treatment of tinni- tus aurium, we beg to call the attention of the reader to a feature of this part of the subject which has as yet received scarcely any consideration-at any rate, not such as it is entitled to. We cannot discuss the treatment of "noises in the ear" without first considering the well- known general mental state brought about by those affec- tions of the ear that are usually at the bottom of such noises. Ever since the study of aural affections has been scientifically pursued, a relation between middle-ear troubles and certain mental states has been a well-recog- nized fact. The stupidity, not only of mind but of ap- pearance as well, of children laboring under acquired hardness of hearing; the loss of mental vigor in older persons, along with loss of interest in their occupation, despondency, moroseness, suspicion, inability to "grasp an idea," or to " see the point," aversion to society, etc., are all familiar pictures to the aurist. All of these con- ditions have been popularly regarded as the direct conse- quence of the inability to hear on the part of those thus affected. There could not be a more cruel mistake. Certainly some of the brightest intellects the author has come in contact with have been in persons practically totally deaf. Again, the total mental and facial change wrought in children by treatment; the revolution pro- duced in the mental state of adults, in either case with or without improvement in the hearing, all go to show that the deafness, per se, has little or nothing to do with the mental states. The introduction of a clinical confirma- tion of the above conclusions, owing to its marked per- tinency, will accentuate them. A gentleman of large business and ample means, forty- five or fifty years of age, who had been extremely hard of hearing for twenty or more years, suddenly appeared in the author's consultation-rooms, in a state of great ex- citement, saying he feared he was losing his mind, as he could not add up a column of figures, did not trust him- self to sign a check, and had an irresistible impulse to do such trivial things as pick up an old scrap of paper or business card from the floor of his store. The fact that one or two members of his family happened to be under treatment for ear trouble determined his visit to an aur- ist, though he said he knew nothing could be done for his hearing. Inflation of his ears, while, of course, pro- ducing no change in the hearing, brought about a marked alteration in the mental state. He said he returned to his office \tith his mind as clear as it ever was, and sev- eral subsequent visits were made simply because, as he said, it made his " head feel so clear." One of the remarks most frequently heard from pa- tients, after inflation of the ears, is, "My head feels lighter and clearer," even though no change has occurred in the hearing. It is a well-known fact, too, that vast numbers of people never complain of their tinnitus, some of whom, however, in the beginning were very much dis- tressed by it. We have thus the clinical evidence, supported by the anatomical fact of a demonstrated lymph-connection be- tween the brain and the ear (Weber-Liel), that mental disturbance is often associated with tinnitus, and it shows us that, when we enter upon the treatment of the noises, it must be not so much to consider the tinnitus as the cause of complaint, as the underlying mental condition induced by the aural trouble. Our position, succinctly stated, is : We would relegate the tinnitus to the back- ground and bring into the foreground the all-important underlying mental state, which can always be entirely relieved or so improved that in either case the noises cease to be annoying. Still, in spite of this assertion, there remains room for the employment of special reme- dies directly for the relief of the noises. Special Measures and Remedies.-As has already been said, the great remedy consists in the treatment of the underlying cause, the middle-ear trouble. This is done by inflations through the Eustachian catheter and by Po- litzer's method, along with treatment of the naso-phar- ynx. Electricity and galvanism, in the hands of some, seem to have relieved isolated cases, as have large doses of hydrochlorate of ammonium (gr. xx.), and the bro- mide of potassium in large doses, repeated at intervals. Iodide of potassium, hydrobromic acid, digitalis, strych- nine, quinine-fifteen grains three times a day (Charcot), atropine, tincture of arnica-ten drops three times a day (Wilde), etc., have all been used. Chloroform and ether, and various medicated vapors, have been injected into the drum cavity; blisters, fo- mentations, and massage upon the mastoid process; warm water or glycerine poured into the external mea- tus ; also solutions of atropine and morphine ; hypoder- mic injections of morphine, atropine, and strychnine ; exhausting the air in the external meatus; pressure by the finger upon the mastoid or on any part in the vicin- ity of the ear ; perforation of the membrana tympani and tenotomy of the tensor tympani muscle, have all been resorted to. Nitrite of amyl has been used in quite a large number of cases, with more or less satisfaction (Michael). In a series of 100 cases of tinnitus, due to chronic aural ca- tarrh, in which this drug was employed, Alt reports : No effect at all, 35 ; momentary improvement, 10 ; tem- porary improvement, 25 ; considerable lasting improve- ment, 16 ; apparently cured, 14. Although this remedy is stated by Binz to be perfectly harmless, Alt met with three cases of alarming fainting spells on the first inspiration, and he recommends care in the beginning in every case. It likewise has an exciting effect on the sexual organs and creates the desire to uri- nate. Alt recommends dropping it on cotton and con- tinuing the inhalations until vertigo ensues. His experi- ence gave him no clew to the class of cases in which good results might be expected ; hence its use, like that of the remedies previously mentioned, is as yet purely empiri- cal. There would seem to be quite a large number of cases in which the subjective noises are either increased or diminished under the influence of external noises or tones. Itard, more than sixty years ago, claimed that the prolonged action of external sounds and noises was sufficient now and then to quiet tinnitus. He recom- mended that the internal sound should be treated by sub- jecting the patient to a corresponding and continued ex- ternal noise, making, however, the external sound greater than the subjective one. Lucse mentions an extremely interesting case of hissing noise in the ear cured by the deep rumbling noise of the railway cars, the patient hav- ing spent quite a time riding in them, as she found that she was free from the tinnitus while so doing. This was a case in wrhich the external noise was of an opposite character to the subjective one. On the other hand, when the tinnitus is made worse by external sounds, more or less permanent relief has been obtained by a resort to quiet places, and by plugging the meatus with a mixt- ure of wax and shellac (Lucse). W. W. Seely. TIN, POISONING BY. Metallic tin, if pure, has no injurious action on the system. The soluble salts of tin, especially the chlorides, are violent irritants ; but cases of poisoning by them have rarely come under observa- tion. Two grams ( 3 ss.) of a solution of the chloride has caused death in three days. In the treatment of cases of poisoning by these compounds, milk or albumen, alkaline carbonates, and emetics are indicated first. The after- treatment should be symptomatic. The compounds of tin owe their toxicological impor- tance chiefly to the fact of their frequent occurrence in various articles of food ; but whether this occurrence of tin is attended with any danger to health is still a dis- puted question. A non-fatal case of acute poisoning has been attributed to the use of salt which had been dried on a tin dish on the stove. It has been suggested, how- ever, that the symptoms described might more reason- ably be attributed, in the absence of a chemical analysis, to lead-poisoning; since much of the tin-plate formerly used was not pure tin, but an alloy of tin with lead. Many cases of acute poisoning have followed the use of canned foods, and in some of these cases the symp- toms have been attributed to tin ; but rarely, if ever, has the theory of tin-poisoning been substantiated by an anal- ysis of the suspected food. It is a well-recognized fact 101 Tin. Tongue. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. that many cases of acute sickness have been caused by the ingestion of food which was entirely free from in- jurious metals. It is considered, therefore, more reason- able, by some authorities, in the absence of any chemical analysis, to attribute the symptoms which frequently follow the ingestion of canned foods to some cause other than metallic poisoning; such as putrefactive changes taking place in the food ; or in a certain number of cases to idiosyncrasy. Some, while denying the probability of tin-poisoning, admit the possibility of poisoning by other metals, as lead or zinc, the former derived from the tin- plate or from the solder, the latter from the soldering fluids used in sealing the cans. It is not disputed that canned foods frequently contain tin, which has been dissolved from the tin-plate by the action of acids or other constituents of the food, or which has been introduced by the careless use of stannous chlo- ride, which is a constituent of some of the soldering fluids used in sealing the cans. But the quantity of tin is usually small, varying from a few one-hundredths of a grain to one grain per pound, rarely approaching, however, the higher figure. These amounts are not likely to give rise to symptoms of acute poison- ing. Winter Blyth states that he found in some samples of canned fruits as much as 14.3 grains of stannous hydrate per pound, and that the average amount in all examined wTas 5.2 grains per pound. In some cases the juice had a me- tallic taste. With such quantities of tin, in a form easily absorbed by the system, the possi- bility of acute poisoning must be admitted. But the facts at present known to us do not seem to warrant the conclusion that acute tin- poisoning, as a result of the use of canned foods, is an occurrence to be greatly feared. A quan- tity of tin-salt sufficient to cause poisoning would probably be recognized by the taste, and the food thus contaminated be re- jected as unpalatable. Stannous chloride is sometimes added to the cheaper grades of mo- lasses to lighten the color and give the sample the appearance of a higher grade of molasses; and sugar crystals are said to be washed with a similar solution, the greater part of which afterward passes into the molasses. Whether this use of the tin-salt is attend- ed with any danger to the con- sumer has not been determined. The chloride is immediately decom- posed by some of the constituents of the molasses and converted into an insoluble com- pound, which is deposited with the sugar, the clear molasses usually not retaining any of the tin. The composition and physiological action of the resulting insoluble compounds have not been investigated. The question of chronic poisoning, as a result of the habitual or frequent use of foods containing traces of tin compounds, is an important one, which has not yet been thoroughly investigated, and concerning which opinions differ. In order to determine how far absorption into the circulation may produce disturbances of health, T. P. White has investigated the action of the double tartrate of tin and sodium, and of stanno-triethyl acetate on ani- mals. He places tin near lead in its toxic power. The administration of the acetate is followed by two series of symptoms-one referable to the digestive tract, namely, loss of appetite, nausea, vomiting, abdominal pains, and diarrhoea; the second referable to the central nervous system, manifested by weakness of the extremities and paralysis, diminution of the power of the heart, severe respiratory disturbances, and convulsions. The urine is scanty, has a high specific gravity, and frequently con- tains albumen. According to White, tin acts directly on the intestinal tract, whatever the channel by which it is introduced. Post-mortem examination showed : Mucous membrane of the stomach and intestines soft, covered with mucus, and hyperaemic; heart in diastole; blood thin and dark; lungs collapsed and hyperaemic ; liver pale and somewhat enlarged. Similar results were obtained with the double tartrate, but larger doses were required. After the administration of these salts tin was found in the muscles, liver, kid- neys, brain, heart, and urine. The blood in most cases contained no tin. White concludes, however, as a result of many experiments, that there is no danger of tin- poisoning resulting from the contact of fruits and vegetables with the metal, and that cases of poisoning which have been attributed to tin were due to solder or to metallic impuri- ties in the tin. Ungar and Bodlander have also investi- gated the action of the two tin-salts studied by White, and with similar results ; conclud- ing that the question of the poisonous action of the tin compounds, aside from any local effects, must be answered in the affirmative. To determine whether foods containing tin are likely to produce any local or general effects, they fed dogs and rabbits on fruits, etc., containing small quantities of tin, but failed to observe any irritant action on the mucous membrane of the stomach and intes- tines. The absorption of tin under such con- ditions was proven by its detection in the liver, spleen, kidneys, brain, heart, muscles, and urine. None was detect- ed in the blood. The authors also detected tin in the urine of man in two cases. William B. Hills. TOBACCO. (Tabacum, U. S. Ph.; Tabaci Folia, Br. Ph.; Folia Nicotian®, Ph. G.; Nicotians ou Ta- bac, Codex Med.) The dried leaves of Nicotiana Tabacum Linn., order Solan- ace®. This familiar plant is a rank-grow- ing, coarse annual, covered with viscid hairs and having a peculiar, disagreeable odor and taste. Its simple or slightly branching stem (from one to two metres high), bears numerous large, entire, alternate, bright green leaves which become brown in drying, and terminates in a short, flattish cluster of pretty pink flowers. The lower leaves, at- taining half a metre or so in length, are ovate, or ovate lanceolate, pointed, tapering into a short petiole at the base, the middle and upper leaves become sessile or amplexi- caul and much smaller. The leaves are en- tire, hairy, and very herbaceous ; on drying, like those of belladonna and stramonium, they become very thin and brittle. Calyx tubular with a rather close throat, five-toothed corolla with a long greenish tube inflated a little near the end, and then spreading in a five-angled pink limb ; stamens five ; ovary one, two- celled ; fruit an oval capsule, partly covered with the persistent calyx, splitting into two, and finally into four valves and liberating innumerable minute, rounded, brown seeds having a small straightish embryo and a coarsely reticulated surface. Tobacco is a native of America, but of what part is not known, since it has never been identified in a wild state. On the contrary, it was found in cultivation in different parts of the continent almost at its first discovery. It Fig. 3929.-Nicotiana Tabacuni Linn. (Bail- Ion.) 102 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tin. Tongue. is a variable plant, existing in many varieties and hybri- dizing freely. The custom of smoking and chewing it was prevalent and long established among the Indians when America was discovered by the earliest voyagers. Tobacco had been carried to Europe as a medicine of Composition.-The dried leaves contain a large pro- portion of ash, from fifteen to twenty per cent., mostly carbonate of lime and various salts of potassium ; there are also considerable amounts of nitrates and of ammo- nia compounds. The principal constituent, however, from a medical and physiological point of view, is the exceedingly poisonous, volatile, liquid alkaloid, nicotine, whose percentage varies from one or two to as much as nine per cent. It was discovered in 1828, by Passett and Keimars, and is a colorless, mobile liquid of sp. gr. 1.018, of a stale, persistent tobacco-odor and a biting, sharp taste. It is very soluble in water, which it absorbs from the air, and it rapidly becomes brown on exposure. Nicotianin is a not very well defined fatty substance with the odor of tobacco. Essential oil, if present at all, is in exceedingly minute proportion. Besides these, To- bacco, which is a very complex substance, contains sev- eral vegetable acids, malic, acetic, oxalic, etc., and a host of ordinary vegetable substances. Some of these are used up and others are formed in the process of curing. Action and Use.-Of course, the principal use of To- bacco is in the almost universal social habit of smoking, which is without the province of this article to discuss. (See article on the Tobacco Habit in Vol. VIII.) Physi- ologically, it depends for its activity mostly upon the presence of nicotine, and its poisonous qualities are essentially those of that alkaloid. Tobacco (nicotine) appears to be rather readily absorbed through the skin when applied in watery solution, as in poultices and fo- mentations ; it is also readily taken by the rectum in either liquid or gaseous form, as well as by the stomach. The prominent symptoms produced by it are giddiness, nau- sea, vomiting, and prostration, something like those oc- casioned by lobelia ; trembling, convulsions, paralysis of motor nerves, diarrhoea, and tenesmus occur later in ex- treme cases. Delirium and coma are more rare. The pupils may be either dilated or contracted. As a medi- cine tobacco may be said to be nearly obsolete. It was formerly used as an anodyne poultice for ulcers and in- flammatory swellings, and a good many fatal cases of its absorption have occurred. In hernia and in obstruction of the bowels it has also had a time of popularity as an injection either of infusion or smoke, but has been dis- continued for the same reason. It is still occasionally used as a fomentation over the scrotum, in acute epididy- mitis, but is unsafe. As an application for pediculi it is superseded by other things. Smoked for the relief of paroxysms of asthma it is certainly of some value, especi- ally to those unaccustomed to its habitual use. Allied Plants.-There are about fifty species of Nicotiana, of which three or four besides the above are cultivated for certain sorts of tobacco. For the order, see Belladonna. Like Capsicum, Tobacco stands apart, therapeutically, from the other medicinal plants of the order. Allied Drugs.-Lobelia, Conium, and Gelsemium, have some properties in common with Tobacco. IE P. Bolles. TONGUE, DIAGNOSTIC SIGNIFICANCE OF. The inspection of the tongue is a part of the routine of every medical examination, and rightly so, for much can often be learned from the appearances presented by this organ concerning the general condition of the patient; and the changes in sensibility, form, color, mobility, etc., when taken in connection with other symptoms, furnish not infrequently most valuable evidence of the presence or absence of disease in other parts. This is a fact well known even to the laity, and a coated tongue is to them one of the surest indices of a disordered state of the sys- tem. It is, however, needless to caution medical readers against placing too great reliance upon the signs fur- nished by the tongue alone, for its appearance is modified by so many and so slight causes, that one might easily fall into error if he attempted to reach a diagnosis by that means only, without considering the indications of disease in other organs. In examining the tongue we have to note its form and volume, the degree of moisture, the condition of its sur- Fig. 3930.-Nicotiana Tabacum. Flower entire and in longitudinal sec- tion. (Baillon.) great value in the early part of the sixteenth century, and the plant itself was introduced soon after the middle of the same century. Tobacco smoking was introduced into England in 1586, and before the end of the century had spread over nearly the whole world. The plant, too, with one or two related species, had worked its way to the East, Turkey, India, China, etc., and established itself in the hearts and gardens of the people in spite of the edicts of statesmen, priests, and moralists. From these times on to the present its use has been becoming more and more general and extensive. Tobacco grows in most di- verse climates, from the north of Eu- rope to the tropics, and from India to Minnesota. That consumed in the United States comes mostly from with- in her borders-to a slighter extent from the West Indies, especially Cuba, whose leaf is considered the best in the world. For centuries that grown in Virginia has been famous, but it is now disappearing on account of the impoverishment of the land. It is also less raised in Connecticut than formerly. Maryland, Pennsylvania, Ohio and other middle and western States supply vast quantities. It is a most exhausting crop, re- quiring high and constant manuring. Curing.-For medicinal purposes the less tobacco is manipulated in drying the better, but the Pharmacopoeia accepts "commercial" tobacco. This is prepared by topping the plants in when they begin to flower and so develop- ing the leaves to the uttermost, cutting near the ground at the end of the summer, and drying the leaves on the stems, hang- ing them in barns built for the purpose. Then they are again dampened (by the weather or otherwise), stripped from the stems, and tied into bundles of a half dozen or more; they are then piled in compact masses for several weeks, during which time a sort of fermentation goes on that modifies their color, turning them to a rich uniform brown, and develops their aroma ; they are then kept damp and pliable, or the sweating may be further repeated. Fig. 3931.-Dehiscent Fruit of Tobacco Plant. (Baillon.) Fig. 3932.-Seed of Tobacco Plant, entire and in longi- tudinal section. (Bailion.) 103 Tongue, Tongue. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. face, whether smooth, fissured, ulcerated, or the seat of an eruption, its color, coating, movements, and its tactile and gustatory sensibility. In health the tongue varies greatly in appearance, but usually it is of a rosy-red color, moist, covered with mi- nute papillae, free in its movements, and almost constantly changing in form. Very many persons, especially smok- ers and those engaged in certain occupations, such as tea- tasting, have a more or less coated tongue even when apparently in perfect health. The volume of the tongue also varies greatly within normal limits. In some the •organ is narrow and pointed at its tip, while in others it is large and flabby, with thick and rounded tip and mar- gins which often show the marks of the teeth. In ner- vous individuals the tongue is protruded quickly and as quickly withdrawn ; in others of a more phlegmatic tem- perament the motions of the tongue, like those of the other voluntary muscles, are sluggish. In old age the tongue is almost always coated and is less moist than in younger years, becoming often very dry and glazed upon the advent of even the slightest ailment. This is a point of some importance, for the physician called to see an aged person may be led greatly to exaggerate the gravity of the condition if he take into consideration the evidence furnished by the state of the tongue alone. The appearance of the tongue is not modified in every abnormal state, and it frequently presents no change in cancer of the stomach, or in gastralgia or enteralgia. In simple jaundice, nasal catarrh, and many other slight ailments unaccompanied by fever, the tongue often pre- sents a normal appearance. Form.-Changes in the shape of the tongue are owing, in many cases, to the absence of moisture, the organ then becoming frequently concave on its upper surface from contraction of the dried epithelial layer. According to Gubler, there is a contraction of the transverse muscular fibres in fevers, so that the organ is less broad than nor- mal. In hemiplegia the shape of the tongue is altered in consequence of the unilateral paralysis. The affected side is soft and flat, and after a time may become re- duced in volume. Hemiatrophy of the tongue has been observed by Ballet (Ze Progrte Medical, October 27,1883) in a number of cases of locomotor ataxia. There is a very noticeable diminution in size of one side of the organ and its surface is drawn up in ridges. M. Ballet regards this as a diagnostic sign of very great importance, as it is one of the earliest symptoms, and may be present before any of the other characteristic manifestations of the disease are present. Volume.-The tongue is swollen oftentimes when there is interference with the return circulation of the head in consequence of heart disease, pulmonary affections, or compression from any cause of the veins of the neck. In chronic diseases of the chylopoietic system the organ is often considerably enlarged, and shows on its margins the indentations from pressure against the teeth. In idiots and in others, suffering from mental disturbance, the tongue is often large and flabby. In general paraly- sis, in paraplegia, and sometimes even in hemiplegia, the organ is large, soft, and flabby, its dimensions being such as sometimes to prevent closure of the mouth. In anae- mia the tongue is broad and flabby, and shows the marks of the teeth. A similar condition is seen in small-pox, typhus fever, scurvy, and various blood dyscrasiae, and in mercurial poisoning. Inflammation with turgescence of the organ occurs as a result of the local action of cer- tain irritant and corrosive poisons swallowed accidentally or with suicidal intent. Atrophy of the organ not infrequently occurs with similar changes in other muscles in the course of pro- gressive muscular atrophy. Moisture.-The tongue is moistened by the secretion of its glands and by the saliva. In ptyalism there is an increase in the secretion of the lingual as w7ell as of the salivary glands. A return of moisture is a favorable sign in adynamic conditions, as it is an evidence that the vital forces are beginning to regain their supremacy. Dry- ness.of the tongue may occur from a variety of causes, and in some individuals it is constantly present in a slight degree, seeming to be a normal condition in them. It is noticed in obstruction of the nasal passages, and in dysp- noea (phthisis, pneumonia, heart disease, etc.), when the patient is compelled to breathe rapidly and through the mouth. Certain drugs, such as belladonna, cause dry- ness of the tongue as well as of the other mucous mem- branes of the head. Long-continued speaking also in- duces dryness of the tongue, and the same condition occurs as a result of fasting. In prolonged febrile con- ditions, especially when the temperature remains con- stantly at a high elevation, the secretions of the tongue become diminished. In acute inflammation of the ab- dominal viscera, in intestinal obstruction, etc., and in typhoid conditions, the tongue becomes very dry, and often fissured. Such a condition is of bad omen, as it indicates that the vital forces are ebbing. Surface.-Normally the upper surface of the tongue is somewhat convex, and is slightly rough from the pro- jection of its papillae. When moderately dry it is smooth and presents a glazed appearance from the presence of inspissated mucus. When very dry the epithelium con- tracts and the surface is marked by rhagades of greater or less depth. Fissures of the tongue, without any fur- ring, dryness, or change in color, are sometimes observed to occur in gastric disturbances. In some individuals, however, the organ is normally fissured even when moist. In syphilis the tongue is often seen to be ulcerated or fis- sured, and after these have healed there remain persistent whitish cicatrices. Mucous patches, gummy tumors, and other manifestations of constitutional syphilis are also oc- casionally noticed, but their consideration, as well as that of the other eruptions occurring as distinct affections or in connection with the exanthemata, belongs rather to the succeeding article on the Diseases of the Tongue. Ulcerations of the fraenum are not uncommonly seen in children suffering from whooping-cough. Wounds of the tongue caused by the teeth are seen in epilepsy, and may be of considerable diagnostic value in cases in which the convulsions are nocturnal. Color.-In anaemia and allied conditions the tongue is pale, as it is also after profuse haemorrhages and in wast- ing diseases. In various diseases, such as icterus, Addi- son's disease, etc., the tongue participates in the general pigmentation and approaches the skin in color. The tongue is abnormally red in scarlatina, in inflammatory fevers, and often in the beginning of small-pox. A red, moist tongue indicates debility, such as occurs in con- sequence of long-continued exhausting discharges. In chronic conditions, affecting permanently, in a measure, the digestive organs, the tongue is often intensely red, more or less dry, and sometimes presents a glazed appear- ance, as if varnished. In true gastritis and in inflamma- tion involving the other organs of digestion, the tongue is ordinarily redder than normal, dryish, narrowed, and pointed; sometimes it is furrowed and becomes of a brownish-red color. The tongue presents a more or less purplish venous hue in all cases in which there exists an impediment to the circulation, or where there is inter- ference with haematosis. Thus wre see this color in many cases of heart disease, in cholera, in croup, in pulmonary affections causing asphyxia, and when large effusions are present in the pleural or abdominal cavities. In malarial fevers the tongue is often purple at its margins, and in plethoric conditions the same venous hue is gen- erally present. A black tongue has been observed in certain cases, but what the causative condition is, or what diagnostic significance this discoloration may have, has not been determined. It is sometimes due to slight haemorrhages from the cracks resulting from the drying of the epithelium. The tongue is often discolored by various alimentary substances, drugs, or corrosive acids, such as blackberries, tobacco, rhubarb, etc. Sulphuric acid, when swallowed in concentrated form, blackens the buccal mucous membranes, nitric or chromic acid causes a yellowish or black stain according to the depth of the eschar, carbolic acid whitens the parts, the acid nitrate of mercury produces a reddish stain, caustic potash pro- duces a gray and gelatinous appearance, argentic nitrate gives a white or pearl-gray eschar. Da Costa, quoting 104 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tongue. Tongue. Chambers, says that tea-tasters have often a smooth orange-tinted coating on the tongue. Coating.-A furred tongue is usually the condition which attracts the most attention, and is the one to which the laity attach the most importance. The organ be- comes coated in many conditions, and the presence of a fur is almost always indicative of some abnormal state. In perfect health the tongue is clean, as a rule, although some individuals who do not seem to present any depart- ure from the normal have an habitually furred tongue. A thin whitish coating is almost always seen also in smokers. The fur may be composed of mucus or of de- tached epithelium, usually both, with the addition of particles of food and micro-organisms. It is due to in- creased production of the epithelium, owing possibly to reflex hypenemia, or to any cause which prevents the removal of the cells normally cast off. When normal secretion is interfered with, as in fevers or in adynamic conditions, there is less chance for the detached epithelia to be washed away, and the coating is further increased by the collection of the inspissated mucus. A dry tongue is almost always coated, and when the mouth is open the dust collects from the atmosphere and imparts a brownish tinge to the fur. Sometimes, when the fur is light or when the papillae are enlarged, the latter project above the surface of the coating as little red points, pre- senting the appearance known as " strawberry tongue." This is seen in its most typical form in scarlet fever, and is recognized as one of the diagnostic points of that affec- tion ; it is also commonly present in rotheln. The fur is variously colored in different conditions, and this coloration often furnishes more valuable diagnostic indications than does the mere presence of the coating it- self. Thus a thin white coating indicates febrile disturb- ance, or slight indigestion ; a yellowish tinge points to hepatic disturbance ; and a dry, brown fur, except in mouth breathers, is usually a sign of profound dyscrasia. The fur may be moist or dry, the former condition prevail- ing in apyretic gastric disturbances, the latter in marked febrile conditions which have persisted for a long time and in which the vital forces of the patient are greatly depressed. In such states the tongue becomes covered with a thick, dry, brown or blackish coating, which is often furrowed and cracked, being perhaps partially de- tached in places, showing a deep red color beneath. In disordered digestion the coating is thick, moist, and often brownish in color. A sign of some importance in the di- agnosis of gastric ulcer from cancer, is the presence of a coated tongue in the first-named affection, and its absence in the second unless there be fever. A clean tongue in the early stages of a continued fever should cause the physician to hesitate in making a diagnosis of typhoid fever. A haemorrhagic coating results from the imbibi- tion of the coloring matter of the blood. It is usually accompanied by great dryness of the tongue, and the blood escapes from the fissures in the mucous membrane resulting from the contraction of its epithelial covering. In diphtheria a false membrane occasionally, though rarely, forms on the tongue. As the coating is often the result of hyperaemia of the tongue, it may be seen in local diseases of the organ, and frequently a yellowish fur forms on one side in consequence of the irritation caused by a carious or broken tooth. In certain cerebral affec- tions, especially in apoplexy, the tongue is covered with a thick sticky fur, and it is also coated and foul in chronic alcoholism. Movements.-The movements of the tongue are slug- gish in all adynamic conditions, in mental hebetude, and when the organ is dry. In paralyses of various kinds the muscles of the tongue are often affected and then the or- gan lies like an inert mass in the mouth, and cannot be protruded. In paraplegia one side of the tongue may be paralyzed, and then, when protruded, it deviates toward the paralyzed side, being pushed that way by the sound muscles. A trembling of the tongue is seen in adynamic conditions, in alcoholism, lead-poisoning, paralysis agi- tans, and when the individual is under the influence of various emotions, such as fear, anger, etc. Fibrillary contractions are sometimes observed in progressive mus- cular atrophy, in general paralysis of the insane, and in locomotor ataxia. Convulsions involving the lingual muscles have been observed in hysteria, epilepsy, chorea, and in tubercular meningitis in infants. Sensibility.-Modifications of tactile or gustatory sensibility are not uncommon. In paralysis tactile sen- sation is often lost, but this has not very much diagnostic importance, as the nature of the affection is usually more certainly determined by other symptoms. Disorders of taste are common in hysteria. In dyspepsia and catar- rhal conditions of the stomach patients often complain of a " bad taste in the mouth," especially upon rising in the morning. In certain conditions there is a loss or perver- sion of taste, sometimes everything seems to be sour, or again, in diabetes mellitus, there is a mawkish taste in the mouth, and all substances seem to be sweetened. To review briefly the main indications furnished by the tongue: In simple indigestion the organ is soft, flattened, covered with a thick white, yellowish, or brownish fur, and shows the marks of the teeth. When actual inflam- mation of the stomach is present the tongue is red or brownish, dry, and often furrowed. In chronic inflam- matory disease of the digestive organs the tongue is commonly redder than normal, somewhat dry, glazed, covered in places by patches of aphthae or epidermal detritus. In apyretic diseases not affecting the organs of digestion the tongue may be normal in appearance, but in all febrile conditions it becomes coated and more or less dry. In the typhoid state it is very dry, brown, or blackish in color, cracked, and covered with sordes. This condition is also seen in many cases of cerebral dis- ease, such as softening or haemorrhage, even when fever is slight or absent. Pallor indicates blood impoverish- ment, a venous hue points to impediment to the blood circulation, and a red, moist tongue is usually a sign of loss of strength. Finally, any troubles which cause loss of appetite or retard digestion, such as severe pain, fear, anger, worry, mental overwork, etc., produce a coated tongue. The reader will find a very full description of the appearances of the tongue in disease in the article Seme- iologie de la Langue, by Dr. A. Rigal, in the " Nouveau Dictionnaire de Medecine et deChirurgie Pratique," vol. xx., Paris, 1875, to which the writer acknowledges his indebtedness in the preparation of the present article. An excellent presentation of the diagnostic significance of the appearances furnished by the tongue will also be found in the Lumleian Lectures, delivered by Dr. W. Howship Dickinson, in March, 1888, before the Royal College of Physicians in London. Thomas L. Stedman. TONGUE, DISEASES OF THE. The various abnor- malities met with in the tongue may be, for convenience of reference, considered under the headings of Deformi- ties, or changes in structure, Functional Disturbances, Inflammatory Changes, Discolorations, Syphilis, and New Growths. Deformities of the tongue may be either congenital or acquired, and consist principally in a complete absence of the organ, a split or bifid condition, a chronic state of prolapsus, hypertrophy, atrophy, adhesions, or a tongue- tied condition, etc. Absence of the tongue has been recorded as a congenital condition in at least one case, seen by Jussieu,1 and as the result of disease in a number of recorded cases. Bifid, or split tongue, a normal condition in some ani- mals and birds (the seal and raven), has occasionally been seen in children. Barling reports a case of congen- ital division of the tongue with a median lobe. Prolapsus Lingua.-In a few rare cases the tongue has been found too long, so that it constantly protruded from the mouth. This condition is also found as a re- sult of hypertrophy and inflammatory action, and must not be confounded with the rarer congenital increase in length. Hypertrophy, or macroglossia, is a diseased condition which may cause enormous and chronic enlargement of the organ. Though believed to begin very early in life, 105 Tongue Tongue. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. or even in some cases to be congenital, the enlargement is not noticed until adult or middle life. Though a predisposition to hypertrophy probably exists in many cases, it seems to be determined by some acute process, such as abscess or ranula, or one of the exanthemata. When of large size the organ protrudes from the mouth, and the patient's saliva constantly flows from it, the gums swell, and the teeth become loose. It causes great discomfort, and interferes with mastication and speech. It must not be confounded with acute glossitis, with the enlargement from mercurial stomatitis, nor with tumor in the substance of the tongue. Virchow describes the hypertrophied tissue as forming a lymphatic cavernous tumor, and it is now the accepted theory that the lymph-vessels are dilated and the con- nective tissue increased, but the muscular tissue is not hypertrophied. There appears, however, to be a form of muscular hypertrophy which constitutes a separate disease. Billroth says there is a fibrous form. In some cases the blood-vessels as well as the lymphatics are en- larged. As regards treatment, Freteau has had good results with a bandage applied so as to make even pressure from the tip backward. Compressiondias also resulted well in the hands of others. A cure may be effected, so long as the organ does not protrude, by applying this pressure as Butlin advises, by inducing the patient to keep the mouth constantly and firmly closed upon the tongue. The mouth, in this case, must be bandaged. Ablation is often the best treatment when the organ protrudes. A V-shaped piece can be removed, or all the part projects ing beyond the line of the teeth. Barling reported in The British Medical Journal of December 5, 1885, a case of hypertrophy of the tongue in a man seventy-five years of age, due to the presence of elastic non-fluctuating tumors which occupied both borders of the organ, leaving the centre free. Hypertrophy of the papillary structures of the tongue must be mentioned as an occasional interesting congeni- tal condition. One or more hypertrophied papillae may subsequently become warty growths. At times one will see a dorsum on which almost all the papillae seem to be raised above the surface, making an uneven though not really warty condition, and at other times only one or more individual papillae will be thus hypertrophied. Atrophy of one-half the tongue was observed by Lewin,2 with nodules near the root. The tongue devi- ated toward the affected side, and could scarcely be pro- jected or elevated to the palatine vault. There was great difficulty in chewing, swallowing, and in pronouncing the letters d, t, I, n. and r. At the autopsy two gum- mata were found in the cranial cavity ; one directly upon the hypoglossal nerve. Such cases may also, but more rarely, be due to peripheral causes. Atrophy of the whole organ is very rare compared with that of one side, as in the above observation. The affected side in hemiatrophy is noticeably decreased in size, shrivelled up, and the mucous membrane covering it is thrown into folds. According to Ballet,3 it may be the first evidence of central disease. Atrophy of the whole tongue may follow a bilateral paralysis of the organ. Adhesions of the tongue, causing the common tongue- tie or bridled tongue of infancy, are not very rare. In this condition they are situated near the median line, be- neath the tongue, and are congenital. Anchyloglossus is another term which has been applied to this condition, when due to an abnormal development in breadth of the mucous fold beneath the tongue, called the fraenum, or to its too high attachment. All movements are restricted and suction is almost impossible, and the nurse or mother soon seeks assistance for the child. If the fraenum is at fault, the tongue will not pass beyond the gums, nor can the fingers be inserted beneath it. In such case alone should the fraenum be cut, when it is too short, from above downward. It may be cut, if found necessary, with blunt-pointed scissors. Haemorrhage may occur from section of the ranine vessels. To avoid this, the vessels should be protected with the fenestrated plate which makes the handle of most grooved directors found in pocket-cases, the lateral wings of this plate serving to raise the point of the tongue. If haemorrhage super- vene, the usual methods of arrest are to be employed. Congenital adhesions may be found upon the under surface of the free portion of the tongue, causing more or less complete immobility, and this condition can also be acquired from accidents. Lateral adhesions have been noted as a congenital con- dition, and also as a consequence of mercurial gingivo- glossitis, noma, scurvy, etc. In all of these cases the treatment by section with scissors is advised. It has also been said that children may be born with the dorsum of the tongue attached to the roof of the mouth, but such instances are exceedingly rare. There are other deformities which may be the result of past disease or of accident. Thus we find deforming scars of the tongue resulting from syphilitic ulceration, from self-inflicted bites of the tongue, or from other wounds or injuries. Again, many of the diseased condi- tions which we shall consider are of themselves deform- ities. Functional Disturbances.-The tongue is protrud- ed with difficulty in low fevers, apoplexy, and sometimes in paralysis ; in the latter condition the sound muscles force the tongue over toward the paralyzed side. In chorea I have seen a positive inability to protrude the tongue in one case, and in another the tongue was so affected by the chorea that it was constantly being thrust far out of the mouth. In chorea, as also in epilepsy, the tongue is often bitten by the patient, and deforming scars may result. Abnormal mobility of the tongue. When at birth the fraenum is too long, it has happened that the infant has swallowed the tongue or drawn it so far back as to cause suffocation and death. This may also happen after di- viding the fraenum. Treatment consists in replacing the tongue with the linger, and exercising care in feeding. A case is reported in The Medical Record of November 14, 1885, by Dr. Jurist, of Philadelphia, of a syphilitic patient who experienced much inconvenience from the accumulations of mucus on the posterior wall of the pharynx from a rhino-pharyngitis. After several attempts he succeeded in cleansing the naso-pharyngeal cavity w'ith his tongue. The fraenum was found ruptured in several places. Other cases will be found reported in The Medical Record, under dates of April 28, May 26, and June 9, 1883. Glossoplegia.-Paralysis may affect the muscles of one or of both sides of the tongue. That of one side alone has been observed by Lewin and others. One case, ac- companied by symptoms almost identical with those of a bulbar paralysis, recovered promptly under corrosive sublimate injections. If due to cerebral lesion, glosso- plegia will be apt to be attended by the same symptoms of headache, dizziness, etc., that accompany any central paralysis. In hemiplegia of the body, the tongue is pro- truded, as we have already said, toward the affected side, and this is also true of monoplegia. I have re- cently seen a woman, in the incurable hospital of the Almshouse, paralyzed on both sides, whose tongue lay as an inert body in the floor of the mouth, the ragged bor- ders quivering when an ineffectual effort was made to protrude the organ, which had become atrophied from disuse. Speech was wholly impossible, and mastication very difficult. Anesthesia of the tongue may interfere with its func- tions. There may be gustatory anaesthesia or a loss of feeling in the tongue. This, like paralysis, may be due to a central or peripheral cause. Loss of taste may depend upon failure of conduction in the nerves of taste, accord- ing to Butlin. Hyperesthesia of taste is seldom met with, but pain located in the tongue alone is quite common. Aside from the pain attending many diseases, elsewhere con- sidered, we have some rare neuralgias limited to this or- gan, and, as a rule, to one side only. Unilateral spasm of the tongue has been observed by Wendt.4 Occurring as an independent affection, any spasm of the tongue is a rare condition. The attacks in 106 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tongue. Tongue. the case referred to would last for several minutes at times, the right half of the organ becoming suddenly hard and contracted by repeated twitchings. The pa- tient recovered under galvanism. Inflammatory Conditions.-Glossitis was a condition well known to the older writers as far back as Hippoc- rates. The causes which may be active in producing inflammations of the tongue are multiple. Thus it may follow a great variety of injuries, the application of irri- tant substances, and may be found in eruptive and other fevers. It may be acute or chronic. When deep seated, inflammation of the tongue may endanger life from suf- focation, and in the acute form its onset is often sudden and may end in pus formation, and the subsequent ab- scess may press upon the epiglottis and thus also threaten life. Acute glossitis is rare. Treatment here consists in hot fomentations, vertical incisions on either side of the median line, if suffocation is feared, and lancing the abscess as soon as it can be made out. Glossitis from the accidental taking of ammonia I have seen in two instances. The tongue is first made white, becomes much enlarged and painful, and subse- quently exfoliates. In one of the cases a patient with asthma mistook the hartshorn for the whiskey bottle at night, and by the time I reached him the thickened tongue filled and protruded from the mouth, and this caused a difficulty of breathing which, added to that of the asthma, was painful in the extreme. Inflammation from the stings of bees and bites of insects may be severe, and for these accidents the application of ammonia to the injured point, and alkaline mouth-washes, are recom- mended by Clarke. Glossitis from mercury is now for- tunately much more rare than in former times. The fetid odor of the breath will often be sufficient to make us suspect the cause. Gangrene of the moist variety may follow any variety of severe glossitis. Treatment.-Mouth-washes containing glycerine and some astringent usually act well, but care must be ob- served after each meal in washing out the mouth, to re- move all particles of food that may become lodged within the fissures. In some cases, a caustic carefully applied may be of benefit, especially chromic acid diluted one- half. In mercurial glossitis a purge with Glauber's salts or a Seidlitz powder, and chlorate of potash or perchloride of iron mouth-washes, are indicated. Professor Renzi, of Naples, washes out the mouth in this condition with a 1 to 4,000 corrosive sublimate solution. Chlorate of potas- sium may also be given, in from five to fifteen grain doses, every four hours. If gangrene supervene, tonics and mineral acids are recommended. Hemiglossitis may be due to a neurosis or to a catarrhal affection. It is rarely described by authors, and the left half of the tongue is the one most always affected. Gen- eral symptoms accompany the inflammation. The swell- ing usually does not last more than a week, but a chronic thickening may persist. A decided nodular enlargement may be made out in the affected side, and this serves to distinguish it, according to Butlin, from general glossitis. Incisions are not necessary, purgation, chlorate of pot- ash or borax washes, applications of ice, and a generous diet being all that is required. Inflammation may ex- tend from a severe tonsillitis to the base of the tongue, and cause protrusion of that organ and subsequent pus formation. Abscess of the tongue, as we have seen, may be a result of glossitis. Still, it may occur independently of this affection, but be confounded with it. Fluctuation or pointing will aid in the diagnosis. If necessary, the ex- ploring needle will decide the matter. Early operation to prevent suffocation is indicated. Excoriations are often the first stage of ulcerations. They may be the result of accident, or be due to inflam- mations and dyspepsia. They are often the result of slight burns in persons having thin mucous membranes. Chlorate of potash usually speedily affords relief. If due to dyspepsia, this must be treated. Weak chromic- acid solutions often do good. Fissures of the tongue, when not due to syphilis, are often the result of much the same digestive disorders as those which produce the ulcer. The cracks may occupy the sides or the dorsum, and vary in extent from mere ex- aggerations of the furrows between the papillae to fissured lesions extending more deeply into the substance of the organ. The deeply fissured tongues are, for the most part, syphilitic. Simple fissures are treated with washes containing chlorate of potassium, tannin, tar, etc., or by the appli- cation of powders made with subnitrate of bismuth, aca- cia, prepared chalk, etc. Fissures are often found associated with leucoplasia, and are usually the only source of pain in this affection. Fissures or clefts, when occurring in patients with a lowered condition of the system, may become ulcers, and cancer may develop from such irritated lesions. Tertiary syphilis is responsible for most fissures. Deep ulcers of a fissured nature are seen in secondary syphilis, but they usually start from a mucous patch against which a tooth has pressed, or which has in some other way been irritated and become fissured. I have now under treat- ment a patient in the secondary stage, whose teeth are peculiarly sharp on the edges, the central portion of all the bicuspids being worn away. Such fissured ulcers are present in his case, and are extremely difficult to heal, and repeatedly recur on account of the constant ir- ritation of the sharp edges of the teeth. The teeth, if carious, should be removed, or the sharp edges of sound teeth should be filed down. Scars are apt to result when such secondary ulcers and fissures heal, and thus serve as diagnostic signs of past syphilis. Ulcer of the tongue may be caused by a variety of conditions. It may be due to syphilis or tuberculosis, as a primary or secondary lesion ; it may depend upon a previous glossitis or injury, such as a burn, or be sec- ondary to such preceding lesion as a gumma or epitheli- oma ; it may be caused by some gastro-intestinal disor- der, or by the parasite of thrush, or result from the constant rubbing of sharp and decayed teeth. The tuberculous ulcer is usually located upon the side of the organ or near the tip. It is not common. The first appearances noted are those of small granulations, which take on a dark hue, break down after the central portion has become yellow, and form an irregular ulcer having a base covered with minute granulations. Tuber- culous ulceration is one of the most important forms we meet with, for although rare, its consequences may be disastrous not only to the subject himself, but to those exposed through kisses, etc., just as in syphilitic disease of the mouth. That the lesion is often overlooked, and not recognized oftentimes when discovered, makes the subject the more worthy of study. Butlin thinks that Paget first described this form of ulcer in 1858. The characteristics, as given by this author, are that in the tuberculous ulcer "the surface is uneven, pale, and rather flabby, granulated, often covered with yellowish- gray, viscid or coagulated mucus ; the edges are some- times sharp-cut, sometimes bevelled, seldom elevated or everted, or undermined ; not usually very red, but often redder than the surrounding tongue ; there is very little surrounding induration, indeed, there may be none; the adjacent portions of the tongue are generally a little swollen, sometimes decidedly swollen and sodden ; the outline of the ulcer has no characteristic shape, but the borders are often sinuous, and the shape is not unusually oval or ovoid or elongated." At first superficial, the ulceration extends more deeply, but in an uneven man- ner. Pain may be quite severe at a later stage. Dimin- utive outlying ulcerations are at times noted. The be- ginning may have been as a vesicle, or as a small yellow nodule, which ulcerated after some irritation. Casea- tion does not take place so readily as in the lung. Under the microscope the same small-cell infiltration, giant cells, etc., are found, and the bacilli are present just as in tubercle elsewhere. The ulcer may be primary or secondary. The prognosis is bad. If not removed by operation, 107 Tongue. Tongue. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. these ulcers usually prove fatal. Healing takes place at times, but they are quite sure to break out anew. The diagnosis is extremely difficult, and the ulcer is often mistaken for carcinoma or for syphilis. Scroful- ous ulcers, so called, are probably only mild forms of this same disease. The situation of the ulcer upon the tip or the edge of the tongue may aid in distinguishing it from a late syphilitic lesion, which would more likely occur upon the dorsum, be deeper, and have undermined edges. Aid must be obtained in most cases from the patient's history and general condition before a positive diagnosis is possible. Absence of induration, a pink color of the ulcer, and a sodden condition of the surrounding tissues, may aid in excluding cancer. In some cases, scraping the ulcer for microscopical examination may throw light upon its nature. Treatment. Butlin favors removal of such tubercu- lous ulcers as appear to be primary, while they are still small and easily operated upon ; first, " because there is the possibility that the operation may preserve the patient from further tuberculous disease by infection through the ulcer; second, because the disease is in most cases not difficult to reach or to remove, and the operation is far less formidable than that for carcinoma; third, be- cause the ulcer is itself exceedingly distressing, and, through the distress which it occasions, leads to debility and death." Such excision has been frequently per- formed, especially by Nedopil, but usually the impres- sion has been at the time that the ulcers were of a can- cerous nature. Where excision is not practicable, local treatment sometimes gives much relief. A powder containing iodoform, 6parts; morphine, 1 part; borax, 18 parts, may be dusted over the ulcer with benefit. Aphthous ulcer, with its attendant inflammation, re- sulting from thrush, is seen almost exclusively in chil- dren, and the white patches and flakes present recall the appearances of curdled milk or cheese. Beneath these are small, round, or oval ulcerations, surrounded by a red areola. In 1842, Gruby and Berg showed the presence of the oidium albicans, a fungous growth upon which the disease depends. Strict cleanliness of the nursing-bot- tles, etc., and careful attention to the food of the infant, are essential parts of the treatment. A laxative of mag- nesia, and the administration of chlorate of potash, which may also be used as a mouth wash, will soon cure the at- tack. There is also a non-parasitic aphthous ulcer, which is not so rounded but presents the same curdy flakes. Obstein thinks thrush is often due to rough and care- less swabbing of the child's mouth. Since forbidding the child's mouth to be washed in his lying-in service at Prague, stomatitis has almost disappeared, while pre- viously fifty-two per cent, of infants under ten days of age were afflicted. (See, also, article Aphthae, in Vol. I.) Ulceration, the result of dyspepsia or other disorders of the digestive organs, is met with as a solitary and quite superficial lesion, usually situated near the tip of the organ. It may be extensive. It is red and inflamma- tory, somewhat painful, and irritated by tobacco, condi- ments, alcoholics, acids, etc. It is quite rare. To effect a cure, which is not always easy, regimen must be strict, and the disease which induced it must be cured. Secon- dary ulceration may occur in cancer, lupus, etc. An ulcer may be the result of an abscess which has burst or been opened. Sharpness of the edges, and ab- sence of induration, will suffice to make its nature clear. Whooping-cough is attended with the frequent forma- tion of an ulcer at the fraenum, usually perpendicular to it, oval, superficial, and covered with a scanty slough. Some observers regard it as a specific lesion of the dis- ease, and Lersch compares it to the sublingual pustule of hydrophobia. Bouchut and others look upon it as ac- cidental, and due to pressure of the fraenum against the lower incisors in severe paroxysms of coughing. While in Paris, in 1879, I spent much of my time in Bouchut's children wards, where pertussis was very prevalent. Every child was carefully examined for the ulcer, and it was found to occur in over half the cases. I remember his calling my attention to its absence in children who had not yet cut their teeth, and I do not remember having seen the ulcer where the inferior incisors had not been cut. Out of 522 cases examined by Bouchut, 372 pre- sented the ulcer, 72 subsequently developed it, and 33 were said to have previously had it. In some severe cases the hypoglossal nerve becomes exposed. Recently some observers have thought to have discov- ered the microbe of pertussis, so that after all it may be shown that the ulcer is specific, and due to these micro- organisms, which are thought to produce the cough. Under this heading I think we may also class many of what might be termed dermatoses of the tongue. They are many of them inflammatory, and for convenience of reference will be here considered together. Some of them are of the nature of chronic stomatitis, while some have identical lesions with those occurring upon the skin, and at times in association with skin eruptions, and hence have a great importance for the dermatologist. Herpes, in connection with the same disease, upon the face, lips, etc., is a not very uncommon condition, and I have seen a number of instances of it. The vesicle wall is naturally of brief duration, and when the patient is seen a red, inflamed, tender, and somewhat indurated area shows where the primary lesions were situated. It is found almost wholly upon the tip and edges. For treatment, the application of powders containing acacia, bismuth, prepared chalk, etc., frequently re- peated, or of borax in honey by means of a camel's hair pencil, act well, and when the parts are less tender, of borax, alum, or tannin washes. Aphthous sore mouth often begins as a vesicular erup- tion. Recurrent herpes of the tongue has been observed in syph- ilitic subjects often several years after the apparent cure of the syphilis. It appears as erosions upon the sides of the tongue, and is characterized by the slight effect pro- duced upon it by anti-syphilitic treatment, and its great tendency to recur after cauterization and similar local treatment. Fournier5 says : 1. The affection appears only in the form of erosions or superficial exfoliation of the mucous membrane. 2. The erosions are small, averaging in size that of a lentil or a grain of corn, and some are scarcely the size of a pin's head. 3. The erosions are numerous and scattered, and al- though usually on the edges, are also found upon the dorsum of the organ. 4. Like herpes, the erosions are only of short duration ; eight to fourteen days if no unfavorable conditions are present, such as smoking, and a general unhealthy con- dition of the mouth. 5. The constant tendency to recurrence favors the theory of herpes. 6. The herpetic character is marked in the polycyclic configuration of the lesions. The color of the lesions is somewhat red, but before the epithelium is removed is rather grayish. The reason the lesions are hot met with in the vesicular stage is because of the ephemeral char- acter of the vesicle. The author thinks the condition is due to the irritation of the mucous membrane of the mouth from excessive use of mercurials, the abuse of tobacco, etc. Hence a mercurial course only makes the condition worse. He does not regard it as a syphilitic manifestation. Lepra may produce lesions upon the tongue quite sim- ilar to those upon the integument. Campana6 saw a leper boy, aged fifteen, upon whose tongue existed a group of small papilliform tumors, forming an oval plaque as large as a twenty-five cent silver piece, slightly elevated, and with a rough surface. Some of the separ- ate tumors were conical in form and some rounded. They had a rose color and were painless. Characteristic bacilli were found in one which was removed and exam- ined microscopically. Leloir gives, in his recent excellent work on lepra, a figure of tuberculous lepra of the tongue, showing a longitudinal fissure, crossed by several transverse fissures lobulating the organ, and giving it much the appearance of certain cases of syphilitic glossitis. 108 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tongue. Tongue. Scattered over the dorsum are numerous miliary tuber- cles, which infiltrate the lingual mucous membrane and give the appearance of an opened fig. A microscopical section through a leprous tongue showed bacilli collected in groups, and in ball-like masses. Leloir says these masses of zoogloea have been taken for cells by many authors, and among them Vir- chow. Lupus is rarely found on the tongue without having previously existed on the face. It occurs mostly upon the back part, near the epiglottis, as small isolated nod- ules, with soft granular surface; star-shaped cicatrices result. It is found in connection with lupus of the larynx, soft palate, etc. Butlin thinks it very rare, but has seen cases. The tip in one case was completely destroyed. The patient believed the tongue had been directly inoculated from the lupus upon the lips, after being scratched by imperfect teeth. The ulcer resem- bled a tuberculous or scrofulous sore, and without the complete history and the existence of lupus elsewhere, a diagnosis would have been extremely difficult. The dis- ease had existed for four years-w'hich would have been against the theory of tubercular ulcer, as would also the absence of pain and the steady progress of the ulceration. Lichen planus, it would appear, not infrequently causes tongue lesions w'hich would present difficulties of diag- nosis were the skin lesions absent. Erasmus Wilson' first showed the possibility of lichen eruption upon the tongue, attended with a sensation of roughness and the formation of round whitish patches. Jonathan Hutchin- son subsequently observed some cases in which the le- sions were small papules. Neumann8 had a case in which the papules were similar to a psoriasis of the mu- cous membrane, being flattened and lentil-sized. Tou- ton 9 reports a case in which the tongue was covered with flat, round, grayish-white plaques. Pospelow 10 showed a patient before the Moscow Medical Society who had lichen planus of the tongue, the papules being flat and without central atrophy. An excellent article by Thibierge on the subject, re- viewing the literature, is to be found in the Annates de Dermatologic et de Syphiligraphie, No. 2, 1885. He cites observations of Besnier and Balzer, and gives extended histories of three cases, showing that the lesions of the tongue may be more or less extensive at the time that the cutaneous eruption is first observed, or that the tongue lesions may precede or follow those of the skin. In most cases the lesions occupy the mucous membrane of the cheeks and of the lips at the same time. Upon the tongue they occur as sharply defined white spots, rounded or slightly irregular, without any projection above the surface, isolated or joined in groups, or as par- allel lines along the borders of the tongue. Thibierge thinks we must look upon these lesions as the manifesta- tion of lichen planus upon the tongue, although the le- sions are acuminated and do not itch. According to Unna,11 the lichen ruber of Hebra is also accompanied by mouth lesions. In a case observed by Unna, there were lesions upon the tongue in the form of multiple erosions, which w'ere altogether different from the plaques of lichen planus. Dermatitis exfoliativa is accompanied by irregular white plaques upon the tongue, according to Brocq,12 but Thi- bierge believes them to be either the result of painful fissures, or the pseudo-membranous productions which are observed in this disease. Ringworm, marginate exfoliative glossitis, exfoliatio areata linguae, wandering rash, geographical tongue, cir- culus migrans, are names given to peculiar circinate eruptions of the tongue which are seen mostly in chil- dren, and w'hich either disappear after a few days to be replaced by new ones, or change their location, creeping from one portion of the tongue to another. Kinnier 13 has observed a number of cases in w'hich true ringworm was present at the same time upon the child's head or body-the rings on the tongue being no- ticed shortly after the appearance of the ringworm. He failed to find evidence of its parasitic nature. The centre of the spot is red and shiny, and the border white. No treatment is necessary, aside from correction of di- gestive disorders.. Hutchinson mentions the ringworm tongue as occur- ring in syphilitic children. Unna14 describes it as a be- nign non-specific eruption, and relates a number of cases. Its seat he finds to be in the uppermost layers of the epi- thelium. It affects the under surface of the tongue as well as the dorsum. It occurs in adults as well as in children, and he regards anaemia, menstruation, gastric disturbances, and dentition as predisposing causes. Molenes16 describes a desquamation of the tongue in areas, which he considers distinct from the forms already noticed, and indeed, a manifestation of the arthritic dia- thesis. The borders of the patch are polycyclic. In other cases the eruption is coincident with a dyspeptic attack and disappears with it. Bridou seems to have been the first to call attention to this peculiar condition. Caspary named it " benign, plaque." It is not at all common, and the cases observed have been for the most part in children. The patches are first very small, smooth, and red, and situated upon the dorsum. Fungiform papillte remain, but the filiform have been shed. Any given ring spreads by extending at the periphery, until the border of the tongue is reached. Rings may intersect each other. Parrot believed the condition to be syphilitic. He found the epithelial structures generally augmented in size, and lymphoid cells around the vessels of the derma. The cause may be said to be not yet known. No treat- ment seems to affect the condition to any degree. Unna has found gratifying results, however, from local appli- cations of sulphur and of sulphuric acid. Pemphigus has been known to occur upon the tongue, and well-marked bullae distended with fluid have been seen. Bullae upon the tongue have even preceded the eruption upon the skin. In a well-marked case of acute pemphigus recently under my care, the tongue was dry, hard, and brown for many days, much like^he tongue of typhoid fever, but no bullae occurred. Purpura is, in some cases, attended with the same pet- echial spots upon the tongue as those found upon the skin. I have recently had two cases which illustrated this fact in a beautiful manner. The first, an adult male, who from the age of three years had suffered from hae- mophilia wTith frequent outbreaks of purpura, showed the tongue and, in fact, the whole lining membrane of the mouth covered with small bluish-brown spots of extrava- sated blood. The second, a woman with purpura sim- plex, had well-marked purple lesions upon the tongue. Xanthelasma.-This peculiar disease of the skin (see Xanthoma) is at times, though very rarely, attended with one or more soft, slightly raised patches upon the tongue. Under the microscope the growth has been found to be the same as that upon the skin, though the color is here white or yellowish-white, while upon the skin it is de- cidedly yellow'. Psoriasis of the tongue is a name given by Bazin to a condition of the organ resembling, as its name would imply, psoriasis upon the cutaneous surface. Debove has given an exact and detailed description of the affec- tion in an inaugural thesis. Some have maintained that the condition is a dermatosis of the buccal mucous mem- brane ; others that it is due to syphilis; and still others that it is an idiopathic affection which may result from a variety of different causes. Ichthyosis linguae is another term under which the same lesions have been described by English writers, and, in- deed, cases have been observed in association with ich- thyosis of the skin ; but it is probable that this name was derived rather from the thickened ichthyosis-like condi- tion of the epithelium of the organ. Both terms are faulty. There is no true psoriasis of the tongue, and as Mauriac has justly observed in the Union Medicale, 1874, ichthyosis is a deformity, and does not follow the evolution found in those cases. Tylosis is a designation adopted by Clarke and Lailler for a marked type of the disease. Keratosis was applied to the condition by Kaposi, who 109 Tongue. Tongue. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. believed it to be due to a transformation from the opaline plaque. Kaposi obtained a history of syphilis in every one of four hundred cases of keratosis. These do not include cases of superficial plaques from the use of to- bacco. Benard thinks the affection cannot be considered a simple dermatosis, nor yet in all cases a consequence of syphilis, but that we are forced to regard it as an idio- pathic affection originating under the influence of a di- versity of causes. Fournier says the epithelium is, so to speak, baked by the hot smoke of tobacco. The same condition has been found in glass-blowers, due to the same cause-heat. Mechanical irritation as a cause has been noted in patients with irregular, broken teeth. Excessive use of highly-spiced dishes, cayenne pepper, etc., has been cited as a cause. Arthritism has been considered to have a causative ef- fect, and many French observers have thought that her- petism played a not unimportant role along with a syph- ilitic or an arthritic diathesis. Levcoma is the name first suggested by Hutchinson, and it has been adopted by Butlin in treating of all white opacities of the tongue, in preference to leuco- plakia, the name proposed by Schwimmer, who also re- fers to the condition as leucoplasia oris, which Vidal changed into the French term leucoplasie. Chronic epithelial stomatitis is the designation which Besnier proposed, and it appears to suit the affection rather better than either of the above, as indicating its nature ; for, indeed, the white patch is not present in all cases and at all stages. According to Schwimmer, the first change which takes place is a hyperaemia, and this is followed by an infiltration of new cells in the super- ficial layers of the derma. Organization of the embryo- nic elements is particularly marked about the vessels and the papillae, and some atrophy follows. The epithelium loses its vitality, becomes opaque and thickened. Leloir has found a general thickening of the mucous derma out- side of the plaques proper, and a compression resulting in atrophy of the superficial muscular fibres of the tongue. The changes are analogous to those in the skin from chronic irritation. Glossodynia exfoliativa has been applied to the same pathological condition. The plaque is found upon the superior and lateral surfaces of the tongue, and only very rarely upon the inferior parts. Circumscribed red patches are said to precede the opaque ones, which look not unlike the effect produced by applying the stick of nitrate of silver to the mucous membrane. Subsequently the patch becomes harder, and the milky or bluish whiteness changes to a silvery or slightly yellowish hue, and the surface, from being at first smooth, may become somewhat rough or even warty with furrowrs and fissures, but never ulcerates. Subjective symptoms are wanting, or there may be an unpleasant burning sensation with decided pain after much talking, or contact with acrid and spicy substances, or after smoking. This is, of course, the case if deep rhagades or fissures are present. It is a disease of very long duration, and complete cure is seldom seen. Diagnosis.-The affection is confounded for the most part with syphilitic diseases of similar nature, but of much shorter duration and attended with ulceration. Specific treatment does not produce any effect upon it, except at times to aggravate it. The insides of the cheeks are often simultaneously affected. The prognosis is unfavorable as to duration and cure, and there is always a possibility of cancerous develop- ment, to which it seems strongly to predispose. Etiology.-Though little is known about the causes of leucoplasia, it seems quite certain that tobacco furnishes one of the most frequent exciting causes. Other irritants, such as carious teeth, abuse of alcohol, etc., may also be active in its production. Kaposi, as I have said, always found evidences of syphilis in patients thus affected. Zeissl thought it the result of mercurial treatment. Schech (Aerztl. Intelligenzblatt, No. 40, 1885) cannot accept syphilis as a cause, but thinks perhaps syphilitics may be predisposed from repeated and prolonged mer- curial courses setting up an irritation of the mucous membrane, if other injurious agents are at the same time present, It never occurs earlier than the age of twenty. Treatment must be directed to the causes if discover- able, and internal treatment should be carried out accord- ing to the patient's general condition. E. Fletcher Ingals recommended in the New York Medical Journal, July 25, 1885, the use of the galvano- cautery. In one case he succeeded in effecting a cure within four months, a small part being destroyed at each sitting. He believes the affection to be due mostly to the use of tobacco, and that it usually terminates in epitheli- oma. Joseph, of Berlin, succeeded well in a case of long standing by the daily application of a tampon wet in a concentrated solution of pure lactic acid, well rubbed in for a few minutes. A superficial loss of substance takes place, which in a few days heals over. The pain is not very great, and can be relieved by cocaine. Schwimmer has found leucoplakia to resist all the remedies he has tried, but the pain resulting from the ulceration and fissures was relieved by the application with a brush of : Papayotin, 0.5 to 1.0 (7| to 15 grains); distilled water and glycerine, aa 5.0 (75 minims). Smokers' Patch.-In inveterate smokers, and especially those using a rough stemmed clay pipe, a white patch develops upon the anterior portion of the dorsum, due to the heat of the smoke and irritation. At first the patch may be smooth and red, or pearly, and look as though the papillae had been rubbed off. Later this may be covered with a yellowish crust, which becomes detached. The patch may gradually extend, and the mucous mem- brane of the cheeks become affected. When the patch is opaline, extensive, persistent, it presents the same ap- pearances, and is, in fact, the same condition described under the various names given to leucoplakia. Early cessation of smoking may prevent the more serious con- dition. Glassblowers' patch is much the same thing, and due to a similar cause. Traumatism, from faulty teeth, may produce a white, thickened patch resembling these con- ditions somewhat. Malignant pustule of the tongue has been described, but Butlin does not believe that it ever occurs as a pri- mary affection. Erysipelas occurs upon the tongue, but whether ever primarily is a question. It does extend to the tongue, however, from neighboring parts. Gangrene of the whole or of part of the tongue is found after severe glossitis, but probably more often after what may be termed the septic form of it, in which through a bite, sting, or the accidental inoculation with some septic matter, a severe inflammation has been set up. Variola may be attended with a few scattered pustules upon the tongue, and a glossitis variolosa has been de- scribed. Morbilli has also been observed, with lesions of the disease upon the tongue. Scarlatina has a bright red tongue, the fungiform pa- pillae being especially red and prominent, from anticipa- tion in the general condition of hyperaemia, and presents a quite characteristic appearance, known as the raspberry or strawberry tongue. Diphtheria at times presents patches upon the tongue ; never, however, unless the throat is coincidently af- fected ; hence the diagnosis will not be difficult. Varicella, like variola, is attended at times with lesions upon the tongue. I recently saw a single pock upon the tongue of a boy with chicken-pox. He had complained the day before of soreness of the tongue. There were no other lesions in the mouth. I have also seen six vari- cella lesions grouped near the lip of the under surface of a child's tongue. Discolokations and Pigmentations.-Most cases of discoloration of the surface of the tongue are accidental, and due to contact with substances which stain, dye, or cauterize. The almost constantly brown discoloration of the tongue in tobacco chewers, and the bluish-black stain in those taking iron, are familiar to all. 110 Tongue. Tongue. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. In Addison's disease dark or black colored areas are found near the tip of the tongue. The pigment lies in the deep cells of the epidermis. In jaundice the tongue is yellow. I have observed that the fungiform papillae, which in the white races are pale or red, have naturally a brown, bluish, and; sometimes black color in negroes, Indians, and dark-skinned Cubans. Kigal gives a table showing that black discoloration may be produced by ink, iron, mulberries, and some kinds of cherries ; yellow from saffron, laudanum, rhu- barb, nitric and chromic acids ; red from rhatany, quin- quina, acid nitrate of mercury, etc. ; grayish-white from sulphuric, carbolic, and oxalic acids ; white or pearl-gray from nitrate of silver and corrosive sublimate. Aside from these discolorations, there is a now well- recognized condition of the tongue which has received the name nigrities, or black tongue. The discolored area is, in this disease, limited to the middle of the dorsum, as a rule, and the edges are not so black as the middle portion. The area is limited at first, but slowly spreads. Desquamation usually follows. The affection may last weeks, months, or even years. The papillae seem lower than normal, and often are, even when the color makes them appear more prominent. Subjective symptoms are usually wanting. Many cases of black tongue are un- doubtedly accidentally or intentionally made black by iron, ink, or dyes. Butlin16 is inclined to believe the affection of parasitic origin. It has been observed under widely varying conditions, by men in different parts of the world who were not acquainted with the literature of the subject. The blackness is marked and persistent, and invariably spreads from a small beginning. Stocker reports a case {Med. and Surg. Reporter, October 30, 1886), which lasted two months ; the color toning down from black to brown, and from the centre to the sides. The appearances agreed with the description given by Raynaud of its resemblance to " a field of corn laid down by wind and rain." Raynaud thought the disease parasitic, but in an ex- haustive review of the subject, by Brosin, in a supple- ment to the Monatshefte f. prakt. Derm., No. 7, 1888, it is shown that it is not so. The author reviews the work of twenty-three observers who have reported about forty undoubted cases since 1835. The changes which occur in abnormally long papillae are found to be secondary, and the result of the age of the epithelial cells. It is a hyperkeratosis like that of leucoplakia, but sharply con- fined to the. filiform papillae, and especially to the horny epithelium. This is found mostly in elderly persons, but has been observed from the age of two to that of seventy- three years, and has been known to last as long as twenty years. Professor Bernhardt reports a case of black tongue in the Monatsheftefur prakt. Denn., No. 8, 1888, in which patches of long black or brown filiform papillae had existed upon the tongue for thirteen years, in a pa- tient who had had syphilis followed by locomotor ataxia. One narrow and long patch occupied the central portion of the tongue, while there was one on either side of the dorsum posteriorly, and a small patch near the tip. The treatment consists in frequent applications of per- oxide of hydrogen on absorbent cotton. Friction with Hebra's spiritus saponis, followed by mild salicylic ointment, or a five per cent, salicylic solution in ether, with the addition of five per cent, collodion to form a thin coating when painted on the affected areas, has been found the most efficacious by Brosin. Syphilis of the Tongue.-The most common form in which the syphilitic poison manifests itself upon the tongue, is that of the mucous patch. The primary sore may occur upon the tongue, and in the later stages we have the gummy tumor and ulceration, fissures, plaques, and tertiary ulcerations. Men are more prone to suffer relapses than women, probably owing to their greater use of tobacco and alcohol. Mucous patch occurs in secondary syphilis as a more or less oval, grayish-white spot, showing congestion, swell- ing, and abrasion without surrounding inflammation. Any part of the organ may be attacked, but the borders are most often affected. They are usually multiple, though a sin- gle patch may exist as the sole manifestation of syphilis. However, other secondary symptoms are usually present. In situations where their growth is not impeded, they may take on a condyloma-like appearance. In situations where the teeth act as a constant irritant, or where the conditions favor it, an ulcer results which may prove very obstinate to treatment, and result in deep destruc- tion of tongue tissue. Several small white mucous patches may coalesce and form irregular patches which, by ex- tending, may cover a large portion of the dorsum. These lesions are extremely contagious, and one of the greatest sources of danger to the innocent. Patients with patches should be most careful in the use of table utensils, pipes, etc., which others might use after them, and should avoid kissing until the mouth is entirely well. As to treatment, mercury internally will probably have been given before the patches appeared ; if not it should be begun at once. Locally nitrate of silver in the solid stick, lightly applied, will in most cases soon cause them to disappear. If this does not act well, from a ten to a fifty per cent, chromic acid solution will almost always bring about a rapid cure. Chancre of the tongue is occasionally observed, occur- ring most commonly at or near the tip. It may run its course before a diagnosis is made. Hutchinson has ob- served the primary lesion thus located three times. The lesion usually ulcerates. Tubercules or nodes of tertiary syphilis have been ob- served as firm small tumors imbedded in the substance of the organ, sometimes quite numerous enough to cause deformity. Their evolution is slow, and they may be resorbed or ulcerate, The diagnosis is made from the concomitant symptoms of syphilis. Gummata may be found upon the surface or within the substance of the tongue. They are rather late mani- festations. Nodules the size of a pea or smaller occur upon the posterior part of the dorsum, and might escape notice if unirritated. When single and laterally situated, beginning cancer is simulated. Those located within the parenchyma are not so easy of diagnosis. They may reach the size of a large hickory-nut and are not very sensitive. For some reason, probably the same as that suggested in the case of the mucous patch, they occur most often in men. Ulcers usually result. (They are treated of under the appropriate heading.) The diagnosis from carcinoma is the most important, though gummata have been mistaken for various tumors to be considered later. Carcinoma is, however, single and situated at the border, while gummy tumor is apt to be multiple and more centrally located. Chronic abscess of the tongue is more clearly defined than the gumma. Under large doses of the iodide of potassium gummy tumors rapidly melt away, and at times this treatment must be resorted to, in order to establish the diagnosis. Ulcerations of the tongue in syphilis may be due to the primary sore or to the general infection of the con- stitution. We have already spoken of the ulcerating chancre. In the secondary stage we have ulcers due to the breaking down of mucous tubercles, and others appar- ently caused by attrition of the edges of the organ against sharp, broken, decayed, or irregular teeth; and in some cases where the teeth are found to be perfect, patients complain that sores come after each course of mercury and disappear as soon as the drug is withheld. In broken-down subjects, as a rule, we find severer forms of ulcer with sharp cut or undermined edges, unhealthy base, foul smelling, deeply excavated, and with a tendency to spread. Fissured ulcers at the tips and edges, without surrounding inflammation, but occa- sionally surrounded by a white plaque, are encountered, giving the appearance of nitrate of silver lightly ap- plied. I saw recently a syphilitic young man with a number of such fissured ulcers with the white border, but without surrounding inflammation or tenderness. Tertiary ulcerations are much more severe than the secondary. Here we have deep, sloughing ulcers from broken-down gummata. These lesions leave loss of tis- sue, and at times are extensive in their destruction, often 111 Tongue. Tongue. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. appearing as deep fissures until the sides are separated. There is apt to be salivation, and chewing is rendered difficult. The edges of the ulcer are usually uneven and the surrounding tissues hard. In form the ulcer is irregular as a rule, but the uneven and ragged edges be- come smooth later on, and granulations spring up. The diagnosis is not always easy in large gummy ul- cer, but the fissured forms are almost invariably syphi- litic when at all extensive. These forms usually attack the dorsum, often far back. The lymphatic glands are said not to be affected in these gummy ulcerations. The treatment must be largely constitutional, and iodide of potassium in moderately large doses, alone or combined with some mercurial, is advised. Any local soothing, astringent, or disinfecting wash may be used, whichever seems to give relief. Strong nitrate of silver solution will at times stimulate granulation. Tertiary Plaques-Sclerosing Glossitis.-Fournier has described the condition as producing cellular hyperpla- sia which becomes organized and condensed, and pro- duces sclerosis. The disease is very chronic and leaves white patches behind. Butlin has described several cases. The sclerosed patch is apt to ulcerate if left un- treated. In the later stages, when the plaque has con- tracted and left deep furrows and fissures, its syphilitic nature is manifest. Treatment may have to be resorted to in the early stages to distinguish this from other simi- lar conditions, as it readily improves under the iodide of potassium. Tumors.-Under this designation we have important diseases to describe-some of which are benign and others malignant. Among benign growths which affect the tongue are angeioma, cystoma, enchondroma, fib- roma, lipoma, nodes, papilloma, etc. (gummata have been considered in the section on syphilis). Of those of a malignant nature, carcinoma is the most important. Angeioma.-Vascular or erectile tumors are not at all frequent upon the tongue. When present the dorsum or sides are the parts involved, as a rule near the tip. The tumor is of bluish aspect, has a soft feel to the touch, and the contained blood can be pressed out of the vessels. I have recently had a patient with a blue- colored venous naevus on the forward portion of the dorsum. It was congenital and gave no trouble. If troublesome, electrolysis or galvano-cautery may be tried or excision practised. Adenoma.-Glandular tumors have been very rarely described. They grow mostly on the back of the tongue and either are imbedded in the tongue structures or are polypoid. Attention has been called of late to adenoid or fungous growths at the base of the tongue, which in some instances are of such dimensions as to receive the name " tonsil of the tongue." Curtis, of this city, and more recently Gleitzmann, have described such growths, which assume considerable importance from the fact of their acting as factors in throat symptoms. Fibromata or fibrous tumors of the tongue are more common, and have their seat of predilection upon the dor- sum, and mostly upon the posterior half. Their form is oblong, their consistence firm, and because of their situa- tion and painless nature, they occasion little inconvenience until they have attained the size of an almond, perhaps. Although usually attached by a broad base, they may at times be pedunculated, and this form may, if the tumor grow to any considerable size, cause much inconven- ience and even danger. The flat variety may be excised, the tongue being drawn well forward by an assistant, and the wound closed by deep sutures. A double ligat- ure may be passed through the base of the peduncu- lated tumors and each ligature tied separately. Barling has seen a case of congenital fibroma in an in- fant of eighteen months. It was removed by cutting. Enchondroma presents the most rarely encountered form of new-growth in the tongue, a few cases only hav- ing been reported. Osteoma. Bony tumor has probably never been ob- served, but particles of bone may exist as a rarity iu fatty, fibrous, and other growths. Keloid of the tongue in association with keloid of the skin lias been seen by Sedgwick, and keloidal scars of the tongue following injury have been noted and re- moved by operation. Nodes may be due to syphilis, tuberculosis, etc., as we have seen, but may also be caused by the irritation of a tooth, when the name " dental node " is applied. Ulcer- ation soon takes place. Papilloma, or warty tumor of the tongue, is quite com- mon because of the papillary character of this organ, and the simpler forms of tumors consist in hypertrophy of the natural papillse. Larger growths may become more dense and horny. I have recently removed from the side of a patient's tongue a warty growth almost identi- cal in appearance with the pointed condylomata found about the genitals. I make it a rule to cut out all such warty growths as soon as possible, for they often prove the starting point of epithelioma. Hypertrophy of the papillae producing a sort of tuft has been observed as a congenital condition. I have seen hypertrophy of single fungiform papillae. It is of the utmost importance that an epithelioma should not be mistaken for a benign papilloma or warty growth. As we have seen, howrever, these tumors may take on carcinomatous change, and the dividing line is often difficult. Condylomata as well as papillomata are found in sy- philis ; the distinction between the two being that the former are more flattened and, besides the hypertrophy of papillae, there is a tumefaction of the intervening tissue making a more firm or solid as well as a more flattened tumor. Cystoma is likewise rare. Cysts may be single'or mul- tiple. They are usually rounded, semi-transparent, and about the size of a small filbert, projecting from the sur- face or more deeply situated. Treatment is in most cases best carried out by excision if too much tissue will not be destroyed. Incision of the sac and the application of caustics to destroy it, is also a means of cure. Dermoid, hydatid, blood, and cysticercus cellulose cysts have been occasion- ally recorded, and the guinea worm and trichina spiralis have been found in one instance each. Sublingual cyst or ranula is now generally considered as due to dilatation of the ducts of the sublingual mucous glands, although at times it is undoubtedly due to obstruc- tion or dilatation of the sublingual or submaxillary gland duct. It is sometimes congenital. The size may vary from that of a filbert to that of a wTalnut. The color is bluish or gray. The contents clear or flocculent. They may be treated by excision, by seton, or by injection. Partial excision is probably the best method. Lipoma.-Fatty tumors are among the great rarities in tongue diseases. Sir Astley Cooper has presented a specimen of this affection to the Museum of the College of Surgeons in London. When they occur, the border of the forepart is the region chosen as a rule. The surface over the tumor loses its papillae. The growth is of slow increase and almost never ulcerates. Lobulation and fluctuation are usually present. When they cause annoy- ance they can be readily removed. Carcinoma is the most important of the new-growths of the tongue. It is indeed the most formidable and fearful disease with which we have to deal. In no other affection are an early diagnosis and early operation so necessary to prevent a speedily fatal ending. Death within a year is the almost inevitable fate of those who do not receive the benefit of early and thorough removal. Cancer of the tongue is almost invariably of the form of squamous celled epithelioma. Primary sarcoma has how- ever been observed in a child by Jacobi, and a few other cases in association with tumors elsewhere have been re- ported. I know of no reason why we may not have lesions of the tongue in multiple sarcomata. The borders of the tongue and the anterior portion are mostly affected in carcinoma, though in my own experience many cancers occur quite far back. For a consideration of the etiology and pathology of lingual cancer I must refer to the article on Carcinoma. The young escape cancer here as they do in other portions 112 REFERENCE HANDBOOK OF TIIE MEDICAL SCIENCES. Tongue. Tongue. of the body. It begins as a hard nodule, unyielding and possibly ragged, or as a fissure attended with induration. It is much more frequent in men than in women, possibly because the conditions which predispose to it are more frequently met with in men. Some of these predisposing conditions are the existence of leucoplakia, syphilis of the mouth (more common in men), and the effects of to- bacco and spirits. Warty growths, fissures, ulcers, and spots irritated by the rubbing and pressure of carious or ragged teeth, predispose in the one sex as in the other to cancerous development in middle life, and should receive early attention. Unless smoking cause some such lesion as described under "smokers' tongue" or leucoma, it is not now considered to predispose in itself to cancer. The same may be said of tobacco chewing. Besides begin- ning as a hard lump, as indicated above, cancer may de- velop in a lesion which for a time has been considered, and which probably has in reality been, a benign lesion, such as an excoriation or simple ulcer or fissure. The first indication that carcinoma is developing or has de- veloped wrill probably be induration, and subsequent enlargement, of a gland in the neck or beneath the jaw. When the beginning is as a nodular growth, puckering of the mucous membrane about its base is noticed ami ulceration soon takes place, or the lesion remains as an indurated mass which slowly increases in size, the in- crease extending tow'ard the base and the median line, but not extending beyond it. When ulceration does take place the edges are ragged, elevated, and hard. The progress is then more rapid, lancinating pain is felt, the movements of the tongue and articulation are interfered with, and the central portion may slough out, the fetor becoming extreme. A deep cavity is left in the mass and the edges may become nodular while the surrounding tissues are infiltrated and dense. Just this condition which I have described had taken place in a case which I saw last summer. The growth had been once removed but had returned, and produced rapid destruction. A secondary operation w'as performed in the Presbyterian Hospital, but the patient died. This case illustrated the two main points that the first operation must be done early and thoroughly, and that the disease almost always returns, and is sure to do so if the glands and other structures have become involved. If they are not yet implicated, partial or complete removal of the organ is the proper treatment as offering a period of temporary re- lief and prolongation of life. The diagnosis between syphilitic lesions, benign warty growths, ulcers, etc., is at times difficult. In doubtful cases microscopic scrapings may show altered epithelial cells in sufficient abundance to make a diagnosis of car- cinoma probable. Prophylaxis offers the best, if not the only, chance of escape. Removal of warty growths is at all events proper, as thus carcinoma may be prevented from developing. The same may be said of the ulcer which will not heal, as it appears in some cases that inoculation by carcinoma occurs in such sores which have existed for some time. It is eminently proper to excise tuberculous ulcers, and Butlin says, " If the same decisive method were adopted in the case of all doubtful ulcers of the tongue, there would be a striking diminution in the number of deaths from lingual carcinoma." The pre-cancerous condition is the one requiring treatment. The treatment of lingual carcinoma consists in excision when the growth is situated anteriorly ; the ligature when haemorrhage is feared ; the use of the ecraseur or cautery. For description of operations see article on Surgery of the Tongue. The mortality from the immediate effects of the opera- tion of removal of the tongue is not high, still the ultimate results are not brilliant. Butlin thinks ten lives may be saved in a hundred operations. Bibliography. Saison : Diagnostic des manifestations de la syphilis sur la langue. These de Paris, 1871. Ingals, Fletcher: Arch, of Laryngology, vol. ii. Raynaud: Discolorations, Gaz. Hebd., April 2, 1869. Rigal: Diet, de Med. et de Chir. Prat., 1875. Agnew's Surgery, vol. ii., 1881. Duckworth: Hemiglossitis, Liverpool Med. Chir. Journ., July, 1883. Fournier: Glossites Tertiaires, 1877. Nedopil: Tuberculous Ulcer, Langenbeck's Archiv, vol. xx., p. 365, 1887. Bosworth : Tuberculous Ulcer, Archiv. of Laryng., vol. ii., p. 329. Browne and Grant: Tuberculous Ulcer, Archiv. of Laryng., vol. ii., p. 7. Schwimmer: Leucoma, Viertelj. f. Derm. u. Syph., p. 511, 1877. Weir: Leucoma, New York Medical Journal, p. 240, 1875. Unna : Bingworm, Viertelj. f. Derm. u. Syph., p. 295. 1881. Caspary: Ringworm, Viertelj. f. Derm. u. Syph., p. 183, 1880. Fox : Ringworm, Lancet, p. 842, 1884. Hutchinson: Lichen, Lectures on Clinical Surg., vol. i. Hutchinson: Syphilis, pp. 30, 373, 521. Butlin: St. Bartholomew's Hospital Reports, vol. xv., p. 37, 1879. Regnoli: Operation, Bui. d. Scien. Med. di Bologna, August, 1838. Saint-Germain: Nigrite de la langue. Compt. rend, de l'Acad. des Sciences, March 28, 1855. Gallois: Coloration noire de la langue. Gaz. Med. de Paris, No. 14, 1870. Dessois : These de Paris, 1878. Clarke, Fairlie: Diseases of the Tongue, 1873. Brosin : Uber die Schwarze Haarzunge. Hamburg, 1888. Schlapfer : Extirpation der Zunge. Zurich, 1878. Jacobi: Sarcoma. Am. Journ. of Obst., vol. ii., 1870. Sedgwick: Keloid, Path. Trans., vol. xii., 1861. Cohen, Solis: Adenoma, Arch, of Laryng., vol. i., p. 274. Malou : Des Lipomes de la langue. These de Paris, 1881. Mackenzie: Calculus and Ranula, Practitioner, vol. ii., 1881. Barker: Dermoid Cyst, Trans. Clin. Soc., vol. xvi., 1883. Parrot: Macroglossia, Gaz. des Hopit., 1881. Clarke: Lupus. Trans, of Path. Soc. of London, vol. xxvii. Heath : Brit. Med. Journal, April 21, 1888. McBride: Adenoid Tissue at Base of Tongue. Edinburgh Med. Journal, p. 211. 1887. Charles W. Allen. 1 Hist, de l'Acad. R. des Scien., 1718. 2 Comptes Rendas de FHopital de la Charite, Berlin, 1883. 3 Archives de Neurologie, vol. vii., 1884. 4 American Journal of the Medical Sciences, January, 1885. 5 La Semaine M6dicale, 1887. 6 Giornale Italiano delle Malat. Vener. e della Pelle, Fasc. 5, an. viii. 7 Journ. of Cutaneous Medicine, etc., July, 1869. 8 Anzeiger der K. K. Gesells. der Aerzte in Wien, 1881. 9 Berlin, klin. Wochenschr., No. 23, 1886. 10 St. Petersburger Med. Wochens., No. 44, 1881. 11 Monatshefte fur praktische Dermat., November. 1882. 12 fltudc sur la Dermatite (These de doctorat, Paris, 1882). 13 Journ. of Cutaneous and Genito-Urinary Diseases, February. 1887. 14 Vierteljahr. f. Derm, und Syph., viii., 1881. 18 La France Medicale, December 10, 1885. 16 Diseases of the Tongue, London and New York, 1885. TONGUE, SURGERY OF THE, Injuries of the Tongue.-Burns and Scalds.-The tongue is not uncom- monly the subject of injury from burns and scalds. Slight burns or scalds are of but little consequence, the superficial portion of the covering of the tongue only being destroyed ; in a few hours, or at most a day or two, the tenderness disappears without treatment. To relieve the pain applications of sweet oil, borax and honey, bi- carbonate of soda, or astringent lotions, are useful. The most severe burns are those caused by chemical agents, such as mineral acids, caustic alkalies, corrosive sublim- ate. When these substances have been accidentally or in- tentionally swallowed, the tongue is not the only part that suffers, for the whole of the interior of the mouth, the fauces, and the throat are also affected. It is often possible to recognize the poison taken by the appearance of the tongue. In poisoning by corrosive sublimate the tongue is white and shrivelled. Carbolic acid renders the mucous membrane white and hard. Vegetable poi- sons, as a rule, produce no alteration in the appearance of the tongue in cases of acute poisoning (Butlin). Scalds of the tongue are not uncommon in young chil- dren, and are often produced by sucking the spout of a tea-kettle. This accident is more common in England than in this country. The injury to the tongue in such cases is of small importance compared with the grave complications which arise from injury to the larynx and air-passages. The tongue swells, becomes red, and is soon covered with blisters ; it is of course tender and painful, and food in any form is difficult to take. This difficulty, however, soon subsides, and is of little mo- ment compared with the grievous results which follow injury to the air-passages. Effects of Cold.-In winter, in this country, one occa- sionally sees an injury to the tongue in children pro- duced by cold, and which, although it is not dangerous, is sufficiently painful. It is generally caused by the child 113 Tongue. Tongue. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. licking with the tongue iron or other metal at a low tem- perature. In such cases the tongue adheres to the metal and the child, pulling the tongue quickly away, leaves behind a considerable portion of the mucous membrane. The writer has frequently seen this accident happen to children playing out of doors when the thermometer registers a temperature considerably below the freezing point. On one occasion several children were induced by a mischief-loving companion to place their tongue on an old iron pot, the result being that each one was de- prived of a large amount of the covering of the tongue and suffered considerably, especially during meals, for several days after. The treatment of such cases is the same, of course, as that of burns. Stings of Insects.-In England it is not uncommon for insects, such as wasps and bees, to be taken into the mouth, concealed in fruit, and serious inflammation has resulted from their stings. In such cases Fairlie Clark 1 recommends that the mouth be frequently washed with an alkaline solution to neutralize the formic acid. A weak solution of ammonia is very efficacious. Wounds.-Usually wounds of the tongue are not seri- ous, but Bryant,2 of London, mentions a case where death followed wound of the tongue, in a small child, from trickling of blood down the larynx, the child dy- ing asphyxiated. Wickham Legg3 relates cases of death following bites of the tongue in persons the subjects of haemophilia. Wounds of the tongue may be produced in various ways, but most commonly the wound is caused by the teeth. Epileptics not infrequently bite the tongue sev- erely during a fit. The tongue may be severely wounded by a fall on the chin, or a violent blow on the jaw when the tongue is protruded. The protruded portion of the tongue may be completely bitten off, or one side only be injured. Injuries to the tongue may be caused by den- tists' forceps while the patient is under the influence of an anaesthetic. The haemorrhage resulting from injury to the tongue is seldom dangerous, and is usually easily controlled by ice or exposure to air. Should the haemorrhage be pro- fuse, its source should be sought for and the bleeding vessel, usually the ranine artery, tied. Oozing from the wound is generally arrested by bringing the edges of the wound together with sutures. In certain cases where the wound is far back, it may be necessary to pass a ligature through the tip of the tongue, draw it out and examine the wound thoroughly ; if it be small, then it should be enlarged and the bleeding vessel secured. In some cases it may be necessary to use the cautery to arrest the haemorrhage; its use, however, interferes with pri- mary union. Sutures are not necessary if the wound be small, but if it be large and a portion of the tongue is hanging loose, then the edges of the wound should be carefully brought together with deeply placed silk or cat- gut sutures. A case is related by Mr. Gant where the tongue was severed by an incised wound extending nearly through the substance of the organ, and dividing the lin- gual and hypoglossal nerves on both sides. The detached portion, which hung by a mere shred on the left side, was replaced promptly and secured, complete union took place, and the tongue slowly recovered power of motion and the sense of taste. The after-treatment of wounds of the tongue is similar to that of other wounds of the mouth. The mouth should be washed out frequently with weak Condy's fluid, or a paint of iodoform and al- cohol may be used. Wounds of the tongue may be caused by foreign bodies, such as the stem of a tobacco-pipe, crochet nee- dles, splinters of wood, etc. Foreign bodies are occasion- ally driven into the tongue in cases of gunshot wounds ; these consist of teeth, portions of the jaw, etc. Foreign bodies have been found embedded in the tongue months and years after the accident. A case is related of a soldier who was shot in the face at the battle of Gross Goerschen, in 1813 ; the bullet passed through the cheek and tongue, carrying away some of the molar teeth ; the wound in the tongue quickly healed ; in 1845, thirty- two years after, the tongue became swollen and dis- charged the second molar tooth which had been carried into it by the bullet in 1813.4 Manget relates the case of a patient in whose tongue a ball had been lodged for six years. During this time the man stammered excessive- ly, but when the ball was extracted, the stammering ceased.5 When a wound of the tongue does not readily heal, or when there is secondary haemorrhage, then a foreign body may be suspected ; or again, if a sinus exists and an in- dolent swelling remains, it is very probable that a for- eign body is present. When the foreign body is re- moved, the wound usually heals up. According to But- lin,6 the removal of the foreign body does not always bring about such a happy result; in more than one case this procedure has been followed by haemorrhage which has caused death. A case is related of a sailor, aged thirty, who was keeping watch on deck, and at the same time smoking ; he either fell or struck against some object by which the pipe in his mouth was driven into his tongue and broken. There was at first but little apparent injury and only slight haemorrhage, but subsequently the tongue began to swell, and on the fourth day he was taken to the London Hospital. His mouth was closed, and he had swallowed little or nothing since the accident. There was swelling at the upper and back parts of the neck ; the tongue was enormously enlarged and fluctuating. An incision was made, and an ounce of purulent fluid, mixed with blood, escaped. This gave some relief, but the symptoms soon returned with greater intensity than before. A probe was then passed into the tongue by the opening made with the lancet, and something hard was felt in the deep substance of the organ. This was grasped with forceps and ex- tracted ; it proved to be a piece of pipe stem four inches long. Immediately after its removal a frightful torrent of blood gushed from the mouth and nostrils, and the man was dead in little more than a minute. At the autopsy it was found that the pipe stem had entered the right side of the tongue near the tip, passed just below the left ton- sil, and completely transfixed the left carotid artery and internal jugular vein.' Tongue-Tie, or shortness of the fraenum linguae. The tongue is bound down and cannot be protruded beyond the incisors. This is a congenital defect which is not un- common, and when it exists to a high degree it prevents the child from suckling, and later may interfere with ar- ticulation. In such cases it is necessary to divide the tightened band ; this should be done with a pair of scis- sors with blunt points. The points should be directed to the floor of the mouth to avoid wounding the ranine ar- teries. Cases are on record of fatal haemorrhage occur- ring from accidentally cutting these vessels. In dividing the fraenum only a small cut is necessary, and then the rest may be torn through with the fingers. This even is generally unnecessary, for the child, in crying, still further frees the tongue. Petit8 draws attention to an- other danger of cutting too freely. He relates three cases in which vigorous sucking in strong and hungry children tore the wound in these tissues still further open, so that the tongue, losing its anterior attachment, turned back and was embraced by the muscles of deglu- tition, and pressed the epiglottis firmly over the larynx until suffocation was produced. Two of the cases died before help could be afforded. The fraenum may be congenitally too long, and cases of death from suffocation have been recorded owing to this condition, the patient swallowing the tongue. A number of cases are reported where by constant practice the patient has acquired the habit of tongue-swallowing. Macro-Glossia.-This is a congenital hypertrophy of the tongue analogous to elephantiasis. It is of slow growth, and as it enlarges causes great trouble, the mere size in- terfering with deglutition and speech. The tongue may protrude over the chin and reach even as far as the ster- num. The subjects of this affection frequently suffer from epilepsy. The great enlargement causes deformity of the teeth and jaws, especially the lower. The teeth frequently become carious and fall out, and the lower jaw has been known to have been dislocated by the 114 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tongue. Ton g tie. pressure.9 There is constant dribbling of saliva, and the protruded tongue is much altered in appearance, in- durated, swollen, and purplish in color; later, nodes, irregularities, and fissures appear on its surface, and oc- casionally the tongue ulcerates. On puncturing it there is not much bleeding, but there is oozing of large quanti- ties of serum. The disease is not, as a rule, noticed for the first two years, as sucking appears to stop the growth of the organ by continuous pressure. The pathology of this disease was first elucidated by Virchow ; he found that there was an overgrowth of interstitial connective tissue, with a remarkable infiltration of the whole organ with white cells collected here and there in a delicate net- work, and forming true lymphoid tissue. The disease, no doubt, is due to congenital defect aggravated by fre- quent attacks of glossitis. Treatment consists in removal of the protruded portion of tongue. In some cases the removal of a V-shaped portion will give the best results. Strapping with plas- ter has occasionally been successful, but excision is the best method of treatment. Quite recently 10 a German surgeon has reported a case in which great improvement occurred in a child aged thirteen months, treated by Pirogoff's method, viz., ligature of the lingual arteries. This is an old method of treatment which years ago was tried and found wanting.11 Ligature of the portion of tongue protruded has been successfully practised, but nothing is so safe or simple as excision with knife, gal- vano-cautery, or ecraseur. The haemorrhage usually is not great, and the result is almost invariably satisfactory. When bleeding is feared in young children, the removal by ecraseur should be preferred, but in adults the knife or scissors is better, as their use is not followed by slough- ing. The tongue should be drawn forward by means of ligatures passed through its substance behind the line of incision, and the incision should be made in such a man- ner that the tongue will be left somewhat pointed ; the bleeding vessels should be tied as cut. The after-treat- ment is the same as that used for partial removal of the tongue for any other cause. Glossitis.-Acute (parenchymatous) inflammation of the tongue is a somewhat rare affection. It is much more common in adults than in children, and more fre- quently attacks males than females. Glossitis was for- merly a much more common affection than at present, being produced by the incautious and excessive use of mercury. It sometimes follows specific fevers, or may be due to injury, cold, septic conditions of the mouth, bites of insects, etc. These, however, are special forms ; ordinary spontaneous glossitis is said to be caused by cold and damp, and is looked upon by some (Butlin, De Mussy, Duckwood and others) as a catarrhal affection. Weber12 describes an epidemic glossitis seen in wet, cold seasons. It attacks more readily individuals in a low condition of health, habitual drunkards, etc. Excessive smoking or a bout of drinking may be the exciting cause. At the onset of the affection the patient complains of tenderness of the tongue while masticating solid food. The organ begins to swell rapidly, and within twenty- four hours it is twice its natural size and protrudes from the mouth. Within the mouth the tongue is livid and shiny, but the part protruded is dry, cracked, and brown. Pressure of the teeth causes its edges to become indented, articulation is impossible, and difficulty of swallowing is always present. Frequently there is dysp- noea. There is also a profuse secretion of saliva, which continually dribbles away from the mouth. The ter- mination of the disease is usually by resolution, in four to five days ; there may be small superficial sloughs on the surface which leave ulcers ; these, however, heal rapidly. Occasionally the inflammation is so acute that gangrene supervenes. One of the rare terminations of this affection is suppuration. Sometimes life is threat- ened by suffocation, and it may be necessary to perform tracheotomy. Constitutional symptoms, as fever, etc., are always present. Treatment.-The majority of cases get well in five or six days, without treatment. A saline purge, a chlorate of potash wash, and the sucking of small pieces of ice, is the proper treatment in the milder cases ; but when the symptoms are urgent and the distress great, surgical in- terference becomes necessary. A deep and long incision should be made in each side of the raphe near the root of the tongue, and free bleeding should be encouraged. The bleeding is rarely severe, and the relief following free incision is immediate, the tongue in a few hours re- suming its natural size. After incision, suppuration is much less likely to occur. In only one case has the writer found it necessary to incise the tongue for acute glossitis ; all the others yielded to ice, chlorate of potash wash (10-15 grs.-§ j.) and saline purgatives. Hemi-Glossitis.-This is a much rarer affection than the preceding. It usually occurs on the left side, though in the only case seen by the writer the right side was the one affected. Hemi-glossitis is a much less severe affec- tion than glossitis, there is not so much difficulty on deg- lutition, and there is never any dyspnoea. The disease is generally ushered in with febrile symptoms and runs a rapid course, ending in resolution. The treatment is simple : ice, chlorate of potash lotion, and a saline purge. Mercurial Glossitis.-At one time this was a very com- mon affection, though now it is rarely seen. The tongue swells considerably, but not to the same extent as in spontaneous glossitis ; the sides and tip of the tongue are much indented by the teeth, and are extremely tender, and its surface is thickly coated. Sloughing followed by foul ulceration is common ; the gums are tender and swollen, and bleed easily. The affection rapidly subsides on removing the cause, viz., the administration of mer- cury. Death has followed mercurial glossitis.13 Treat- ment by chlorate of potash washes, tonics, and a saline purge is usually sufficient. Abscess of the Tongue.-This may be the result of acute inflammation of the tongue; in such cases it is deeply seated, and has been mistaken for cancer, the tongue be- ing removed on account of it. The more chronic forms of abscess are usually small and deep-seated. The swell- ing is firm and elastic, and there is no superficial discol- oration, so that, as in similar cases in the breast, it may readily be mistaken for a cyst. The abscess is generally situated toward the anterior portion of the tongue, near the edge, and is usually very chronic. An exploratory puncture quickly clears up the diagnosis, and treatment by longitudinal incision rapidly brings the case to a fav- orable conclusion. Tumors of the Tongue.-Vascular Tumors.-Naevi are occasionally found in the tongue ; if superficial, they may be treated by nitric acid or by puncture with thermo- cautery needles. When the growth is prominent and can be isolated, it may be excised with scissors or treated by ligature. When treating a naevus growth by excision, the healthy tissue should be cut all around, the haemor- rhage then being inconsiderable. If there be much dan- ger of haemorrhage, the thermo-cautery knife may be used. When the growth is large and more diffuse, ex- cision by means of the wire ecraseur is a valuable method of treatment; the ecraseur should cut through healthy tissue. Ligature is seldom necessary in such cases, but when used should be passed deeply into the substance of the tongue and tied very tightly. Sir Joseph Fayrer has described14 an affection called Cirsoid Aneurism of the lingual vessels. It simulated ranula. Cystic Tumors of the tongue are not uncommon. They may be due to dilatation of the mucous follicles, and contain a gelatinous mucus. Sebaceous Cysts occur in the tongue but very rarely ; they should be treated by excision. Fatty Tumors are sometimes met with, and are usually of small size and easily removed. Enchondromata have been described by Weber.16 Sarcomata of the tongue are almost unknown as prim- ary growths. Keloid has been noticed by Sedgwick.16 Fibro-cellular Tumors of the tongue have been des- cribed by Mason,11 Clarke,18 and others. They occui- mostly in adults and may be congenital; these tumors 115 Tongue. Tongue. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. are situated on the dorsum of the tongue and are quite painless and innocent. Treatment should be by exci- sion. Papillomata or Warty Tumors occur on the dorsum of the tongue, and consist merely of hypertrophied papillae. Butlin 19 describes a case in which there was warty en- largement of all the fungiform, papillae. The diagnosis is easy when the affection occurs in early life, but when it exists in old people it is sometimes difficult to diagnose from epithelioma. Treatment.-Removal by scissors is the simplest and best mode of treatment when the growths are small; when large, ligature is more satisfactory. If there be any induration at the base or the slightest suspicion of the growth being malignant, then, to insure complete re- moval, the healthy tissue around should be excised as well as the growth. Butlin20 states ' ' that the treatment of the larger and doubtful warts, in persons over forty years of age, by caustics and other similar measures, cannot be too strongly deprecated." The writer has frequently seen commencing epitheliomas in middle-aged persons treated for several months by caustics, under the suppo- sition that the case was one of warty growth ; such treat- ment increases the rapidity of the growth if cancerous, and lessens the chance of a cutting operation being suc- cessful. Ulceration of the Tongue.-Ulceration of the tongue may be simple, syphilitic, tubercular, cancerous, or mer- curial. Simple Ulcers may be due to irritation from a sharp tooth or to traumatism of any kind. We may have a sim- ple ulcer as the result of long-standing superficial glos- sitis. Dyspeptic ulcers of a superficial character are not infrequently met with, also aphthous ulcers. These are more common in children than adults, and general treat- ment by salines is often of great benefit, combined with astringent lotions of alum or tannin. Borax and chlorate of potash washes are also useful. In treating simple ul- cers the removal of the cause is generally sufficient to cure the disease. If the ulcer does not heal readily, But- lin 21 recommends the frequent painting of the surface of the sore with a solution of chromic acid (gr. x. to § j. of water), or with a lotion of borax ( 3 ss.), glycerine (lf[xx.), and water (§ j.). Burning these ulcers with nitrate of silver, especially in the old, is not to be recommended, as the irritation caused may induce a cancerous condition in those predisposed. Should the ulcer not heal rapidly under simple treatment in a man over forty years, then cancer is to be suspected, and the ulcer should be cut out. A simple operation of this kind may save the pa- tient much future trouble. Tuberculous Ulcers usually occur on the tip of the tongue. When extensive, they are difficult to diagnose from cancer. The ulcer is irregular, with sharp cut edges or pale flabby granulations at the base. There is very little induration of the surrounding tissue. The ulcer in its advanced stages may eat deeply into the tongue. It is generally acutely painful, so much so that the lingual nerve has been divided to ease the sufferings of the patient. In the late stages there is considerable salivation. A tuberculous ulcer of the tongue may be the primary manifestation of tubercle, or may occur sec- ondarily. Primary ulcers are rare, secondary more com- mon. The writer has seen several cases which were secondary to ulceration in the larynx and tuberculous disease of the lung. When the ulcer is primary the di- agnosis is difficult. From syphilitic ulcer it may be dis- tinguished by the history; syphilitic ulcers are usually on the central part of the tongue, and if due to gummata are preceded by local swelling. With tertiary ulcers the glands are never affected, with tuberculous ulcers they are frequently enlarged. A tuberculous family history and the existence of tubercle bacilli will help one to a correct diagnosis. The diagnosis between carcinoma and tubercle is more difficult still, for in both affections the lymphatic glands are involved. The age of the patient and the existence of extensive induration would point to cancer. Cancer does not usually occur under the age of thirty. A diffi- cult case presented itself to the writer quite recently : a young girl aged twenty-two, with a decidedly tubercu- lous family history, had extensive ulceration of the right side of the tongue with slight induration, and involve- ment of the lymphatic glands of that side ; the ulcer was painful to the touch and there was considerable saliva- tion. A portion was excised and presented under the microscope the typical characters of epithelioma ; no ba- cilli were found in this case. The patient declined op- erative interference. The prognosis of tuberculous ulcer is quite as unfav- able as cancer, and the patient succumbs to the disease in from a few months to two years. Treatment.-An endeavor should be made to relieve the pain by soothing lotions, etc. Papaitine often relieves pain, and according to some is curative, but this the writer cannot endorse. Scraping with a sharp spoon and then painting with tincture of iodine has been advised. Butlin22 strongly recommends excision when possible, even if the ulcer be secondary, as both a painful disease and a focus of further infection is removed. Great relief has followed the application of the following: finely powdered iodoform, one grain, morphine, one-sixth of a' grain, borax, three grains. The surface of the ulcer should be cleansed and dried before application, and the powder should be applied three or four times a day. Should the pain be very intense and confined to one side, division of the lingual nerve must be thought of. Gen- eral treatment by cod-liver oil and tonics should not be omitted. Syphilitic Ulceration commonly occurs during the sec- ondary stage, along the edges of the tongue. The ulcer- ation is superficial, and a white patch on the mucous membrane of the cheek, corresponding to the ulcer of the tongue, will nearly always be found. Fissures or cracks which plough up the dorsum of the tongue in every direction are peculiar to syphilis ; these are usually the re- sult of tertiary syphilitic ulceration ; single cracks or fis- sures are sometimes seen in the secondary variety. Su- perficial syphilitic ulcers have no induration at the base. Mucous tubercles may also appear on the tip and borders of the tongue during the secondary stage, but at the same time they exist on the lips, vulvse, and anus ; they are oval or round in shape, grayish in color, and covered with partly macerated epithelium. The deep syphilitic ulcer is caused by the breaking down of a gumma, and is usually situated on the dorsum of the tongue. It has sharp-cut edges which may be undermined, the base is sloughy and ragged, and there is always some induration and swelling of the neighbor- ing parts. Diagnosis.-These cases are difficult to diagnose from cancer ; however, the history of the case and the situa- tion of the ulcer will help one to form an opinion. If syphilitic, such ulcers are preceded by a lump ; in cancer the induration follows the ulcer and does not precede it. There may be two or more gummata on the tongue, but a cancerous ulcer is always single. Cancerous ulcera- tions occur more commonly on the side of the tongue, syphilitic on the dorsum. In tertiary syphilis the glands are rarely enlarged, in cancer which has existed some time the lymphatic glands are always enlarged. Syphil- itic ulceration yields to antisyphilitic treatment. Many cases, however, occur in which the diagnosis is very difficult and can only be settled by the microscope. It must be borne in mind that the primary lesion of syphilis may occur on the tongue, the infection being usually du.e to inoculation from secondary sores. The occurrence of a primary sore on the tongue is rare, and presents the appearance of primary sores in other parts. The submaxillary lymphatic glands are usually enlarged from the first. In the superficial forms of secondary syphilitic ulceration the treatment should be constitu- tional as well as local, viz., mercury internally, in the form of gray powder, with local application of half a grain of bichloride of mercury to one ounce of water. Butlin speaks highly of chromic acid as a local applica- tion (ten grains to one ounce of water), applied three or four times a day. 116 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tongue. Tongue. In the tertiary syphilitic ulcer, iodide of potassium in doses of from ten to twenty grains three times a day, combined with tonics, will effect a rapid cure ; local ap- plications other than those of a soothing character are rarely necessary. Syphilitic ulcers always leave scars ; the puckered and furrowed scar left behind by a deep ul- cer is characteristic. Cancerous Ulceration.-This form of ulceration of the tongue is always of one variety, viz., epithelioma. It generally commences as a small ulcer on the side of the tongue, though no part of the tongue is exempt. The posterior half is, however, much less commonly affected than the anterior half. In eighty cases collected by But- lin,23 cancer affected the sides and borders of the tongue in seventy-one. It occurs more frequently in men than in women; according to Barker,24 in the proportion of 247 to 46. It will be found, on examining the various statistics, that cancer of the tongue occurs more fre- quently between the ages of forty-five and fifty-five. Billroth26 states that it is more common between the ages of fifty and sixty, and such has been the writer's expe- rience. It very rarely occurs in young adults. Barker mentions a case at twenty-six years of age. The writer has seen one case in a woman twenty-two years of age, in which the diagnosis was verified by the microscope. There is no doubt that smoking predisposes to cancer of the tongue, as many cases are preceded by leucoma or the so-called psoriasis of the tongue. This condition may be produced by dram drinking, smoking, and also syphilis. In eighty cases collected by Butlin," sixteen were preceded by leucoma. The psoriasis and scars pro- duced by syphilis, injury, or any other cause, will pre- dispose to cancer ; any irritation such as a sharp tooth, the stem of a tobacco-pipe, a bad-fitting tooth-plate, etc., will in some persons excite ulceration which may take on a cancerous action. The writer saw one case of epithe- lioma of the hard palate in an old man, produced by the irritation of the stem of a clay pipe, which continually rested at that point owing to the toothless condition of the gums. There is no doubt, however, that cancer of the tongue may originate without any pre-existing dis- ease or irritation, but in the majority of cases some form of irritation is the exciting cause of the disease. Many practitioners who are consulted by elderly people for ul- cers of the tongue, are in the habit of cauterizing the sore freely with nitrate of silver or other caustic ; this is a most pernicious custom, and one which, while it does no good, may do infinite harm ; for, should the ulcer be can- cerous, it only aggravates it, and it may excite cancer in an ulcer which is of a simple, non-malignant character, by the continued irritation. Again, it does harm in can- cerous ulcers by putting off operative measures until a period when operation can be of but little use, by sooth- ing the patient with the idea that something is being done for him. Ulceration of the tongue in people over forty years of age should always be regarded with sus- picion, and if there be any doubt as to its nature, the ul- cer and a portion of healthy tissue around it should be -excised. Sir James Paget holds that there is a pre-can- cerous stage of cancer, when the simple inflammatory condition of an ulcer is passing into a cancerous condi- tion ; indeed, the transition from a simple inflammation to a cancerous one is so imperceptible, that no clear line of demarcation between the two conditions can be drawn, either histologically or clinically. When the cancerous ulcer is well developed, or the induration at its base is marked, the diagnosis is not so difficult, but if there be any doubt a portion should be excised, and the microscope will usually establish the character of the ■disease. When the ulcer commences on the border of the tongue it rapidly infiltrates not only the tongue, but the floor of the mouth and gums, and finally the bone of the jaw itself is affected. The tongue becomes fixed and its motion is so limited that it cannot be protruded. Should the disease begin further back, the ulceration or infiltra- tion extends to the pillars of the fauces, soft palate, and tonsils. These cases have proved fatal from haemor- rhage caused by ulceration into the internal carotid or tonsillar arteries. When the disease has advanced thus far the glands in the neighborhood become enlarged. First there is tenderness in the submaxillary region, with pain which shoots up to the ear ; later the glands may be felt small and hard but movable ; as they increase in size they become fixed. In some cases, in the early stages of the disease the glands may be affected, yet the fact may not be recognized by external manipula- tion. As the disease progresses deglutition and speech become difficult, there is profuse salivation, and a horri- ble fetor of the breath. Patients may die from haemor- rhage due to the grow'th ulcerating into some large ves- sel, or there may be frequent haemorrhages from smaller vessels which may hasten the end. The usual mode of death, however, is from exhaustion due to pain, sleep- lessness, starvation, sloughing, etc. The average dura- tion of the disease in patients who have had no operation is a year to eighteen months. Many cases succumb in less than a year, and few live longer than two years. Diagnosis.-In the advanced stages of cancerous dis- ease of the tongue the diagnosis is not difficult; the foul, deeply excavated ulcer with everted ragged edges and widely infiltrated base, with large granulations protrud- ing from it, the pain, fixation of the organ, and the in- duration of the submaxillary glands, stamp the affec- tion unmistakably as carcinoma. At this stage operation is not very hopeful. The diseases with which carcinoma of the tongue are most likely to be confounded are : 1, Syphilitic ulcera- tion, primary and tertiary ; 2, Tuberculous ulcer, and 3, Simple ulcer. The differential points of diagnosis be- tween these diseases and cancer have been sufficiently dwelt on above. The writer would strongly urge that when the diagnosis is doubtful, the disease should be treated as cancer and removed ; for, should the surgeon wait until all doubt is dispelled by the involvement of the glands and the infiltration of the surrounding tissues, then he has committed a grave fault, and one which can- not be repaired. Butlin57 truly says : " Medical men are coming to the belief that, to ' give the patient a chance,' means usually to give the carcinoma a chance of obtain- ing a firm and irresistible hold, and to take all chance of complete recovery from the patient." It is much better to remove a suspicious wart or ulcer by a simple and safe operation, and thus save the patient from the rav- ages of a fatal disease, than to wait until the disease is pronounced, when to operate means not only great dan- ger to the patient, but the certainty of a rapid recurrence of the disease. Prognosis.-Cancer of the tongue, like cancer of other parts, if not operated on, proceeds invariably to a fatal termination. It is of the utmost importance that the dis- ease should be recognized in its early stages, when it is a purely local affection. At this period, if operation by removal of the tongue be undertaken, the chances of the patient remaining free from the disease are greater, and should the disease recur the interval of freedom is much increased. Treatment.-There is but one method of treatment of cancer of the tongue, viz., removal by surgical opera- tion. Operation always relieves, if it does not cure. In Butlin's table of 80 cases already referred to, 70 were op- erated on, and 9 patients were in good health a year after the operation. Heath reports a case well eleven years after operation. Dr. Fenwick, of Montreal, reports a case where the patient lived fifteen years after operation. Bryant,28 of London, mentions a case well ten years after operation, and one where the disease recurred fifteen years after operation. Barker29 found 17 recoveries in 170 cases. According to Billroth's30 statistics, fourteen per cent, of cases are cured after operation. Even such a small percentage of cures is very creditable to surgery, and would in itself more than justify removal; but put- ting aside the cures, the patient's life is prolonged and suffering is diminished by operation. With regard to other methods of treatment by caustics, pastes, etc., they are not only useless but hurtful. It cannot be too strongly insisted on that the treatment of cancerous ulcers by caustics is bad treatment, and that 117 Tongue. Tongue. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the only chance the patient has of a cure is the early removal of the disease by surgical operation. In cases of ulcers, warts, etc., on the tongue of a person over forty years of age, where the diagnosis is doubtful, if any treatment is desired previous to removal, it should be of a soothing, non-irritating character; all irritating substances, as tobacco, spirits, highly spiced foods, etc., should be avoided. If the sore is produced by a sharp tooth it should be extracted. Caustics should be shunned, as nothing is more likely to convert a simple into a can- cerous ulcer than continual irritation by caustics. Operations for Partial and Complete Removal of the Tongue.-Small warts are most easily removed with curved scissors, whether on the border, tip, or dor- sum of the tongue; no anaesthetic is required. Should the growth be of larger size and far back, it is better to anaesthetize the patient and place a gag on the mouth, then the tongue may be drawn out by a strong ligature passed through the tip, or by means of a vulsellum. The growth should be removed with a knife and the bleeding points secured with ligatures or arrested'by the thermo- cautery. Some surgeons advise the use of the galvano- caustic loop, as by this method all fear of haemorrhage is banished and the tissues for a short distance round the base of the growth are destroyed. Removal of a Portion of the Tongue.-Should the cancer of the tongue be confined to the tip, or a small part of the border of the anterior half of the tongue, and should the submaxillary glands not be enlarged-in other words, if the ulcer be early recognized to be cancer-the removal of a portion of the tongue is justifiable and gives a fair chance to the patient, without submitting him to the much more formidable operation of excision of the whole tongue. Partial removal of the tongue may be performed with galvano-ecraseur, wire ecraseur, knife, or scissors. The knife is to be preferred when it is nec- essary to remove only a small part of the tongue. Should the ulcer be on the border of the tongue, then the tongue should be split in the median line and the af- fected half removed with knife, scissors, or ecraseur. In all operations on the tongue of any magnitude the mouth should be kept open with a suitable gag, such as Cole- man's, Whitehead's, Hutchinson's, etc., and the tongue drawn out by a stout ligature passed through its tip, and the disease removed by the method recommended by Mr. Baker. Baker's Method.31-A gag having been introduced, the tongue is drawn out by means of two ligatures placed on each side of the median line of the tongue near the tip. The tongue is then split down the middle and the diseased half is freed from the floor and side of the mouth with scissors. Needles are now passed through the tongue behind the disease, and the loop of the ecra- seur is placed as far back as possible, tightened, and the affected half removed. The loop of the ecraseur should be of wire or whip-cord. The objection to the use of the galvano-cautery is the troublesome slough which fol- lows. Removal of theWhole Tongue.-In cases where the can- cerous ulcer involves the posterior half of the organ or is very extensive, it is necessary to remove the whole tongue. The complete removal of the tongue is the bet- ter operation, even when the ulcer is small, for the chance of recurrence is much less than when only part of the organ is taken away. In removing the tongue one of the chief dangers is from haemorrhage, and before proceeding further it might be as well to mention a very simple and effica- cious method of arresting haemorrhage, occurring either accidentally during operation or afterward. This meth- od was introduced by Mr. Heath, of London, and has been adopted by most surgeons. It is this:32 "The forefinger, passed well down to the epiglottis, is made to hook forward the hyoid bone and drag it up as far as practicable toward the symphysis menti. The effect of this is to stretch the lingual arteries so as to completely control for a time the flow of blood through them, and in this way portions of the anterior part of the tongue may be cutoff almost bloodlessly." In operating on the tongue for cancerous disease, the question arises as to the kind of operation which should be performed. After even the most radical operation the disease is apt to recur ; in fact, the more severe the operation, as a rule, the more rapid the return of the disease. Some surgeons hold that the operation is merely palliative, es- pecially if the glands are enlarged in the submaxillary region and under the sterno-mastoid. In such cases, they advise simply a removal of the tongue and non-in- terference with the glands.33 Others again, as Kocher, hold that the extirpation of the diseased glands cannot be too thorough, and they in every case make an incision in the neck to search for enlarged glands, which cannot be found by external manipulations. They argue that if the glands in the axilla are removed in all cases of ex- cision of the breast for cancer, it is quite as important to remove the submaxillary lymphatic glands in opera- tion for cancer of the tongue. It is a simple enough operation to remove a portion of the tongue with the ecraseur ; the recovery from the operation is rapid, but so is also the return of the disease. In cases between the ages of forty-five and sixty a radical operation, with ex- tirpation of the glands, is the proper one, but in cancer in old people approaching seventy years of age the case is different, and a simple removal of the tongue will prob- ably be as successful as a most complete and radical operation. When there is extensive involvement of the glands of the neck, the case is hopeless and operation should be undertaken for the relief of the patient only, as it is impossible to remove all the disease in such cases. Operations for the removal of the tongue, or part of the tongue, are much facilitated by dividing the cheek horizontally from the angle of the mouth to the border of the masseter muscle ; 'this incision gives much more room and the scar left is insignificant. Jaeger first ad- vocated this method, and Gant and Furneux Jordan practised it in Great Britain. This procedure does not add to the risk of the operation, and it gives the operator greater facility for arresting haemorrhage. Removal of the tongue through the mouth by the ecraseur or scissors, without a submental incision, is only suitable in those cases in which the disease is limited to the anterior part of the tongue and when the glands are not involved ; or it may also be practised in those cases in which the degree of gland infiltration is so great that ex- tirpation is hopeless, and the tongue is removed purely for the purpose of relieving the patient from great suffering. In all other cases some form of submental operation should be practised, for then the enlarged glands can be easily reached and removed, and the chance of a perma- nent cure is much increased if the glands be extirpated. The points to be kept in view in operations on the tongue for malignant disease are : (1) The possibility of removing all the disease ; (2) the prevention of haemor- rhage ; (3) the avoidance of the entrance of blood into the air-passages ; and, after operation, (4) the preservation of an aseptic condition of the mouth and secretions un- til healing is complete. In order to accomplish this, some form of submental operation is necessary. Opera- tions involving division of the jaw are more serious, are disagreeable to the patient, and delay convalescence. The various operations which have been practised for the removal of the whole tongue are very numerous. The most popular operation with English surgeons at the present day is that known as Whitehead's, viz., re- moval of the tongue by scissors ; this may be done with or without preliminary ligature of the linguals. A few years ago nearly every surgeon employed the galvanic or wire ecraseur, but the occurrence of secondary haemor- rhage when the slough separates is so frequent that the ecraseur is much less popular with surgeons than for- merly, and has been supplanted by the scissors. With scissors the entire tongue can be removed easily and simply. Whitehead's Method.™-" 1. The mouth is opened to the full extent with Mason's or any oth'er suitable gag, the duty of attending to this important part of the operation being entrusted to one of the two assistants required. "2. The tongue is drawn out of the mouth by a double 118 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tongue, Tongue. ligature passed through its substance an inch from the tip. This ligature is given in charge of the second as- sistant, with instructions to maintain throughout the operation a steady traction outward and upward. "3. The operator commences by dividing all the at- tachments to the tongue to the jaw and to the pillars of the fauces, after the manner suggested by Sir James Paget, with an ordinary pair of straight scissors. "4. The muscles attached to the base of the tongue are then cut across by a series of successive short snips of the scissors, until the entire tongue is separated on the plane of the inferior border of the lower jaw, and as far back as the safety of the epiglottis will permit. "5. The lingual, or any other arteries requiring tor- sion are twisted as divided. It is generally found that a moment's pressure with a piece of sponge held in sponge forceps, suffices temporarily, if not permanently, to ar- rest any bleeding ; it is, however, regarded as desirable to twist, either immediately or after the tongue is re- moved, every bleeding vessel. "6. A single loop of silk is passed by a long needle through the remains of the glosso-epiglottidean fold of mucous membrane, as a means of drawing forward the floor of the mouth, should secondary haemorrhage take place. This ligature may with safety be withdrawn the day after operation, and, as it is invariably a source of annoyance to the patient, it is always desirable to adopt this rule. "The after-treatment consists in feeding for the first three days absolutely and solely by nutrient enemata, satisfying thirst by occa- sionally washing out the mouth with a weak iced so- lution of permanganate of potash ; forbidding any at- tempt at speaking, and re- quiring that all the wishes of the patient shall be ex- pressed in writing or by signs. The difficulties and dangers of the operation are few and more imaginary than real. Haemorrhage, the bete noire of most sur- geons who contemplate re- moving the tongue, is in re- ality easily controllable and frequently trifling. I have twice removed the entire tongue without having to secure a single vessel, and more than once have only had to twist one lingual ar- tery." The operation prac- tised by the writer is that commonly known as Billroth's, viz., excision of the tongue by scissors with preliminary ligature of the lin- guals. This operation enables the surgeon not only to avoid danger from haemorrhage, but also to remove the neighboring glands and structures which are involved in the disease through the same incision made for ligating the lingual arteries. In Billroth's operation the mortal- ity is not greater than that following other operations. Billroth's Operation.™-The head of the patient having been well thrown back and the chin turned to the side op- posite to that on which the artery is to be tied, a curved incision is made from near the symphysis menti to near the angle of the lower jaw, the convexity downward, hav- ing its lowest portion running along the upper border of the great cornu of the hyoid bone ; a careful dissection is then made through the platysma and deep cervical fascia, and if any veins are cut they should be ligatured before proceeding further with the operation. The tendon of the digastric muscle should now be searched for, and in the angle this tendon forms with the hyoid bone, the ar- tery will be found-but not immediately, for covering it we have the hyoglossus muscle with the hypoglossal nerve and ranine vein running over it. The hyoglossus muscle should be carefully divided, and then, all bleed- ing having been arrested by Pean's forceps and ligatures, the artery is felt pulsating at the bottom of the wound. Haemorrhage should now be completely arrested and the artery being brought into view can be easily tied. The artery on the opposite side having been secured in the same way, any glands that may be involved should be looked for. and removed through these incisions in the neck. As a rule, they can be found without difficulty. If the submaxillary glands are not involved they should be treated tenderly and not cut into, as afterward they may take on troublesome inflammatory action. The mouth should now be kept open with a gag and the tongue drawn out by a double ligature passed through its substance about an inch from the tip. The operator, holding the ligature in his left hand, draws the tongue outward and upward and removes it with a straight pair of scissors. The attachments of the tongue to the jaw and pillars of the fauces should first be freed and then the muscles at the base, and now, the attachment to the hyoid bone being divided with a few short cuts, the whole tongue will come away, leaving the epiglottis behind. The removal of the tongue takes, as a rule, only two or three minutes. If the tissues of the floor of the mouth be involved, they should now be attended to. The wounds in the neck, which during the excision of the tongue should be filled with carbolized sponges, are then sewed up with catgut or silk ligatures and dressed with iodoform and pads of jute or cotton wool. If the floor of the mouth has been removed it will be better to pass a large drainage-tube into the mouth through the neck incision ; in fact, this ought to be done in every case. The mouth is now packed with sticky iodoform* gauze and the operation is complete. The after-treat- ment is the same as after excision of the tongue by other methods. The advantages of the operation above described are many : 1. The diseased structures, and especially the glands, are discovered and removed with the greatest ease through the neck incisions. 2. The removal of the tongue is bloodless, and there is no fear of secondary haemorrhage. 3. The incision made by the scissors is a clean cut one, and there is no bruising of the tissues as in the oper- ation with the ecraseur. 4. The tongue can be more completely and more eas- ily removed with scissors than with any ecraseur. 5. Drainage of the mouth can be more thoroughly carried out by means of the incisions in the neck. 6. The operation is easy of performance and few in- struments are required, no more than every surgeon pos- sesses, viz. : straight scissors, knife, and a few pairs of Pean's forceps. Kocher's Operation.36-A still more radical and exten- sive operation than the one described above is the oper- ation performed by Kocher, of Berne. It is the only operation for the removal of the tongue which aims at preserving the parts in a thoroughly aseptic condition. Tracheotomy is first performed and a well-fitting cannula introduced, the pharynx is then packed with a carbolized sponge with a cord attached, so that it can be easily re- moved when necessary. An incision is now made com- mencing a little below the tip of the ear and extending down the anterior border of the sterno-mastoid muscle to about its middle, then forward to the body of the hyoid bone, and along the anterior belly of the digastric muscle to the jaw. The resulting flap is turned up on the cheek and the lingual artery is ligatured as it passes under the hyoglossus muscle. The facial artery and any veins that may be in the way are also secured. Com- mencing from behind, all the structures in the submaxil- lary fossa are removed, viz., the lymphatic glands, the Fig. 3933.-Incisions for Operations on the Tongue, a. Incision through the cheek, after Jaeger ; 6, von Langenbeck's Incision, with divis- ion of the jaw ; c, incision for re- moval of glands and ligature of lingual arteries as practised by the writer. * The sticky gauze is prepared With resin, alcohol, and iodoform. Weir, of New York, recommends the following formula as an improve- ment on that introduced by Billroth : Resin, 10 parts; castor-oil, 6 parts : iodoform, 5 parts, and alcohol, 15 parts. This is rubbed into the gauze, and certainly, as the alcohol evaporates, it is sticky enough. The writer has, in cases where the gauze failed to remain in the mouth, painted the surface over with the liquid. 119 Tongue. Tongue. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. submaxillary, and, if necessary, the sublingual glands. The opposite lingual artery is now tied by a separate in- cision if the whole tongue is to be removed. The mucous membrane along the jaw and the mylo-hyoid muscle are then divided and the tongue drawn out through the neck incision, and removed with scissors or galvano-cautery ; the latter is preferred by Kocher, as there is less liability to after-oozing. The after-treatment is most important; if the operation be an extensive one, the external wound should not be closed. Kocher's endeavor is to avoid the two great after-dangers of excis- ion of the tongue, pneu- monia and general sep- ticaemia. To prevent the discharge causing infection, the whole cavity of the mouth and pharynx is plugged with carbolized sponges and iodoform gauze. The operation as first described was per- formed under the spray. The patient is fed by the rec- tum partly, but chiefly by the throat with a tube, twice a day, when the dressings are changed. Thus, if all the minute directions are enforced, the wound remains asep- tic throughout, and no food or discharge from the wound can possibly enter the air-passages. There is one thing that Kocher has not guarded against, and that is vomit- ing ; should the patient vomit, as is so often the case after the administration of anaesthetics, the elaborate preparations against sepsis may come to naught. In Kocher's hands this operation has been most suc- cessful. He had one death in fourteen cases, eight recurred, one died a year afterward of pneumonia, one lived four- teen months, two five years, and one six and a half years. With the modern methods of keeping the mouth aseptic, preliminary trache- otomy is rendered almost unnecessary. There is no doubt that it adds to the danger of the operation. The one death in Kocher's series of cases was caused by haemorrhage from the tracheotomy wound. Regnoli's Operation.'1-This operation consists in the removal of the tongue by wThat is known as the sub-mental incision. It was per- formed for the first time in 1838,37 on a young girl aged fourteen, for tumor of the tongue. The following is a description of the operation as modified by modern meth- ods. A semilunar incision is made along the line of the lower jaw from the angle of one side to that of the other, care being taken not to wound the facial arteries. From the centre of this line a perpendicular incision is made as far down as the hyoid bone. The triangular flaps thus made are dissected back and the mus- cles exposed ; the anterior bellies of the digastric muscles, the mylo-hyoid, and the muscles attached to the mental spines are successively divided. The mucous membrane of the mouth is cut through and the tongue drawn out by means of vulsellum forceps or hooks, and the whole tongue is removed by knife or galvano-ecraseur. If necessary, the lingual arteries are seized and tied. The flaps are now sewn up and a large drainage-tube inserted into the lower end of the vertical incision. A modifi- cation of this operation has beeA devised by Nunneley, of Leeds. The operation was previously performed by Chassaignac. It should only be performed when the disease is confined to the anterior part of the tongue, as it does not provide for the extirpation of diseased glands. The tongue is drawn forward out of the mouth as far as possible, and is trans- fixed behind the point of disease by two strong curved needles passed through it from below the chin. A stout needle to which the noose of an ecraseur has been at- tached by a ligature, is made to penetrate in the middle line of the floor of the mouth, about midway between the jaw and hyoid bone, so that its point emerges in the mouth close to the fraenum of the tongue. The loop of the ecraseur is drawn up through this opening, the nee- dle is withdrawn, and the loop of the ecraseur is widened out so as to permit the tongue to be once more drawn forward through it until it lies behind the curved needles which were first introduced. The ecraseur is tightened and the tongue cut through. The writer has seen this operation performed by Dr. Roddick, of Montreal, with the modification of first cut- ting the attachment of the tongue to the lower jaw with a few short snips of the scissors. This enables the organ to be still further drawn out, and allows the needles and ecraseur to be placed still nearer the root of the tongue*. Chassaignac's, or Nunneley's, operation is a very suit- able one in cases of macro-glossia where it is necessary to remove a part of the tongue. Billroth's modification of Regnoli's operation is very simple and much to be preferred to the original opera- tion. The longitudinal incision is omitted and the curved incision is carried further outward on ea^h side, so that the linguals may be ligatured before removal of the tongue. J t is a very suitable opera- tion in those cases in which the submaxillary fossa is involved in the disease. The tongue can be re- moved by scissors. Removal of the Tongue after Division of the Loir er Jaw.-This operation was introduced by Sedillot, of Strasburg, and afterward practised by Syme, of Edinburgh. It consists in making a vertical incision in the lower lip, sawing through the inferior maxilla at the symphysis, separating the two sides of the jaw, and drawing out the tongue and remov- ing it by scissors, ecraseur, or knife. The divided por- tions of the jaw are afterward wired together. It is a good plan to make the holes for the sutures before divid- ing the jaw. v. Langenbeck3b has advised a lateral section of the jaw opposite the first molar tooth. The skin incision is made from the angle of the mouth downward. (See Fig. 3933.) Division of the jaw adds to the danger of the operation, and makes it more unpleasant for the patient. Conval- escence in these cases is usually prolonged. It is seldom necessary to divide the jaw in extirpating the tongue, even when the disease is most extensive, for the infiltrated glands in the floor of the mouth can be easily removed by one of the submental operations, with less danger and greater comfort to the patient. In some cases where the disease has extended to the gums and bone itself, a portion of the jaw may require resection. It is often sufficient to remove the alveolar process only. Occasionally, after removal of the tongue through the mouth, it is found that the glands in the submaxillary region subsequently become enlarged, although appar- ently healthy at the time of operation ; then, if they ap- pear movable and there is no recurrence of the disease in the mouth, a special operation for their removal is ad- visable. If, on the other hand, the glands are fixed and the tissues infiltrated, operation is of little avail. In cases of carcinoma where the glands and the sterno-mas- toid are first affected, operation is usually of little bene- fit. The following list of operations, taken from Barker's article in " Holmes' System of Surgery," vol. ii., 1882, will prove of interest to the reader, and will serve to Fig. 3934.-Line in Neck Showing Extent of Kocher's Incision for Removal of the Tongue. Fig. 3937.-Curved Line Below the Chin, Showing the Extent and Sit- uation of Billroth's Incision. Fig. 3935.-Line of Incision in Reg- noli's Operation. (After Erichsen.) Fig. 3936.-Tongue Drawn out be- tween Jaw and Hyoid Bone. (Af- ter Erichsen.) 120 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tongue, Tongue, give him some knowledge of the history and progress of the operation of excision of the tongue. EARLIEST IRREGULAR OPERATIONS. 1. Pimpernelle. Died 1658, was probably the first to ex- cise the tongue with success. 2. Marchetti, 1664. Extirpated a cancer of the tongue by actual cautery ; probably the first recorded ex- tirpation for this disease. 3. Vai. Hoffmann, 1692. Removed a tongue affected with macro-glossia. 4. Ruysch, 1737. Excised tongue with knife. 5. Memonista, 1737. Cauterized with a hot iron. 6. Heister, 1743. Gave the first methodical description of operative treatment of cancer of the tongue. 7. Buxdorf, 1754. Excised a true cancer of the tongue with knife. 8. Guthrie, 1756. Was probably the first English sur- geon to excise a cancer of the tongue, using the knife, followed by cauterization of the cut surface. 9. Louis, 1759. Ligatured a fungus of the tongue, and in 1774 spoke in favor of total excision for cancer. DEFINITELY DESIGNED OPERATIONS. Ligature. 10. Lnglis, 1803. Introduced ligature of the tongue from the mouth for cancer, the cords being drawn with needles through the tongue and round the tumor. (Edin. Medical and Surgical Journal, 1805, p. 34.) 11. Major, 1827. Split the tongue down the centre to apply ligature to the diseased half through the mouth. 12. Cloquet, 1827. Also split the organ, but introduced the ligature by supra-hyoid incision and strangled . the diseased half. ("Archives Gen.," xii., 511.) Wedge-shaped Excision. 13. C. J. Langenbeck, 1819. Introduced wedge-shaped excision of the diseased part of the tongue with careful suture of resulting flaps. (" Biblioth. f. Clin. u. Augenh.," Bd. 2, 487. Preliminary Ligature of the Lingual. 14. Mirault, 1833. Introduced preliminary ligature of lingual artery to give a clear, bloodless field for ex- tensive incisions. He was followed later by Roux and Roser. (" Archives Gen.," vi., 5, 636.) Ecrasement. 15. Chassaignac, 1854. Introduced the ecraseur, employ- ing Cloquet's supra-hyoid method and defining it more exactly, i.e., using puncture instead of in- cision. (" Traite de 1'ecrasem. lin.," p. 31.) 16. Middeldorpf, 1854. Introduced the galvanic ecra- seur (" Schmidt's Jahrbiicher," Bd. 107-260.) 17. Nunneley, 1856. Introduced the supra-hyoid use of the ecraseur into England. Adopting Chassaig- nac's modification. (Med. Timesand Gaz., 1862.) 18. Girouard, 1857. Employed circumpuncture with rods of caustic. ("Arch. Gen.," 1857.) Division of the Cheek. 19. Jaeger, 1831. Was the first to divide the cheek for free access to the tongue. (De Extir. Linguae, 1831.) 20. Maisonneuve, 1858. Divided both cheeks from the angle of the mouth for same purpose. 21. Collis, 1867. Reintroduced Jaeger's operation, using the ecraseur. (Dub. Quart. Jour., xliii., 1867.) Division of the Lower Jaw. 22. Roux. Died 1836. Was the first to divide the lower jaw and lip in mid-line in order to gain free access to the floor of the mouth and tongue. (Maison- neuve, These, p. 146.) 23. Sedillot, 1844. Improved this method by dividing the bone by a serrated cut. (Gaz. des Hop., 1844, 83.) 24. Syme, 1857. Divided the jaw in mid-line and ex- cised with knife. (Lancet, 1858, vols. i. and ii.) 25. Billroth, 1862. Divided the jaw and soft parts at the side in two places, and turned down the flaps of skin and bone so formed, replacing and wiring the bone afterward. (Archiv f. Klin. Chir., 1862.) 26. B. v. Langenbeck, 1875. Divided the jaw and soft parts opposite the first molar tooth on one side, in order to gain access to the side of the mouth for re- moval of tongue, glands, and part of palatal arch and tonsil. Infra-Maxillary Operations. 27. Regnoli, 1838. Opened the floor of the mouth from below by an incision from- middle of hyoid bone to chin, ending in another semilunar incision along the border of the jaw. The tongue was drawn through the opening and excised. (" Bull. Sci. med. Bol- ogna," 1838.) 28. Czerny, 1870. Modified Regnoli's procedure, form- ing lateral flaps. 29. Billroth, 1871-6. Modified it still further, extending both ends of the curved incision much further back- ward, and omitting the incision in mid-line. (Ar- chiv f Klin. Chir., Bd. 16, Hft. 2.) 30. Kocher, 1880. Introduced a method of opening the mouth from behind and below the angle of the jaw to reach the base of the tongue and remove it with all the lymphatic glands situated there. (Deutsche Zeitschrift f. Chir., Bd. xiii.,*146, 1880.) Results of the Operation.-The immediate results fol- lowing excision of the tongue are fairly good, consider- ing the severity of the operation. Whatever operation for excision of the tongue is practised, the mortality in a series of cases is about the same, so that the method of operating seems to have less effect on the result than the after-treatment. Still, certain operations are more fav- orable than others as regards the recurrence of the dis- ease, and it is reasonable to suppose that when the dis- ease is most completely removed it is least likely to return. Agnew,39 of Philadelphia, reports 10 deaths in 76 cases of excision of the tongue collected by himself. Nunneley reports 19 cases with 1 death ; Baker,40 40 cases with 4 deaths ; Whitehead,41 58 cases with 9 deaths ; Langenbeck,43 12 cases with 1 death ; Kocher,43 14 cases with 1 death. In all, 219 cases with 26 deaths (8.42 per cent.). Barker 44 has collected 218 cases of excision of the tongue from the tables of Billroth, Rose, Kocher, Whitehead, University College Hospital, Middlesex Hos- pital, and others, with a mortality of 16.9 per cent. This list includes cases operated on between 1860-1880. In the later operations the mortality has been much reduced. Woelfler45 (1882) reports that the last 17 cases operated on by Billroth all recovered. The chief causes of death were pneumonia (septic), septicaemia, pyaemia, shock, and exhaustion. With regard to the frequency of recurrence it may be said that recurrence is the rule. Barker46 has collected 170 cases in which the whole or part of the tongue was extirpated, and in only 17 cases was there non-recurrence after an interval of a year. According to the same au- thor the duration of the disease, in cases not operated on, was 11.7 months, and in those operated on 19 months, a clear gain of 7.3 months. The longest period of freedom from the disease after operation seen by the writer was 18 months. It is to be hoped, with the modern methods of antisepsis which are now so universally practised, that the excision of the disease will be more complete, and hence the period of freedom from recurrence prolonged, and also the mortality after operations much decreased. Dangers of Excision.-Formerly the danger most dreaded during and after operations on the tongue was haemorrhage, primary and secondary. Since the gal- vanic ecraseur has been discarded, secondary haemor- rhage is much less frequent, and both primary and sec- ondary haemorrhage is avoided by preliminary ligature of the linguals. This procedure is a very simple one when the tongue is removed by one of the submental operations, as Billroth's, Kocher's, etc. Even should the linguals not be previously ligatured, there is usually little 121 Tongue. Tonics. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. danger from haemorrhage, owing to the facility with which a bleeding vessel can be seized by the modern ar- tery forceps. The greatest danger connected with excision of the tongue is without doubt septic pneumonia, or other lung affection, produced by direct infection from the fetid dis- charges of the decomposing wound. In some cases there is gangrene of a portion of the lung, or numbers of small, foul, circumscribed abscesses ; in others a condi- tion of broncho-pneumonia. Whatever affections of the lung ensue after excision of the tongue or severe opera- tions on the mouth and jaws, they are all due, either to the inhalation of fetid gases from the sloughing wound in the mouth, or to discharges from the same source passing down the trachea to the bronchi and lungs. In other words, the lung affection is produced by direct in- fection from a foul wound. Barker41 has collected 52 cases of death following operation ; of these 30 died from some pulmonary affection ; 12 from septic affections, in 6 of which no mention is made of the condition of the lungs ; and in the remaining 10, death was due to various causes, as shock, collapse, asphyxia, exhaustion, etc. The passage of blood into the trachea during operation is another cause of lung affection, and to avoid this anaes- thesia should not be too profound. Usually symptoms of pneumonia and broncho-pneumonia appear soon after the operation. The case may go on favorably for two or three days, then there is a troublesome collection of ropy mucus in the mouth and the wound becomes very fetid, cough is complained of, the temperature and pulse run up, respirations are very rapid, and the patient becomes cyanosed and dies in a few days with symptoms of pneu- monia. The breath during all this period has been hor- ribly fetid. The autopsy discloses acute congestion of the trachea and bronchi, and in the lungs are numerous small foul-smelling abscesses with, in places, patches of gangrene. Cases occur also in which the patient dies of simple pneumonia threatening to become gangrenous. Treatment after Excision.-The most important point in the after-treatment is to preserve a condition of asep- sis in the wound, for, as has been shown above, the greatest danger is due to direct septic infection from the wound itself. Again, the swallowing of blood at the time of operation, tainted with the foul discharges of the cancerous ulcer, should be carefully guarded against by having the mouth thoroughly and frequently washed out with some antiseptic solution, as Condy's fluid, car- bolic acid, etc., before operation, and, during operation, avoiding a condition of too profound anaesthesia. After operation the wound in the mouth should be packed with sticky iodoform gauze as recommended by Billroth, painted over with alcoholic solution of iodoform and resin, or at least dusted with iodoform crystals. Billroth, as already mentioned, had seventeen cases of excision without a death or even a serious symptom, owing to the mouth being kept thoroughly aseptic by the packing with sticky iodoform gauze, which in a day or two be- comes incorporated with the wound. The writer has found great difficulty in keeping the gauze in the mouth after the first day ; he has found that it becomes loose and covered with mucus, and that the patient finds it very troublesome. Lately he has used the following paint, advocated by Weir, of New York, to impregnate gauze : Iodoform, 5 parts ; resin, 10 parts ; castor-oil, 6 parts ; and alcohol, 15 parts. When painted on, the alcohol evaporates and leaves the resin and iodoform behind coating the sur- face of the wound. This should be painted on twice daily. The first three or four days after operation the patient should be fed entirely by the rectum, and occasionally allowed to rinse out his mouth with water to allay thirst. After this, feeding should be by the mouth through a tube introduced into the oesophagus. A very good arrange- ment is a soft catheter with a piece of rubber tubing at- tached to it, and to this again is attached a glass funnel; by pouring liquid food into the funnel the patient can be easily and comfortably fed. Should any fetor ap- pear in the wound, the mouth should be frequently washed out with a solution of Condy's fluid, carbolic acid, or chlorate of potash. Washing out is much facili- tated if there is a drainage-tube through the incision in the submaxillary region. Palliative Treatment of Cancer of the Tongue.-The ob- ject is to relieve pain and lessen fetor and salivation. To relieve pain division of the lingual nerve is advised, and also the administration of opium. Fetor and salivation may be controlled by frequent washings with some anti- septic solution, as Condy's fluid or carbolic acid, and the after-dusting on of iodoform or salicylic acid. Bleeding, which so frequently terminates the case, may be con- trolled by styptics, or lint soaked in tincture of the muri- ate of iron and kept continually pressed against the bleeding points with forceps. Should the bleeding be distinctly arterial, then ligature of the lingual artery of that side is the only remedy. Excision or Stretching of the Lingual Nerve.-Division of the lingual nerve was first put in practice by Hilton ;48 then Moore49 advised a more simple procedure than Hil- ton's. This was to make an incision with a curved bis- touri through the mucous membrane in a line from the last molar tooth to the angle of the jaw. The simplest method is as follows, and this method is suitable for division, excision, or stretching. The writer has prac- tised it and found no difficulty in reaching the nerve. The mouth should be opened with a suitable gag, then a ligature is to be passed through the tongue near the tip, and the tongue drawn out to the side opposite to that on which it is desired to stretch the nerve ; this puts the nerve on the stretch and it can be felt standing out as a cord at the side of the tongue ; a sharp hook is passed under it, and then the nerve is exposed by a small incis- ion, pulled out by a blunt hook, and excised or stretched as the necessities of the case may indicate. Mr. Clement Lucas60 was the first, as far as the writer's knowledge goes, to put this plan in practice. Francis J. Shepherd. 1 Diseases of the Tongue, p. 231. 2 System of Surgery, vol. 1„ Ed. 1884, p. 585. 3 Treatise on Haemophilia. 1872. 4 Oester-Medicinische Woch., 1846. 6 Legouest: Trait6 de Chir. de l'Arm6e, 1872. * Diseases of the Tongue. 7 Lancet, August 26, 1837, quoted by Fairlie Clark. 8 Histoire de FAcad. Roy. des Sciences, 1742, p. 247 of Memoirs, quoted by Barker in Holmes's System of Surgery, vol. ii., 1883. 8 Chalk: Transactions of Pathological Society of London, vol. viii., p. 305. 10 Fehleisen: Berlin. Klin. Woch., No. 50, 1887. 11 Fergusson ; Practical Surgery, 5th edition, p. 519. 12 Pitha and Billroth, Band 6. 1866-73. 13 Stromeyer: Chir. Krankh. d. Kopfes. 1868. 14 Clinical Surgery of India. 16 Pitha and Billroth : Handb. d. Chirurgie, p. 329. i" Transactions of the Pathological Society, vol. xii., p. 234. 17 Ibid., vols. xv. and xviii. 18 Loc. cit., p. 213. 18 Loc. cit., p. 247. 20 Loc. cit., p. 250. 21 Loc. cit., p. 95. 22 Loc. cit., p. 107. 23 Loc. cit. 24 Loc. cit., p. 590. 26 Klin. Chir. 26 Loc. cit. 27 Loc. cit. 28 Practice of Surgery, 4th Ed., vol. i., p. 603. 28 Loc. cit. 30 Koenig. Lehrbuch der Chirurgie, Bd. 2, p. 451. 31 Brit. Med. Jour., vol. ii., p. 765, 1883. 32 International Encyclopaedia of Surgery, vol. v., p. 508 ; and British Medical Journal, April 21, 1888. 33 Heath : British Medical Journal, April 21, 1888. 34 Transactions of the International Medical Congress of 1881, vol. ii.; and Lancet, October 22, 1881. 36 Shepherd. Annals of Surgery, November, 1885. 34 Deutsch. Zeitschrift fur Chirurgie, 1880. 37 Bulletino delle Scienze Med. di Bologna, August and September, 1838. Quoted by Butlin. 38 Vorlesungen ttber Akiurgie. Berlin, 1888. 39 Principles and Practice of Surgery, vol. ii., p. 918. 49 Butlin : Loc. cit., p. 363. 41 Ibid. Loc. cit., p. 362. 42 Loc. cit., p. 378. 43 Deutsch. Zeit. f. Chir., Bd. xiii., 1880. 44 Loc. cit., p. 607. 45 Archiv f. Klin. Chir., Bd. xxvii., p. 419. 46 Loc. cit. 47 Loc. cit., p. 610. 48 Guy's Hosp. Rep., 2d series, vol. vii., 1852. 48 Med. Chir. Trans., vol. xlv., 1862. 60 British Medical Journal, November 15, 1884. TONICS. Tonics are medicines which promote nutri- tion and thus increase the strength of the body when it is reduced. The term tonic is derived from the Greek word tonos, tension, and was applied to agents which re- store the normal strength, because it was supposed that they specially increase the tone or tension of the contrac- tile tissues, that is, restore the constant, _ active, but weak, involuntary contraction normally existing in all organs containing such tissues. They were held to act either directly upon the contractile tissues, or upon the nerves by which they are innervated. This view is no 122 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tongue. Tonics. longer entertained, as it is evident that the tone or strength of all organs and tissues depends upon the state of their nutrition, any diminution of which becoming manifest in more or less weakness and loss of functional power. For practical purposes all tonic medicines may be di- vided into three classes : gastric tonics, blood tonics or hamatinics, and general tonics. Gastric tonics improve the digestive process when it is enfeebled, thus enriching the blood, and supplying all the organs and tissues with an abundance of nutritive material. Blood tonics, or haematinics, supply the blood with material in which it is deficient, especially increasing the number of red blood- corpuscles. General tonics increase the nutrition and weight of the body by augmenting or otherwise modify- ing the process of assimilation in the tissues. Gastric Tonics.-Some of the medicines which im- prove the process of digestion when it is weak or imper- fect, act directly upon the organs of digestion, enab- ling them to perform their function more powerfully ; others, however, have no direct influence upon the stomach and intestines, and act only upon the substances undergoing digestion, hastening this process. The lat- ter are distinguished from the former by the term diges- tives. Nearly all gastric tonics have an intensely bitter taste and act similarly upon the. digestive organs. Hence they are called bitter tonics. Since they closely resemble one another in action, it is unnecessary to consider them sepa- rately, with the exception of the principal alkaloids of cinchona and nux vomica, which are supposed to pro- mote nutrition by acting also upon other organs. Bitter Tonics.-All bitter tonics increase the secre- tion of saliva, and, soon after coming into contact with the gastric mucous membrane, produce a feeling of hun- ger. In consequence of the stronger appetite a larger quantity of food is eaten. In cases of atonic dyspepsia the digestion of the large meal is not attended by the feeling of heaviness and discomfort, and other symp- toms which usually result from slow and imperfect digestion, showing that the bitter tonics cause some de- cided improvement in the digestive process. This im- provement, however, follows only when the bitter tonics are given in moderate doses ; excessive doses, especially if frequently repeated, soon causing symptoms of gastro- intestinal catarrh, nausea, vomiting, and diarrhoea. In regard to the mode of action of bitter tonics the fol- lowing facts have been ascertained : 1. They increase the salivary secretion. The saliva hastens the digestion of amylaceous food and stimulates the gastric glands, and thus excites an abundant secre- tion of gastric juice. It has been held that this suffi- ciently accounts for their utility in cases of atonic dys- pepsia (Leube). 2. They gently irritate the gastric mucous membrane, and thus, it is supposed, excite the feeling of hunger. As the larger quantity of food consumed is digested more easily and speedily in cases of dyspepsia, it may be assumed that the secretion of gastric juice becomes aug- mented, either directly by the moderate irritation, or in- directly by the greater relish of the food. It is supposed that in many cases of dyspepsia due to slight catarrh of the stomach, the moderate irritation gradually restores the normal circulation of the gastric mucous membrane. 3. In experiments it has been found that bitter tonics retard fermentation and putrefaction. The small doses usually effectual in atonic dyspepsia may doubtless ex- ert some antiseptic influence, but it is improbable that their utility is chiefly due to this action. 4. Cetrarin and calumbin, injected into the jugular vein of animals, cause a rise of the general blood-pres- sure by exciting the vaso-motor centre (Koehler). Hence it has been supposed that possibly all bitter tonics may to some extent act like digitalis, which, in indiges- tion dependent upon enfeebled heart action, improves the digestive process by causing the supply of arterial blood to the stomach to be increased. But no changes of the blood-pressure have been observed after the ad- ministration of bitter tonics until a notable improvement of the general nutrition of the body has resulted. It seems probable, however, that the action of quinine and strychnine upon the digestive organs is in part due to an improvement of the general circulation. The bitter tonics display their therapeutic power most markedly in atonic dyspepsia, that is, in cases of dys- pepsia in which the slow and imperfect digestion results solely from weakness of the stomach. In such cases the appetite is feeble, and the tongue clean or only thinly coated, and generally pale and flabby. Unless only very digestible food be eaten, in moderate quantities, the meals are soon followed by a feeling of weight in the epigastrium, and often by fulness and eructations, which sometimes have a rancid taste. But decided pain in the region of the stomach, and thirst, fever, and vomiting are absent. The bitter tonics are also employed in dyspepsia due to chronic catarrh of the stomach ; generally small doses, in slight or mild cases, soon cause a notable abatement of the symptoms ; but they generally aggravate severe catarrh, and are decidedly injurious in ulcerative affec- tions of the stomach. They should therefore not be used when there are present severe pain and tenderness of the epigastrium, a heavily coated tongue, and vomiting of blood or large quantities of mucus. As the bitter tonics improve general nutrition and strength solely by their action upon the digestive organs, they are useless in all forms of general or local debility which are not attended by enfeebled or disordered diges- tion. As a rule, the bitter tonics should be given a short time before meals, so that a keen appetite may set in as soon as food is taken. Of the officinal preparations, the tinctures are the most useful in atonic dyspepsia ; gen- erally the compound tincture of gentian, the compound tincture of cinchona, the tincture of quassia, and the tincture of calumba are sufficiently active in doses of one- half to one drachm. The tincture of nux vomica is ef- fective in doses of five to ten drops, and even smaller quantities sometimes in slight catarrh of the stomach. If no other morbid state is present requiring active rem- edies, the bitter tinctures may be prescribed undiluted, the patient being told to take each dose in a small quantity of water or sweetened water. Sometimes they are or- dered with a small quantity of syrup or with an aromatic water to modify their taste. The following formulae il- lustrate the usual modes of prescribing in atonic dyspep- sia: B- Tinct. cinchon. comp., ? jss. ; syrupi, 5 ss. M. Sig.: A teaspoonful in water before meals. B ■ Tinct. gentian, comp., § jss. ; syrup, aurantii, § ss. M. Sig. : A teaspoonful in water before meals. B • Tinct. quassiae, § jss. ; syrup, zingiberis, § ss. M. Sig.: A teaspoonful be- fore each meal. B ■ Tr. nucis vom., 3 j.; aq. menth. pip., aq. destill., aa § j. M. Sig. : A teaspoonful before each meal. Quinine.-In dyspepsia due to weakness of the stom- ach the salts of quinine seem to act in the same manner as other bitter tonics. But they are more efficient than the latter when dyspepsia is associated with malarial af- fections, or is consequent upon pulmonary and cardiac diseases. Probably this is due to the fact that, given in moderate tonic doses, they somewhat increase the gen- eral blood-pressure. The opinion is prevalent that quinine may sustain the strength of the body under circumstances contra-indica- ting bitter gastric tonics, such as prolonged fevers with a high temperature. Very commonly doses of two or three grains are given three or four times daily, or even more frequently, in typhoid fever, pneumonia, pleuritis, and other similar diseases. Whether this use of quinine is ever beneficial is very doubtful, and there is reason to suppose that in typhoid fever, especially if the quinine be not given in acid solution, it may increase the tend- ency to haemorrhage and perforation. As gastric tonics the salts of quinine should be given in small doses, one-half to one grain, or at most two grains, preferably in solution. B- Quin, sulph., gr. xvi.; acid, hydrochi. dil., q. s. ; tinct. cinchon. comp., syrup, au- rantii, aS | j. M. Sig. : A teaspoouful before each meal. 123 Tonics. Tonics. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. B- Quinime hydrochi., gr. xvi. ; glycerini, 3 ss. ; aq. menth. pip., jss. M. Sig. : A teaspoonful before meals. Strychnine.-The salts of strychnine are frequently employed as gastric tonics, and are very efficient. They are preferred to all other bitter medicines when feeble digestion is associated with diseases of the respiratory organs impairing the breathing process, such as phthisis, chronic bronchitis, and emphysema. Doses of one-thir- tieth grain often notably ameliorate both dyspnoea and dyspepsia. In those diseases of the heart which are pro- ductive of disorder of the general circulation, and of slow and feeble digestion, strychnine also should be pre- ferred to those bitter tonics which act solely on the di- gestive organs. In cases of dyspepsia complicated with habitual constipation, small doses of strychnine some- times restore normal intestinal peristalsis. As a gastric tonic it should be given in solution or in powder. B- Strychn. sulph., gr. ss.; acid, hydrochi. dil., 3 ss. ; tinct. gentian, comp., syr. aurantii, Sa 3 j. M. Sig.: A teaspoon- ful before meals. B- Strychn. sulph., gr. ss.; sacch. lac- tis, 3 j. M. Div. in partes sequales xvi. Sig. : One pow- der before each meal. Alcohol.-As a tonic no substance is more beneficial when properly used, or more detrimental when abused, than alcohol. Taken in small quantities well diluted, as contained in some alcoholic beverages, especially light wines and malt liquors, it is doubtless the most pleasant and active remedy in cases of atonic dyspepsia. It was observed from time immemorial that wine, taken very moderately with meals, enables a weak stomach to digest food more easily and speedily, and increases the general vigor of the body. Hence the advice of St. Paul to Timothy : " Drink no longer water, but use a little wine for thy stomach's sake, and often infirmities." In experiments it has been found that alcohol, applied in small quantity to the gastric mucous membrane, causes a more copious secretion of gastric juice than any other substance. Doubtless it is this action, a decided increase of the secretion of gastric juice when wine is taken with full meals, which augments the appetite and enables the stomach easily to dispose of the larger quantity of food. Taken in excessive quantity alcohol retards digestion and causes gastric catarrh. This effect always results if large quantities are rapidly imbibed so as to produce de- cided intoxication. It is frequently observed also in in- dividuals who habitually drink to excess, especially in those who take ardent spirits before meals. Some per- sons, however, who indulge very excessively in beer or light wine, do not exhibit any symptoms of gastric dis- order. In cases of atonic dyspepsia only light wine or malt liquor should be recommended for prolonged use, as the danger of excessive indulgence and hence injury to the stomach is much greater from ardent spirits. If it be- come necessary to use whiskey or other strong alcoholic, the patient should be warned against taking it undiluted before meals. Alcohol is superior to other gastric tonics not only be- cause it is more agreeable, but because it exerts a more favorable influence on general nutrition. It is now well established that alcohol is nearly completely consumed in the body, and that in undergoing oxidation it yields heat and other force, and thus behaves in the same man- ner as other non-nitrogenous food. Robust persons with strong digestive organs, who easily dispose of sufficient food to maintain perfect nutrition, do not require alco- hol as a nutrient; but those who naturally have a weak stomach and " often infirmities," are decidedly benefited by moderate quantities. Alcohol displays its greatest utility in diseases so pro- foundly disordering the digestive organs that little or no ordinary food can be digested. In typhoid fever it is often the means of saving life. As it requires no diges- tion and is quickly absorbed, it may be given when no gastric juice is secreted. In chronic wasting diseases in which the digestive process gradually becomes more and more enfeebled, alcohol is capable of maintaining for a long time a fair state of the general nutrition. The quantity of alcohol to be taken for therapeutic purposes varies with the nature of the disease. In atonic dyspepsia a few ounces of wine w'ith the principal meal often suffice. Many persons having a weak stomach prefer to take a small quantity of wine with a little bread or other light food between the ordinary meals. Thus they eat more frequently, but never overload the stom- ach. In febrile diseases, when little or no ordinary food can be digested, alcohol should be administered, like other medicines, at regular intervals. The quantity to be given will depend chiefly upon the temperature and general condition of the patient. If the temperature is very high and ordinary food cannot be digested, more will be required than when the temperature is less elevated and the digestive power is somewhat better preserved. So, too, more is usually required when the patient is very weak than when he is in a fair state of strength. Whis- key or other form of spirits should always be diluted be- fore administration. In all cases in which patients seem to require the pro- longed use of alcohol in any form, and its recommenda- tion is deemed advisable, they should be informed that its excessive use will surely produce serious pathological changes, and that " one gramme of absolute alcohol per kilo (two pounds) of body-weight is the average limit per diem that cannot safely be exceeded." (See Vol. I., p. 105.) Digestives.-Digestives are medicines that act directly upon the food in the digestive organs, causing it to digest more rapidly and perfectly. They are used when the stomach is unable to secrete a sufficient quantity of gas- tric juice, or when the juice secreted has an abnormal composition. The digestive power of the gastric juice depends upon the presence of hydrochloric acid and pep- sin. If either one of these be deficient, digestion be- comes tardy and imperfect, and the symptoms of dys- pepsia supervene. Hydrochloric acid is probably secreted in insufficient quantity in all cases of atonic dyspepsia. Usually the bitter tonics, especially the preparations containing alco- hol, excite a more abundant secretion, and hence suffice to allay the symptoms of defective digestion. But some- times the symptoms persist notwithstanding their proper and continued use. When this is the case, recourse should be had to hydrochloric acid, which is generally followed by rapid improvement. According to recent careful investigations (see Deut- sches Archiv f. klin. Med., Bd. 42, p. 489) hydrochloric acid is not present in the contents of the stomach, that is, is not secreted by the gastric glands, during the continu- ance of the high temperature in typhoid fever and other febrile diseases of an infectious nature. But in some febrile affections in which, however, the temperature is rarely high, such as phthisis and serous pleuritis, the con- tents of the stomach are not found deficient in acid. The fact that in typhoid fever the hydrochloric acid is absent from the gastric juice until the high temperature subsides, is of great practical importance, as in this af- fection, continuing for weeks, it soon becomes necessary to adopt all possible means to sustain the patient's nutri- tion. It has long been observed that acids have a fav- orable influence on the course and termination of the disease, and sulphuric, nitric, hydrochloric, and nitro- hydrochloric have been supposed to be equally usefid. Doubtless their utility is due to their influence on the di- gestive process ; but whether or not they have any other action, it seems proper to prefer hydrochloric acid, as it is the normal acid of the gastric juice. In cases of obstinate dyspepsia it is best, as a rule, to administer the acid soon after meals, and, if necessary, to repeat the dose once or twice at intervals of two hours. During the continuance of the high temperature in typhoid fever, the acid should be given about ten or fifteen minutes after each draught of milk. In most cases it is proper to repeat the dose of the acid, as well as the milk, at intervals of three hours. Some writers hold that in cases of dyspepsia in which acid eructations frequently occur, the acid should be given before meals, as by its astringent action upon the 124 Tonics. Tonics. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. gastric mucous membrane it will tend to diminish the excessive secretion of acid. The presence of an excess of acid in the stomach during the digestive process is usually due to fermentation which gives rise to abnor- mal acids ; generally the administration of hydrochloric acid after meals prevents such fermentation. Should, however, this method of administration fail to give re- lief, the acid may be given before meals, as, of course, it is not impossible that an excess of it may be se- creted. The dose of the officinal dilute hydrochloric acid may vary from ten to thirty drops. It should be diluted ■with several ounces of water, and may be given in mix- ture with a bitter tincture and a small quantity of syrup. R. Acid, hydrochlor, dil., 3 ij. ; tinct. gentian, comp., syrup, aurant., aa §i.; aq. destill, q. s. ad 5 vj. M. Sig.: A tablespoonful after meals. In typhoid fever from one to two drachms, or even more, of the dilute acid may be given every day in a sufficient quantity of water to ren- der its taste agreeably sour. Or it may be ordered with a little syrup as follows : R. Acid, hydrochi. dil., 3 ij. ; syr. rubi id., § ss. to 3 i. ; aq. dest. ad § viij. M. Sig. : From one to two tablespoonfuls every three hours. Pepsin, like hydrochloric acid, is essential for normal digestion. But being a ferment, a small amount may suffice to digest very large quantities of albumen if there be constantly present a sufficient quantity of acid. As a digestive it is indicated when the stomach is unable to secrete a sufficient amount ; but it is impossible to state when this is the case. The contents of the stomach of dyspeptic patients, removed at various intervals after meals, were rarely found to digest fibrin more rapidly after the addition of pepsin, while this almost invariably took place after the addition of hydrochloric acid (Leube). So, also, the contents of the stomach of ty- phoid fever patients, while constantly found destitute of hydrochloric acid, always seemed to contain a sufficient amount of pepsin (Gluzinski). Hence, in cases of dys- pepsia, if hydrochloric acid, properly given, have failed to improve digestion, pepsin should be used together with the acid. The dose of pepsin is about ten grains, and is administered soon after meals. The officinal solution of pepsin, containing some hydrochloric acid, is given in doses of half an ounce. Extract of malt, when properly prepared, contains a small quantity of diastase, and hence may promote the digestion of amylaceous food. For this purpose it may be taken with the meals, in quantities of one to four drachms, either alone or mixed with milk, bouillon, or wine. It has been recommended as a nutrient in wast- ing diseases, but should, not be employed unless it is not possible to administer more useful substances. Pancreatin has been recommended in cases of imper- fect intestinal digestion. It is doubtful whether it can pass through the stomach without losing its activity. In some cases of dyspepsia it has been found to give relief when administered together with a little soda about two hours after meals. Papain, a ferment obtained from the juice of carica papaya, digests fibrin and albumen more readily than pepsin, and has therefore been recommended in dyspep- sia in doses of five to ten grains. H^ematinics.-This term is applied to medicines that increase the coloring matter of the blood, the luemoglo- bin. The most important of these are the preparations of iron or the Chalybeates.-Iron is an efficient remedy in most forms of anaemia. Usually the symptoms due to the defective state of the blood gradually vanish when it is properly administered for some weeks; the integuments lose their waxy pallor and resume a healthy glow ; the pulse again becomes full and forcible ; the vertigo and head- ache cease ; and the languor and depression give way to the normal strength and vigor. This remarkable action was observed long before it was known that iron is a component of the haemoglobin of the red blood-corpus- cles. Since it has been ascertained that a diminution of the coloring matter of the blood indicates a deficiency of iron, it has been held that chalybeates cure anaemia by supplying material necessary for the rapid regeneration of the red blood-corpuscles. It is generally supposed that the preparations of iron produce little or no effect in healthy persons, if given in such forms as not to cause serious gastric disorder. But careful observations recently made (see Therapeutische Monatshefte, Bd. 2, p. 11, 1888) show that even minute doses of chloride of iron, repeated day after day for sev- eral weeks, may induce notable disorder of the stomach, accelerate the heart's action, and cause severe attacks of dyspnoea, a feeling of general heat, occasional flushing of the face, itching of the skin, acneiform eruptions, and slight conjunctivitis. In anaemia, if the cause of the defective state of the blood be irremediable, iron fails to produce any marked or permanent increase of the red blood-corpuscles. Hence its use in chronic wasting diseases and in organic affections is generally futile. Its utility is most strikingly mani- fested in chlorosis ; often a steady increase of the haemo- globin from day to day is observed, and in a few weeks the blood again contains the normal number of red blood- corpuscles. It is also very efficient, though usually less essential, in the anaemia remaining after severe acute dis- eases and after haemorrhages ; but is almost powerless in pernicious or idiopathic anaemia. In all cases of anaemia it is essential for success in the use of iron that all the circumstances influencing nutri- tion be favorable ; that the patient have a plain nutritious diet, that he take a sufficient amount of bodily exercise, that he spend a considerable part of each day in the open air, and that he be regular in all his habits. Iron is contra-indicated as a haematinic when the tem- perature is abnormally elevated, when there is present an organic disease of the stomach, or any affection of the lungs attended with congestion of the pulmonary cir- culation. The officinal preparations of iron are excessively nu- merous, and young practitioners are often in doubt as to the most efficient ones. When the object is simply to hasten the regeneration of the red blood-corpuscles, it is immaterial which preparations are selected, as all, if given in such doses and forms as not to disorder the di- gestive organs, act equally well. The dose should be small, even of those preparations which have little local action. The quantity of iron contained in the food daily consumed by a vigorous per- son is about one grain; it is doubtful whether a much larger quantity can be assimilated when iron is given as a medicine. It may be observed, even when small doses are given, that the greater part is not absorbed and is voided with the faeces. The preparations most frequently used are reduced iron, saccharated carbonate, mass of carbonate, citrate, pyrophosphate, iodide, and tincture of the chloride. Reduced iron is given in doses of one to two grains, generally in pill or powder. 1). Ferri reducti, 5.0 (gr. Ixxv.); pulv. rad. althaeae, 4.0 ( 3 j.) ; gelatin., q. s. ut ft. pil. No. 90. Sig.: At first one and gradually two or three pills three times daily. If properly prepared these pills are soft, and hence well borne by the stomach (Leube). I). Ferri reducti, gr. xii. ; sacch. albi, 3 j. ; ol. menth. pip., gtt. ij. M. Div. in part, aequal. xij. Sig.: One pow- der after each meal. Saccharated carbonate of iron is given in doses of from five to ten grains. In cases of atonic dyspepsia with anae- mia. it may be given together with quinine as follows : R. Ferri carb, sacch., 3 j.; quin, sulph., gr. xij. M. Div. in part. aeq. No. xij. Sig. : One powder after each meal. It may also be administered in the form of an effervescent draught as follows : R. Ferri carb, sacch., sodii bicarb., aa 3iv. M. Div. in part, aequal. viij. Sig. No. 1. R. Acid, tartarici, 9ij. ; sacch. albi, 9ij. ; ol. limonis, gtt. ij. M. Sig. No. 2. Dissolve one powder of No. 1 in some water, add one powder of No. 2, and drink while effervescing. Mass of carbonate of iron is given in pill. It is fre- quently ordered together with quinine as follows : R. Quin, sulph., gr. x. ; mass, ferri carb., 9ij. M. Ft. pil. No. xx. Sig. : One or two pills after meals. Citrate of iron is usually ordered in solution, and some- 125 Tonics. Tonka Beans. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. times in powders and pills. The bitter wine of iron is an excellent preparation in atonic dyspepsia and anaemia, given in doses of one or two teaspoonfuls after meals. Pyrophosphate of iron is given like the citrate, in doses of five to ten grains after meals, usually in solution. The syrup of the phosphates of iron, quinine, and strychnine, is frequently employed in atonic dyspepsia and anaemia, in doses of one or two teaspoonfuls. The tincture of chloride of iron contains about five per cent, of metallic iron. It is given in cases requiring an astringent preparation, in doses of ten to thirty drops, largely diluted. Glycerine modifies its taste very mark- edly. Tinct. ferri chlor., 3 ij.; glycerini, 3 xiv. M. Sig.:'A teaspoonful in a wineglassful of water after meals. General Tonics.-Some general tonics act chiefly as nutrients, gradually increasing the weight of the body, and invigorating all the organs by supplying needed material ; others seem to exert a stimulating or modify- ing action upon the tissues, in consequence of which they assimilate the nutritive material of the blood more rapidly. Cod-liver oil,-In chronic wasting diseases and in vari- ous kinds of malnutrition, cod-liver oil displays remark- able power. Usually it improves the appetite, invigorates the digestive organs, augments the number of red blood- corpuscles, and increases the body-weight. Besides the ordinary constituents of oil, it contains free fatty acids, the quantity varying with the kind of oil. According to recent analyses, the quantity of free oleic acid in the pale variety of oil varies from 0.18 to 0.71 per cent., and in the dark variety from 2.54 to 5.07 per cent. Cod-liver oil contains also traces of iodine, bromine, chlorine, phosphorus, sulphur, ammonia, and trimethylamine, and the dark variety, biliary matter. The superior digestibility of cod-liver oil has recently been satisfactorily explained (Buchheim, 1874). It had long been observed that this oil diffuses through animal membranes more rapidly than other oils. As the pres- ence of bile greatly increases the diflfusibility of other oils, and the early analyses of cod-liver oil had shown the presence of bile in it, the remarkable digestibility of the oil was attributed to the biliary matter. But Buch- heim showed that the pale oil contains no bile, and that its digestibility is solely due to the free fatty acids. The modifying influence of the fatty acids can be readily ob- served by placing a small amount of dilute solution of soda (3 to 1,000) in a test-tube and adding a few drops of cod-liver oil. In a very short time the mixture becomes milky, the union between the soda and fatty acids com- pletely emulsifying the oil. It is well known that all fats and oils, before they can be absorbed, must undergo a similar process in the small intestine. This is accomplished chiefly through the in- fluence of the pancreatic juice, which contains a peculiar ferment having the power to decompose fats into gly- cerine and free fatty acids. The free fatty acids, coming into contact with the alkali present in the intestinal juices, are quickly saponified and thus enabled to emulsify any undecomposed fat. Cod-liver oil, containing free fatty acids, becomes emul- sified more readily than other fats in the alkaline intesti- nal juice ; hence many persons, who are soon disordered by other fats, perhaps from defective secretion of pan- creatic juice, readily digest cod-liver oil. Perhaps the utility of cod-liver oil is not fully explain- ed by its great digestibility ; it may after absorption dif- fer in action from other fats. It is said to have been ob- served in horses that the fat laid on from corn is tolerably permanent, while that produced by feeding on grass is soft and quickly disappears when the animal is put to work (Brunton). Possibly cod-liver oil is so useful in some wasting diseases by promoting the growth of cells more rapidly than other fats and oils. It certainly, in many cases of anaemia, rivals iron in the rapidity with which it causes an increase in the number of red blood- corpuscles. Cod-liver oil is indicated in all chronic diseases at- tended by anaemia and emaciation. It has been found, by the most careful observers, to be the best means of sustaining and increasing nutrition in chronic pulmonary affections, especially phthisis and chronic bronchitis. Often, soon after its use is begun, the symptoms of phthi- sis greatly abate, and in some cases, when little pulmo- nary tissue is invaded and injured, a complete cure re- sults. It is also successfully employed in debility of the nervous system resulting from prolonged overwork, and in hysteria and neuralgia. Usually it is strikingly bene- ficial in diseases of the bones, rickets, chronic rheumatism, and tertiary syphilis ; in malnutrition of the heart with defective general circulation, and in scrofulous affections of the glands, mucous membranes, skin, and bones. The dose of the oil should at first be small, about a tea- spoonful. As soon as the stomach has become accus- tomed to it, and eructations having the taste of the oil have ceased, the quantity should be rapidly increased to one or two tablespoonfuls three times daily. Children rarely require more than a dessertspoonful. As the alka- line intestinal juices are most abundantly secreted after meals, the oil should be taken a little while after eating. As a rule, the various means used to disguise its taste, except perhaps alcoholics, soon become repulsive. Chil- dren, and many adults, soon become accustomed to its taste, and often take it with a relish. For the various methods of disguising its taste, see Vol. II., p. 222. Lipanin.-This term has recently been applied by J. von Mering, of Strasburg (see Therapeutische Monats- hefte, Bd. ii., p. 49), to a substitute for cod-liver oil, con- sisting of pure olive oil and six per cent, of oleic acid. Like cod-liver oil, it speedily emulsifies in weak solu- tions of soda. It has an agreeable taste, and hence is readily taken even by fastidious patients. In numerous cases it was found to agree well with the stomach, even during the summer months, and in no instance did it cause nausea, vomiting, or diarrhoea. Given to adults in doses of from two to six tablespoonfuls daily, it notably increased the general strength and the body-weight. J. von Mering concluded, after observing its action in nu- merous patients, that it is well adapted to all affections in which cod-liver oil is successfully used, and especially to cases in which a deficiency of pancreatic juice and bile in the small intestine renders the absorption of ordi- nary fats difficult or impossible. Probably other oils, to which oleic acid has been added, such as cotton-seed oil, will be found to be equally digestible and useful. Arsenic.-Arsenious acid and Fowler's solution, given in minute doses in cases of impaired general nutrition, slowly increase the body-weight and the power of all the functions. Under their prolonged use, diseases due to malnutrition, especially those of the skin, nervous system, lungs, and stomach, generally improve, and sometimes completely subside. Even in the healthy state of the body, arsenic may in- crease nutrition. Thus Kopp, who had been experi- menting with arsenic and could not entirely prevent its access to his organism, in two months gained twenty pounds in weight. It is now well established that in Styria some peasants have the habit of consuming arsenic at regular intervals for the purpose of increasing their powers of endurance. In numerous careful experiments upon animals, Gies (Arch. f. exp. Path. u. Pharm., Bd. viii., p. 175) found that arsenious acid greatly promoted nutrition and decidedly increased the weight of the ani- mals, and especially hastened the growth of osseous tis- sue. In doses but little larger than those which promote nutrition, arsenic may cause incipient symptoms of poi- soning-thirst, nausea, pain in the epigastrium, head- ache, sleeplessness, fever, conjunctivitis, and oedema of the eyelids. Usually these symptoms quickly subside when the use of arsenic is discontinued. Until recently nothing was known of the mode of action of arsenic. Experiments made by Binz and Schulz (Arch. f. exp. Path. u. Pharm., Bd. xi., p. 200), show that arsenious acid becomes oxidized and converted into arsenic acid in the body, and that the arsenic acid is again reduced to arsenious acid. The blood was found 126 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tonics. Tonka Beans. to oxidize arsenious acid very slightly, while it strongly reduced arsenic acid. On the contrary, the gastric mu- cous membrane, the pancreas, the liver, and the brain strongly oxidized arsenious acid, and only slightly re- duced arsenic acid. The transmutations of the acids into each other occurred only in protoplasmic tissues. Binz concluded that the arsenious acid which passes from the blood into the protoplasm of the glands in the abdomen, and into that of the nervous system, strongly reduces the protoplasm, becoming oxidized at its ex- pense. In the capillary and venous blood the arsenic acid is easily again reduced to arsenious acid, and the latter is thus enabled to repeat the process in the pro- toplasm as often as it passes to it, that is, as long as it re- mains in the body. From these changes it seems that elementary arsenic acts simply as a carrier of oxygen, and that its effects upon nutrition are due to more rapid tissue-change. Arsenic is employed in numerous diseases due to mal- nutrition-the early stage of phthisis, chronic diseases of the skin, irritability of the stomach from catarrh, ulcer, or cancer, chorea, and in various forms of neuralgia. In malarial affections it is often used successfully, even when quinine fails, especially in the anomalous forms known as masked ague. According to late reports, it has proved more useful in idiopathic or pernicious anaemia than iron, cod-liver oil, and other remedies which aug- ment the number of red blood-corpuscles. As a rule, the dose of arsenious acid should at first be minute ; if necessary it may be gradually increased until the pathological condition for which it is given has im- proved, or until the incipient symptoms of its poisonous action become manifest. As soon as any of these take place, especially gastric irritation or conjunctivitis, the dose should be diminished or discontinued. In some cases, especially diseases of the skin, small doses should be given for some time after the symptoms of disease have disappeared, in order to prevent their recurrence. The minute dose of one-fiftieth grain of arsenious acid, or two drops of Fowler's solution, given after each meal, will usually produce a notable effect upon the general nutrition in one or two months. Prudence requires that Fowler's solution be ordered in a dilute form. B- Liq. potassii arsen., 3 ss.; aq. menth. pip., aq. destil., aS j- M. Sig.: A teaspoonful after meals. B- Liq. potassii arsen., 5 ss.; tinct. gentian, comp., § jss.; syr. aurant., 5s9- M. Sig.: A teaspoonful after meals. Phosphorus.-In minute doses phosphorus markedly promotes the growth of osseous tissue. In larger doses it augments the interstitial tissue of the stom- ach and liver, and induces chronic inflammation of these organs with atrophy of the secret- ing cells. Poisonous doses rapidly cause fatty degeneration of the stomach, pan- creas, liver, kidneys, heart, muscles, and blood-vessels. As it forms a chemical com- ponent of nervous tis- sue, it has been sup- posed to be-specially useful as a nutrient for the nervous sys- tem ; but nothing in- dicating such action has been observed af- ter the prolonged ad- ministration of minute doses, except that functional nervous diseases sometimes im- prove during its use. Phosphorus is held to act upon protoplasm in nearly the same manner as arsenic. Outside of the body, in contact with water and air, it produces ozone. There exists no reason why it should not produce the same in the inter- nal organs, into which it penetrates dissolved in fat, and the ozone, not the phosphorus as such, is the active prin- ciple. Phosphorus quickly produces ozone, and hence acts severely and destroys rapidly ; arsenic, on the con- trary, slowly renders oxygen active, and therefore acts less violently, but this is compensated for by. the longer du- ration and more frequent repetition of its action (Binz). Phosphorus is indicated in diseases of the bones requir- ing a more rapid or perfect growth of osseous tissue, such as osteomalacia, rickets, and insufficient ossification after fractures. It has been recommended also in various diseases of the nervous system, and seems sometimes to have been successful in those of a functional nature, such as neuralgia, nervous debility, incipient dementia, and impotence. It has been used with alleged success in ob- stinate skin diseases, and in leucocythamiia. The dose of phosphorus ranges from the T|o to the of a grain. In rickets a daily dose of the of a grain was found sufficient. In neuralgia and other functional diseases of the nervous system, some practitioners have succeeded with doses of to grain given thrice daily. As much as grain every four hours for twenty- four hours has been given in severe neuralgia. The officinal phosphorated oil, containing one per cent, of phosphorus, and the pills of phosphorus, each contain- ing the to^ of a grain, are convenient forms for admin- istration. B. Olei phosphorati, Tf[ xvi. to xxxvi.; mist, amygdalae, §ij.; ol. gaultheriae, gtt. viij. M. Sig.: A teaspoonful one hour after meals. Phosphide of zinc contains one-fourth its weight of phosphorus and is given in pill, in doses of to £ grain. Mercury.-Until recently it was supposed that mercury in minute as well as in large doses, given for some time, always exerts a deleterious influence on the general nu- trition. In 1869 Liegeois reported that he had observed that subcutaneous injections of minute doses of corrosive sublimate had increased the body-weight of healthy men. Bennet (1874) found that small doses increased the weight of dogs. Keyes (1876) carefully investigated the effect of small doses of mercury upon the red blood-corpuscles and the general nutrition, and concluded that mercury acts as a tonic upon persons in fair health and not syphilitic, in- creasing the number of red blood-corpuscles and the body- weight. Schlesinger (1881), who made numerous careful experiments upon rabbits and dogs, fully confirmed the facts found by the above-mentioned observers. But he came to the conclusion that mercury is not a true tonic like iron, but, as it does not increase the excretion of urea, it augments the body-weight by retarding tissue-change. Although no physician will be inclined to use mercury as a tonic in ordinary forms of emacia- tion and debility, yet it seems rational to employ it when the low state of nutrition occurs in persons who present symptoms of syphilis. According to Keyes (" Ven- ereal Diseases," p. 119, New York, 1880), tonic doses may be continued steadily during several years without injury to the patient. Samuel Nickles. TONKA BEANS. (Tonka, Codex Med.) The seeds of Couma- rouna odorata Aubl., order Leguminosce. This tree, which is a native of Guiana, has large alternate pinnate leavesand small papil- ionaceous flowers in racemes ; its fruit is a one-seeded drupe-like pod, in shape and ap- pearance like an enor- mous almond. The seed, which is the valuable product, is long, narrow, flat- tened, wrinkled, soft, black, and pleasantly Fig. 3938.-Coumarouna odorata. Flow- ering branch with fruit. (Baillon.) 127 Tonka Beans. Tonsils. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. odorous. It contains a peculiar crystalline, volatile, neu- tral principle, coumarin, to which it owes its odor and value. Coumarin is also made artificially on a large scale. Tonka Beans have no medicinal value. They are used as a perfume and a flavor, especially by manufacturers of tobacco. Allied Plants.-See Senna. W. P. Bolles. TONSIL OF THE TONGUE. [Glandular (or adenoid) tissue at the base of the tongue.] This tissue, the existence of which has long been known, is more or less analogous with the adenoid structure of the faucial tonsils and the adenoid tissue at the vault of the pharynx. As has been suggested by Waldeyer, it completes the circle of glan- dular tissue which surrounds the pharynx. Histologically, the principal difference between the faucial tonsil and the lingual adenoid masses is, that while in the tonsils the adenoid tissue is collected together into a circumscribed and well-defined mass, the adenoid tissue at the base of the tongue is disseminated in small groups over a considerable surface. Strictly speaking, these groups are not glands, since they have no excretory duct nor outlet, but are enclosed bodies and belong in reality to the lymphatic system. They are usually three or four lines in diameter, and are loosely embedded in the submucous tissue. Their hilus is covered with a thin mucous membrane. Their sac contains a varying num- ber of follicles, closely resembling those of Peyer's glands of the intestines. The existence of the lingual tonsil, so- called, is a normal condition. The collections of tissue are located between the circumvallate papillae and the epiglottis. Normally they are not conspicuous, nor is their presence manifest excepting upon irritation, when it will be discovered that the region which they occupy is highly sensitive, and liable to marked reflex phenomena. In examining the base of the tongue with the laryngos- cope there is found, normally, a free interval between the base of the tongue and the epiglottis. When the ade- noid tissue is hypertrophied, this interval is more or less tilled up, and the tip of the epiglottis may be seen im- pinging against the tongue or, apparently, buried in a mass of enlarged and prominent glands. The hyper- trophy may extend laterally, and thus shut off the view of the pyriform sinus. It is often more markedly de- veloped upon one side than upon the other. The glands may be seen projecting backward, each one more or less distinct and by itself, and the whole forming an aggrega- tion which is clearly more prominent and conspicuous than is seen in the natural state of the parts. Dilatation of the blood-vessels of the neighborhood is generally a marked feature. As to what constitutes the normal con- dition of the base of the tongue, it may be said that in the vast majority of cases pathological symptoms will only be caused by abnormal enlargement of the adenoid tissue so pronounced that, when sought for, it can hardly fail of being recognized. Pathologically, it is only within a few years that atten- tion has been directed to this fact. Since 1877, Stoerk, Betz, Lennox Browne, and Llewellyn Thomas, have suggested the importance of the condition as a factor in the production of symptoms before unexplained, 'and later the subject has been exhaustively treated of in an able article by Swain, of New Haven, and by Gleitsman, of New York. The disease commonly met with in the lingual tonsil is a condition of general hypertrophy, in which the whole gland is increased to double the normal size or more, and its follicles themselves are considerably en- larged. This hyperplasia is very similar to the condition seen in chronic hypertrophy of the faucial tonsil. It is said that hypertrophy of the lingual tonsil generally ap- pears at the time of puberty. Judging by analogy from the other deposits of adenoid tissue in the pharynx, there is no reason why it should not occur at any age. More- over, as a matter of fact, it is not uncommon to see it in children. The causes of the hypertrophy are, to a great degree, identical with those of chronic hypertrophy of the faucial tonsils. Of these, the most frequent and important are probably struma, or hereditary syphilis, indigestion, and the rheumatic diathesis. The symptoms observed in these cases are many and, as a rule, well marked. They are more commonly ob- served in women than in men. The patient complains of a sensation of pricking, or of the presence of a foreign body in the throat. The pain is usually localized, but sometimes radiates to other parts, these subjective phe- nomena being increased if the tongue be drawn back- ward. The explanation of these symptoms is simple. Normally, the margin of the epiglottis is free. When the lymphoid tissue of the tongue is so enlarged as to come in contact with it, then, two parts being in con- tact which usually do not touch each other, the subjec- tive sensation of a foreign body results, accompanied or not by pain in proportion to the amount of irritation produced. According to Swain, patients occasionally complain of pain shooting up to the ears, or refer their discomfort to the stomach, larynx, trachea, or intra- scapular region. Pain is also present when the glands are in a state of subacute inflammation. The effect of hypertrophy of the lingual tonsil .upon the voice is marked and disastrous, for fatigue in speak- ing and singing is a common symptom. When the trouble is not severe the only complaint may be that the patient has pain while talking, without being hoarse, the neighboring parts of the throat being normal. In some cases the vocal fatigue can be traced to deficient innervation. In cases in which the difficulty is more pronounced, the voice may be entirely lost. " In some cases the voice is uncertain, being sometimes good and sometimes poor. Sometimes it is unreliable, or difficult to control, breaking during the effort to sing. Again, there may be a marked tendency to sing out of tune, and the timbre of the voice may be seriously impaired. Quite a number of patients suffer from cough, which is observed in two different forms. It is either violent, spasmodic, and almost incessant, or of a hacking charac- ter, appearing at shorter or longer intervals. The spas- modic form, as a rule, occurs when the hypertrophied glands encroach upon the epiglottis, and is less frequent than the hacking cough. The latter often gives rise to great anxiety on the part of the patient and his relatives, as they fear it to be a symptom of developing pulmonary phthisis. This form of cough is often present when there is merely contact between the glands and the epiglottis, and it is probably due to the friction of the tongue and epiglottis against each other during their movements. It is a question whether the so-called " globus hyste- ricus," as seen in nervous women, is not often less a mat- ter' of the imagination than has been commonly sup- posed. In patients afflicted with this complaint, hyper- trophy of the lingual tonsil has frequently been observed by the writer, while in patients of nervous temperament other reflex symptoms of the condition are often severe. On the other hand, the globus hystericus has been seen in patients in whom the base of the tongue was practically normal. Finally, attacks of dyspnoea resembling asthma may occur in patients with enlarged lingual glands. The prognosis is good, but the length of time required to effect a cure is not always easily determined. Treatment should be both general and local. In many cases attention to the state of the digestion, or improve- ment in the constitutional condition of the patient, will be sufficient to effect a cure. The treatment most highly effective for local purposes consists mainly in the removal of the hypertrophies by some form of cauterization. In simple cases, marked benefit has been derived from the local application of iodine, in the form of Lugol's solu- tion, and of various strengths, as the case may require. In more pronounced cases the actual removal of the dis- eased tissue is necessary. For this purpose, the wire snare, applications of chromic acid or Vienna paste, and the galvano-cautery are employed. In the hands of the writer, the last-named has proved by far the most satis- factory. The cautery may be used in the form of a flat elec- 128 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tonka Beaus. Tonsils. trode applied to the surface of the gland, or, still better, the excellent platinum-iridium galvano-caustic snare proposed by Gleitsman may be employed. The mate- rial of which this loop is composed is better than pure platinum, because more elastic, and, therefore, more easily managed during the operation. Under the influence of cocaine these operations are usually painless. Meanwhile, as has been suggested be- fore, general measures should not be omitted. D. Bryson Delavan. TONSILS, THE. [Faucial tonsils. Amygdalae. Ton- sillae.] [Tonsils of Luschka. Adenoid tissue at vault of pharynx.] [Tonsils of the Tongue. Adenoid tissue at the base of the tongue.] These organs are essentially collections of adenoid tis- sue, differing somewhat in appearance and function, but composed largely of the same elements, and so situated as to form an interrupted circle extending completely around the pharynx. In the normal condition their presence is hardly perceptible. Pathologically, each may be affected by diseases pe- culiar to itself, or, as in certain inflammatory states, all may suffer. A knowledge of the latter possibility is im- portant, for we are then forewarned that disease in one may mean the involvement of all, and no examination can be considered complete which has not included the study of all. Faucial Tonsils.-General Anatomy.-The fau- cial tonsils are two glandular organs situated one on each tical diameter is 20 mm., and its transverse diameter is 13 mm. Often a collection of adenoid tissue lies below the tonsil, and sometimes above it, large enough to look like a small additional tonsil. Sometimes it extends as a narrow but slightly elevated strip far lower down in the pharynx than the usual limit. It is not uncommon to find the gland divided by a deep sulcus running across its antero-posterior diameter, generally above rather than below the centre, and thus separating it apparently into two distinct lobes. Rarely the tonsil has been found to consist of a pendulous mass, resembling a tumor, arising from the deeper parts of tlie pharynx and gravitating downward into the pyriform sinus. Again, a super- numerary tonsil, the tonsilla accessor ia, has been described. In these cases there has been found a distinct tumor, composed of tonsillar tissue, and springing from some location upon the lateral wall of the pharynx more or less remote from the normal site. In early infancy it is sometimes impossible to demon- strate the presence of the tonsil at all, while in other cases it has been found in a condition of marked hyper- trophy soon after birth. Its period of greatest activity is just before puberty. It atrophies with old age. The surface of the tonsil is perforated by a varying number of slit-like and circular depressions, the common orifices of the system of cavities which it contains. If the tonsil of the rabbit be considered as a single lingual follicular gland, we have in man a multiplication of this to the number of from eight to eighteen, the interval be- tween any two adjacent glands forming a lacuna tonsilla- ris, crypt, or one of the system of cavities mentioned above. Many of them are spacious in extent, and they often pene- trate deeply into the substance of the gland, sometimes al- most reaching to its hilum. Often there are found in the inte- rior of the tonsil sin- gle larger cavities, each of which in- cludes several folli- cular folds and se- cures their common discharge at the per- iphery. The crypts of largest size and greatest depth are, as a rule, found in the middle part of the tonsil. By rea- son of this arrange- ment of the crypts, the surface of the tonsil is thrown into numerous and extensive folds, and an extraordinary in- crease in the superficial extent of the gland is obtained. The crypts generally are filled more or less with a yellow- ish substance, composed of fat molecules, loosened pave- ment epithelium, lymph-corpuscles, small molecular granules and cholesterin crystals, which probably arise from retained and decomposed epithelial matter, and per- haps, now and then, from the bursting of follicles whose cells have increased by proliferation and have undergone a retrograde metamorphosis and fatty degeneration. In its minute anatomy the tonsil is for the most part like other so-called adenoid glands. In common with the rest of the oral cavity it is invested with a thick covering of pavement epithelium. Proceeding from without in- ward, the surface epithelium is scaly, each cell having a flattened, circular nucleus. Beneath this the cells and their nuclei become less flattened. Still lower are found several layers of polyhedral cells, which have spherical nuclei and are connected together by intercellular cement substance, and are furnished with prickle cells. The whole rests upon a single layer of columnar epithelial cells with oval nuclei, and is furnished abundantly with simple papillae. Under the epithelium is a delicate en- dothelioid basement membrane. Following this is a Fig. 3940.-Section of Normal Tonsil. (Morell Mackenzie.) A, hilum; B, mucous gland; C, epithelial covering; D, lymphatic folli- cles; E, stroma. Fig. 3939.-The Tonsils. 1, Hard palate; 2, uvula; 3, 4, anterior pil- lars ; 5, 6, posterior pillars ; 7, 8, tonsils. side of the fauces, and between the anterior and posterior pillars of the soft palate. They consist essentially of re- duplications, more or less extensive, of the oral mucous membrane, in which are enclosed an abundant deposit of adenoid or lymphoid elements, the whole organ having an identity and a special function of its own. The gross structure of the tonsil varies in different animals. In some the gland is altogether wanting. Its simplest form is found in the rabbit, where it resembles closely a large lingual follicular gland. In the lion and in certain other of the larger animals, it is an almost cylindrical pocket with thick walls, and opening into the pharynx through a somewhat narrow orifice : while in the grizzly bear its surface presents a laminated appearance, due to a longi- tudinal disposition of its folds. In man many variations are found according to age and individuality, and in some instances resemblances to the types described above have been observed. Its usual shape is ovoid, and it more or less completely fills the triangular space between the an- terior and posterior pillars of the palate. Its base is gen- erally defined clearly, and corresponds with the greatest antero-posterior diameter of the tonsil. Its average ver- 129 Tonsils. Tonsils. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tolerably compact mucosa formed of interlacing bands of fibrous connective tissue and containing many connec- tive-tissue corpuscles. In the normal adult tonsil this structure is so delicate that sometimes it is hardly rec- ognizable. In chronic disease of the gland it may be- come enormously increased. From it bands of connec- tive tissue extend centrally into the larger' tonsillary folds, and the whole forms essentially both an enclosure and a framework for the adenoid tissue or proper sub- stance of the gland, as well as a nidus for its vessels. The adenoid tissue consists of a dense mesh work of fine, homogeneous fibrils which contains, besides occasional endothelioid connective-tissue cells, a large number of lymph-corpuscles. These are small, round cells, each of which has a distinct spherical nucleus surrounded by a very thin covering of cell protoplasm. Near the cortex, the lymph-corpuscles are collected by means of delicate septa given off from the inner stratum of the capsule into a single row of oval masses called lymph-follicles. Throughout the rest of the gland the lymph-cells are dif- fused without any particular arrangement. Occasionally they extend so near' the periphery as to penetrate the mucosa and encroach upon the epithelial layers. This is particularly the case in the interior of the crypts, where the epithelial layer is, as a rule, either wanting altogether or only to be found in occasional patches and in modified form, and where its thickness tends to decrease as the bottom of the lacuna is approached. In other words, the epithelial and subepithelial layers, thick at the periphery, become rapidly more delicate the deeper we trace them down the crypt-wall, until, toward the lowest depth of the lacuna, they generally disappear, by reason, probably, of the attenuation of the mucous membrane in this locality, and its consequent liability to rapid post- mortem decomposition and to mechanical injury in the preparation of the microscopical section. The tonsil is supplied abundantly with racemose mucous glands. The arteries which supply the tonsil are larger and more abundant toward its lower part. They accompany the connective-tissue sheath and its septa, give off a branch to each follicle and to the papillae of the mucous membrane, and divide into a network of capillaries which unite to form one or more veins. A lymph-sinus, in open connection with a network of lymphatic vessels of the neighboring tissue, surrounds each follicle over more or less of its circumference, and sends prolongations outward. According to Sappey, injections of the lymph-vessels of the soft palate reach the surface of the tonsils in a newly-born child, a foetus, and an infant of from six to seven months. These injections, however, were not suc- cessful in every instance. Whenever they did succeed they rarely went beyond the surrounding cellular tissue, and only exceptionally into the follicles themselves. Be- sides this scanty connection with the velum palati the tonsil has a similar one with the anterior and posterior pillars of the velum and with the glands adjacent to the common carotid artery. These lymph connections are more scanty in the adult than in the infant, and with ad- vancing age they become still less abundant. The minute distribution of the nerves is not definitely known. Krause believes that they terminate now and then in the simple papillae of the follicular cavities. Fibres from the sympathetic, undoubtedly, are supplied to the tonsil. From its peculiar position with regard to important adjacent parts, and by reason of the frequency with which operative interference is called for in the treatment of pathological conditions to which it is liable, the surgi- cal anatomy of the tonsil is of the utmost interest. The average interval between the free borders of both tonsils has been estimated to be 2.5 centimetres (1 inch), so that, when the mouth is closed, the inner aspect of the tonsil touches the tongue. In cases of normal size the tonsil extends but slightly, if at all, beyond the anterior palatine arch, which is formed by a projection of the palato-glossus muscle, and not at all beyond the posterior pillar, formed by the palato- pharyngeus. With both of these muscles it has fibrous attachments. A loose submucous cellular tissue extends from the anterior and posterior palatine arches toward the pharyngeal side of the tonsil, which facilitates infil- trations and the formation of abscesses, particularly in the anterior arch. Small bundles of muscular fibres, ap- parently independent, are to be found in the connective tissue of the external side of the tonsil which corresponds with the hilum. This side is also surrounded by fibres from the superior constrictor of the pharynx. Its outer aspect, moreover, is directed toward the internal ptery- goid, from which it is separated by the above-mentioned muscular fibres, by the bucco-pharyngeal fascia, and by a thin layer of fat. The relations of the tonsil with the internal carotid ar- tery are not so intimate as is commonly supposed, for, between the lateral wall of the pharynx, the internal pterygoid, and the upper cervical vertebrae, there is a space filled with cellular tissue, the " pharyngo-maxillary interspace," in the posterior part of which are located the large vessels and nerves, and which lies almost di- rectly backward from the pharyngo-palatine arch. The tonsil corresponds to the anterior part of this interspace, so that both carotids arc behind it, the internal carotid 1.5 centimetre (a little over half an inch), the external carotid two centimetres (f inch) distant from its lateral edge. Zuckerkandl's investigations tend to support this view, and he also holds that, apart from the wall of the pharynx and the fat which occupies the region behind the tonsil, there is in addition a muscular layer which lies in front of the internal carotid artery. The study of the surgical anatomy of the tonsil would be incomplete were the consideration of its blood-supply omitted, and so much interest has of late attached to the accidents which may happen in operations upon the or- gan, that it seems desirable to investigate the matter in detail, and describe it as fully as possible. The supply of blood conveyed to the tonsils is, considering the size of these bodies, remarkably large. They are nourished by the tonsillar and palatine branches of the facial artery, and by branches from the descending palatine, and from the ascending pharyngeal and dorsalis linguae. The palatine branch of the facial artery, called also the inferior, or ascending, palatine artery, ascends between the stylo-glossus and stylo-pharyngeus muscles, and reaches the pharynx close to the border of the internal pterygoid muscle. After having given small branches to the tonsil, the styloid muscles, and the Eustachian tube, it divides near the levator palati muscles into two branches, one of which follows the course of the circumflexus palati mus- cle, and is distributed to the soft palate and its glands, while the other penetrates to the tonsil and ramifies upon it with the tonsillar branch, with which it anastomoses. The place of this artery upon the palate is often taken by the ascending pharyngeal. The tonsillar branch ascends along the side of the pharynx, and penetrating the su- perior constrictor of the pharynx, terminates in small vessels upon the tonsil and the side of the tongue near its root. The posterior or descending palatine artery is a branch given off from the third or spheno-maxillary portion of the internal maxillary. It descends perpendicularly through the posterior palatine canal, with the palatine nerve, and runs along the hard palate. While descend- ing in the canal this artery sends off twigs through the bone, which communicate in the soft palate with the as- cending palatine branch of the facial artery. The dorsalis linguae arises from the lingual artery be- neath the hyo-glossus muscle, and, ascending to the dor- sum of the tongue, it supplies the mucous membrane, the tonsil, soft palate, and epiglottis, and anastomoses with its fellow of the opposite side. The ascending pharyngeal artery, a long and slender vessel, arises from the external carotid, most commonly from half an inch to an inch from its origin. It divides into three sets of branches; of these the pharyngeal branches are three or four in number. The largest of them passes inward, running upon the superior con- strictor, and sends ramifications to the soft palate, Eu- stachian tube, and tonsil. The ascending pharyngeal is 130 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tonsils. Tonsils. often anomalous, for it not only varies greatly in its place of origin from the carotid, springing occasionally from the occipital or the internal carotid, and now and then being double ; but, also, that branch which is distributed to the pharynx is often much larger than normal when the ascending palatine branch of the facial artery is un- usually small. Cases are not infrequently observed in which the pulsations of the artery, enlarged as above stated, are plainly visible upon inspection of the pharynx. The vessel seems, generally, to lie directly behind the tonsil, and to be of considerable size. A detailed description of the circulation of the tonsil has been given for the purpose of calling special attention to certain features in the surgical anatomy of the gland, which have never been sufficiently recognized and ex- plained, and which will be discussed in the section of this article which treats of haemorrhage after tonsillotomy (p. 143). Physiology.-The physiological function of the ton- sil, so far as it has been reasonably explained, is to act mechanically in shaping the bolus of food as it passes the pharynx in the act of deglutition, so that it shall change its rounded form for one more cylindrical, and therefore better adapted to the diameter of the oeso- phagus. It secretes also a viscid fluid, somewhat re- sembling saliva, by which its surface is lubricated and the passage of food thus facilitated. Various other theories as to its use have been proposed. None, how- ever, seems to have been proved. Acute Inflammation. Tonsillitis.-In the tonsil, as in other parts of the body, the general term inflammation includes a great variety of affections. Not only do we find in this organ the ordinary inflammatory conditions, general and specific, which may attack its various struct- ures, but besides these there may occur special affections not commonly met with in other parts. The study, therefore, of the inflammations of the tonsil becomes a matter of unusual interest. While acute inflammations of the gland in general pos- sess characteristics of greater or less similarity the one to the other, the symptoms being quite uniform, it is nevertheless important to understand what symptoms are common to all cases, and what indications they offer for treatment, and also to appreciate the special conditions and needs which may exist in a given case. In dealing with the treatment of tonsillitis, therefore, the means of relief applicable to the general symptoms of the diseases which come under this head will be con- sidered, and afterward the means especially useful in the different varieties of the disease, and attention will be called to the important and varied pathological conditions which the term tonsillitis may embrace. Thus tonsillitis may be divided into : 1. Simple or superficial, acute, subacute, or chronic. 2. Follicular. 3. Parenchymatous. 4. Tonsillitis with abscess in the substance of the gland (quinsy). 5. Peri- or retro-tonsillar abscess. Follicular tonsillitis, so called, may be subdivided into the simple or catarrhal, and the diphtheritic, forms; to which varieties certain writers have added two others, the fibrinous and the purulent. While the diphtheritic variety should not, properly, be classified with follicular tonsillitis at all, since the disease must in reality be either distinctly diphtheritic or distinctly non-diphtheritic; there are yet so many cases which, to all appearance, oc- cupy an intermediate position between the two, that diagnosis becomes difficult and the disease is worthy of consideration side by side with the simple form. Etiology.-The causes of tonsillitis may be both predis- posing and exciting. Of the former the most important factor seems to be youth, since it is most prevalent be- tween the ages of fifteen and twenty-five years. It is rare in early childhood and after fifty, although a case is recorded in which suppurative tonsillitis took place in a child of only seven months. In many cases the ten- dency to tonsillar inflammations seems to be directly hereditary, and not referable to any mediate condition ; for, while in such instances it might be supposed that the presence of such an inheritance might be due to the existence in parent and child of a common diathesis-the rheumatic, for instance-nevertheless more than one case has been known to the writer in which no such diathesis could be traced. Climate may also play an important part. Hypertrophy of the tonsils greatly increases the liability of the individual to acute attacks of tonsillitis. Some- times this seems to be due to the retention in the en- larged lacunae of excretory matter, which acts as an irritant and so excites the adjacent tissue that a tonsil- litis supervenes. Again, the tonsil seems, in many cases, to be a vulnerable spot, which is apt to sympathize with various irregularities of the body, and to be subject to inflammation as the result of dyspepsia, menstrual ir- regularities, or uterine influence, the strumous diathesis, and, most important of all, rheumatism and gout. A general condition of ill-health may predispose to tonsil- litis, and it is a matter of common observation that it may be caused by mental depression, and by unusual anxiety or care. The exciting causes of tonsillitis are usually ascribed to exposure to wet and cold. There can be no doubt, however, but that septic influences often play an impor- tant part in their production, and the writer ventures to predict that this question will receive in the future more extensive consideration than has heretofore been accorded to it. Besides these things, bad hygienic surroundings, bad drainage, sewer-gas, all may be directly concerned in the production of the disease in its various forms ; and it is highly probable that, without the existence of some predisposing general condition, the chilling of the surface of the body through exposure to cold would have little effect. As to the influence which the season of the year may have upon acute affections, of the tonsils, the following statistics, compiled from one thousand five hundred cases of tonsillitis seen during several years' service in the throat department of the Demilt Dispensary, New York City, may fairly be taken as representing the relative frequency with which such attacks occur during the dif- ferent months of the year in this latitude (New York City): Acute. Chronic. Suppura live. Follicu- lar. Total. M. F. M. F. M. F. M. F. January 39 45 8 11 7 3 24 20 157 February 39 33 9 14 7 4 15 32 153 March 45 40 10 22 3 10 21 30 181 April 41 39 12 15 2 6 20 22 157 May 30 43 18 4 16 24 149 June 29 22 7 17 3 5 16 10 109 73 July 20 20 4 6 1 4 11 August 25 19 3 8 1 7 19 14 96 September 17 10 1 5 1 1 10 6 51 October . 25 28 8 11 5 6 10 27 129 November 20 32 14 16 4 5 10 32 133 December 35 23 15 13 14 28 18 153 365 £54 98 156 48 69 196 246 December, January, February = 163. March, April, May = 487. June, July, August = 278. September, October, November = 304. From the above it would appear that tonsillitis is most frequent in the spring, next most frequent in the winter, less so in the fall, and least prevalent in the summer ; that, of the months of the year, it is most frequent in March, and least frequent in September. Comparison of these tables with the statistics given by Morell Mackenzie gives such marked variation that the existence of decided dif- ferences between the corresponding seasons in New York and London is at once suggested. The inference is also apparent that what may be true of one latitude may not at all apply to another. The disease is uncommon in tropical and in very cold latitudes. Tonsillitis may be present as a complication in scarlet fever, measles, and small-pox. It may also be caused 131 Tonsils. Tonsils. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. by the inhalation of irritating vapors or the swallowing of caustic substances. A case was seen by the writer at the Vanderbilt Clinic, in which a severe attack was brought about by the swallowing of a small quantity of strong ammonia. Finally, it may arise from various traumatisms, such as wounds, laceration from, or impac- tion of, foreign bodies in swallowing, and from the irri- tation due to accretions in the tonsillar crypts. Symptoms.-Mackenzie believes that, while the actual pathological condition in tonsillitis may vary as between several forms of the disease, there is clinically no well- marked line of demarcation between the varieties de- scribed ; and that, as regards treatment, it is sufficient to make two divisions : 1, superficial or follicular tonsillitis, and 2, deep or parenchymatous tonsillitis. The symp- toms which usher in an attack of tonsillitis are, in gen- eral, much the same for all varieties of the disease. In fact, it is often impossible for the physician, or even for the patient, who perhaps has been for years accustomed to recurrent attacks, to predict, at the outset the proba- ble course of the illness. In many cases of true suppura- tive tonsillitis, however, there is from the first a sensation of deep-seated pain and throbbing, which to the experi- enced sufferer marks the attack as one of quinsy. The general symptoms are malaise, chilliness, and febrile tem- perature, more or less pronounced, together with a sense of stiffness and dryness of the throat, and more or less pain in deglutition. As the soreness of the throat be- comes worse the temperature tends to rise, until it may reach as high as 106° F. It is apt to rise most rapidly and to the highest point in the young, and, in the follicu- lar form of the disease, may attain a maximum in a com- paratively short time. Generally, however, the consti- tutional symptoms are more marked in the suppurative form. In patients of debilitated constitution the fever may assume almost a typhoid character, while the tonsils become dotted with a grayish exudation or are actually covered with sloughing, unhealthy ulcerations. In some instances the disease seems epidemic, attacking several persons in the same household and constituting the so- called "spreading quinsy," a disease suggestive of septic infection, and rarely observed without the coexistence of a definite source of infection, such as bad sanitary sur- roundings. The progress of the disease may be unfavor- able, leading to a true phlegmonous condition closely allied to genuine erysipelas, if not identical with it, and to extensive infiltration of the tissues of the neck in the vicinity of the tonsil, which has been known to extend downward as far as the clavicle ; while the violence of the inflammation not infrequently produces an oedemat- ous condition of the throat, which in the experience of the writer has been known to be fatal. The inflamma- tion usually extends to the mucous membrane lining the Eustachian tube, causing decided temporary loss of hear- ing, and sometimes inflammation of the middle ear. Dysphagia in a severe case of quinsy is often intense, the patient being unable to swallow even his own saliva, and absolutely refusing to take food, because of the inordinate pain caused by every attempt at deglutition, and because, from the tumefied state of the parts, the stiffening of the muscles, and the general local disability, the act of swal- lowing is a physical impossibility. The patient may be unable to move the jaw, the mouth becomes covered with a thick yellowish-gray deposit, the breath is fetid, the teeth are covered with sordes, and the countenance presents an expression of great anxiety and suffering, so characteristic of the disease that once seen it can hardly be mistaken. Nothing can be more distressing than such an attack, excepting, perhaps, the knowledge that, having had them before, they are likely to recur. The location of the abscess may be either in the parenchyma of the tonsil or in the layers of connective tissue which lie between it and the outside of the pharynx. In the former case death has more than once been produced by the sudden rupture of the abscess during sleep, and the consequent strangling of the patient. When the abscess is peritonsillar this danger is also present. An instance is recorded in which, through the presence of a periton- sillar abscess the walls of the internal carotid became weakened. An aneurismal dilatation took place, and rupture occurring, the patient died in a few moments. Several cases are recorded in which death has resulted from ulceration and rupture of the artery due to the same cause. In follicular tonsillitis, supposing the case to be one of simple catarrhal inflammation, and not diphtheritic, the swelling of the tonsil is less considerable than in the suppurative form, but the mu- cous membrane is of a bright red color, and a whitish exudation is seen issuing from the mouths of the lacunae, giving to the surface of the tonsil the appearance of being covered with a number of small, rounded patches. This exudation is not, however, a superficial membrane deposited upon the external surface of the gland, but the result of a diseased condition of the follicles or lacu- nae themselves, which, becoming filled, manifest the presence of the exudation at and around the mouths of the crypts. The con- dition is well illustrated by the accompanying figures. Sometimes the deposit extends beyond the mouth of the crypt, and, this happening in the case of two or more lacunae, the surface of the tonsil may present a considerable area of exudation from the coalescence of several individual patches. Follicular ton- sillitis usually undergoes spontaneous resolution in from two to five days. Another variety of tonsillitis is that in which there is observed upon the surface of the gland a distinct her- petic eruption, the mucous membrane and the paren- chyma at the same time being violently inflamed. This condition generally runs the course of a simple acute tonsillitis, subsiding in two or three days. It is often associated with the earlier symptoms of some more seri- ous affection, and particularly with those of pneumonia. A severe form of tonsillitis is sometimes seen in per- sons who have been exposed to debilitating influences, and who are at the same time surrounded by bad hy- gienic conditions. The writer has seen it most often in badly nourished attendants and overworked internes in large public hospitals. It is characterized by the ap- pearance upon the tonsil of a deep, unhealthy, more or less extensive sloughing ulcer, which gives rise to much local pain and profound general dis- turbance. Its course is slow, and convalescence may be attended with much prostration. Paralysis of the pharynx and palate, with or without anaesthesia, such as occurs after diphtheria, is sometimes seen after suppurative, follicular, and even after simple, tonsillitis. It is by no means as rare a condition as has been supposed (tide article on Uvula and Velum Palati), and when present may be limited or not to the side upon which the tonsil has been affected. The existence of such a paresis may be demonstrated with ease by observing the nasal, metallic intonation of the voice, the relaxed condition of the velum, its lack of sensibility, and the difficulty met with by the patient in swallowing ; the act of deglutition be- ing apt to force particles of food or fluids into the upper pharynx and nasal passages. Obstinate constipation almost invariably precedes and accompanies tonsillitis. The urine is highly colored, loaded with urates, contains an excess of urea, and is deficient in chlorides ; albumen is sometimes found. Haig Brown has observed that the existence of albu- men in the urine seems to be indirectly dependent upon Fig. 3941.-Exudation from L a c u n ee of Tonsil, a, Moderate exudation ; b and c, exudation extending outside mouth of crypt; e, coalescence of several patches ; /, empty lacunae. Fig. 3942.-Lateral Sec- tion. a, Coalescence of contents of two crypts. 132 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tonsils. Tonsils. the height of the temperature. When this is over 103° F., a trace of albumen is often present; but there are no casts, and the albumen always disappears when the temperature begins to fall. Its presence is of no more importance than the transient albuminuria of pneumonia and erysipelas, although upon first finding it one is apt to feel uncertain as to whether the affection of the throat may not be diphtheritic. Pathology.-Simple tonsillitis can hardly prove fatal unless complicated with some intercurrent affection, so that few opportunities have been offered to study the effect of simple inflammation upon the gland. The pathology of this class of affections of the tonsil, however, is of surpassing interest and importance, embracing, as it does, so many conditions of vital moment to the pa- tient and so many questions as yet under dispute, and apparently by no means near a satisfactory explanation. Of these by far the most important is the question as to the infectiousness of tonsillitis. This must depend largely upon the actual pathological character of several of the grand divisions of the affection, the condition present being recognized and accepted as either simple, septic, or diphtheritic. Thus, in follicular tonsillitis, so-called, we may have a case beginning with the characteristic punctate, whitish spots upon the tonsil, which may as- sume quickly the local appearances and general conditions of a true diphtheria ; or we may have a distinctly folli- cular exudation, followed by the general symptoms and the sequelae of diphtheria ; or, in a household in which there may be one or more children suffering from diph- theria, there will often be seen other cases, apparently of simple follicular disease, and occurring rather more com- monly in the adult members than in the other children ; cases which give perhaps no other evidence of being diphtheritic than the history of direct exposure to the contagion of diphtheria. Again, in cases of follicular tonsillitis apparently simple, there may be swelling of the cervical glands, albuminuria, paresis of the soft palate, tedious convalescence, and marked tendency to recur- rence. Finally, an undoubted attack of diphtheria is said to have followed exposure to what seemed to be fol- licular tonsillitis. All of these phases of the disease point directly to an intimate relation between it and true diphtheria, and make it impossible, with our present knowledge, to determine with precision where the one ends and the other begins. Froelich has met with several cases of follicular ton- sillitis in soldiers in garrisons, where the disease began with repeated chills, more or less fever, dysphagia, much general disturbance, anorexia, headache, lassitude, and severe pains in all the extremities. The lacunae of the tonsils were filled with a yellowish-white pus. In from one to three days, after a profuse perspiration, the patient felt comparatively w'ell. In one case, however, death occurred during the progress of the disease. Two days after the patient first noticed the throat affection, he was attacked with peritonitis, and died after an illness of five days. The autopsy showed enlarged tonsils, an enlarged thyroid gland, and peritonitis with flbro-puru- lent effusion. At the autopsy Froehlich slightly wounded his finger, and within twenty-four hours had lymph- angitis of the arm with swelling of the axillary glands, and on the second day follicular tonsillitis. His wife had an attack of follicular tonsillitis which appeared two days later than his, and the pathological assistant, who was present at the autopsy and also suffered a slight post-mortem wound, passed through a train of similar symptoms, attended also with tonsillitis. From the above statement, the truth of the opinion held by Jacobi and others seems highly probable, namely, that follicular tonsillitis may radically vary in its nature, and that it may be distinctly either diphtheritic, puru- lent, or septic. In addition to these more severe mani- festations there may be the catarrhal form, as commonly observed, and one in which the exudation is fibrinous in character. Thus, four varieties seem to be fairly dis- tinguishable, differing radically as to their origin and relative importance. In view of the anatomy of the ton- sil, and, particularly, of the number and extent of its crypts, and of the nature of the mucous membrane lining them, a thorough appreciation of the above conditions is most desirable. The disease is not limited to a small superficial area, but penetrates deeply into the remotest regions of the gland, and covers an extent of surface far in excess of what might be supposed. Thus the exuda- tion is brought into intimate relation with the lymphoid structures of the organ, its whole parenchyma is stim- ulated to a high degree of inflammation, and remedies ap- plied to the surface in the usual way fail largely of their object in that they cannot reach the localities principally affected. In conclusion, there is in all of these follicular forms of tonsillitis so much prodromic general disturbance, that it is hardly possible not to regard the tonsillar symptoms as largely local manifestations of a general constitutional affection ; and the idea advanced by Lennox Browne, and accepted by a considerable number of respectable author- ities, namely, that the rheumatic diathesis is accountable for many of the acute inflammatory diseases of the tonsil, can by no means be allowed to pass disregarded. Differential Diagnosis.-The diseases which may be mistaken for tonsillitis are diphtheria, phlegmonous pharyngitis, retro-pharyngeal abscess, scarlatina-when the rash is not well developed-syphilis, cancer, and phar- yngo-tonsillar mycosis. In suppurative tonsillitis, the inability to separate the jaws, the fetid breath, the coated tongue, and the peculi- arly anxious and suffering expression of the countenance, together with the comparatively slight systemic disturb- ance which often accompanies its earlier stages, are fail- evidence of its nature. Examination of the tonsil by palpation, will often be of material assistance ; the organ feels hard and prominent, while the slightest pressure upon it gives rise to intense pain. By means of the finger the presence of pus may be demonstrated, the tissues having a characteristically doughy feeling, or else actually presenting fluctuation. In cases in which pus is suspected, but in which fluctuation is not apparent, Stoerk has suggested that, while the exploration of the tonsil is being made with one hand, the gland be sup- ported from the outside by pressing gently with the other hand, behind and below the ramus of the jaw. It is in follicular tonsillitis that the greatest difficulties of diagnosis will present themselves, the desideratum being to distinguish the simple forms of that disease from true diphtheria. While simple follicular tonsillitis is generally distinguished from diphtheria by the absence of glandular swelling of the neck, albuminuria, and subsequent paresis of the pharynx, nevertheless, all of these symptoms may be present. The nature of the ex- udation also may be misleading. Usually the catarrhal exudate is confined to the mouths of the crypts, and may be easily stripped from the surface of the mucous mem- brane and dragged from the crypts, leaving the sub- jacent membrane intact ; while in diphtheria the mem- brane is deposited in patches upon the surface of the gland, is adherent, and, when torn from its place, leaves the membrane underneath distinctly eroded and bleeding. Nevertheless, these differences are not always to be de- pended upon. The indications which have seemed to the writer most diagnostic, and upon which, in doubtful cases, he has been able to place the greatest reliance, are the relative height of the temperature and the quality of the pulse. In follicular tonsillitis the temperature is usually high, rarely under 102°, and occasionally as high as 106°, rising suddenly and, in many cases, falling with almost equal rapidity. In diphtheria it seldom rises above 102°, gradually attaining that point, and remaining in its neighborhood for a considerable length of time. In follicular tonsillitis the pulse, although perhaps rapid, is usually full, bounding, and regular. In diphtheria it is rapid, markedly depressed, and sometimes irregular. Haig Brown believes that the occurrence of albuminu- ria may have a certain diagnostic importance. If albu- men be found for the first time on the second or third day, the temperature being at 103° or more, and disap- pear on the fourth, we are almost surely dealing, he says, with a case of simple tonsillitis; if, however, we 133 Tonsils. Tonsils. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. find albumen in the early days, with a comparatively low temperature (100°-101° F.), and especially if the albumen persist for two or three weeks, the case is probably one of diphtheria ; and, finally, if there have been no albu- men early and it be found for the first time at the end of two, three, or more weeks, it is most probable that the case has been one of latent scarlet fever. The diagnosis will, of course, be rendered more simple if a history of exposure to the diphtheritic poison can be obtained. Again, it is easy to suppose that a case, which is actually simple at the outset, may become affected with diphtheria, and later develop the full symptoms of that disease. Tonsillitis may be differentiated from the sore throat of scarlet fever by the absence of the characteristic exan- them and of the symptoms of the latter disease usually seen upon the tongue and pharynx. It must be remem- bered, however, that in true tonsillitis there is, rarely, a slight skin eruption. Syphilis may be differentiated from tonsillitis by the symmetry of its manifestations and by the presence of ulceration, the latter being an unusual condition except- ing in the former disease. On several occasions the writer has seen primary cancer of the tonsil mistaken for quinsy. The gradual develop- ment of the former and its duration, extending over a period of weeks or months, will exclude tonsillitis, while the fact that cancerous disease is unilateral, that it almost invariably occurs in patients over forty years of age, and that it is unattended with febrile symptoms, points clearly to the true nature of the case. Duration.-The duration of an attack of simple paren- chymatous tonsillitis is generally from three days to a week. In follicular tonsillitis the disease may run its course in a surprisingly short time. From two to five days would be a fair estimate of its average length. In quinsy the probable duration is most uncertain, and there is in many cases a tendency to relapse ; or, the process having been completed on one side, the opposite tonsil may be- come affected, and the whole tedious history of suppura- tion be repeated. Thus, the time required may extend over several weeks. Prognosis.-The prognosis in the milder forms of ton- sillitis is almost invariably good, and the progress toward recovery often wonderfully rapid. This is by no means invariably the case. Follicular tonsillitis is often fol- lowed by marked debility, while an attack of suppurative tonsillitis may be succeeded, in persons of debilitated con- stitution, by a tedious convalescence and long-continued general depression. Moreover, one attack seems to predis- pose to others, and with some patients every year brings with almost certain regularity one or more exacerbations. Death from quinsy has been known to occur in one of three ways : By sudden rupture of a large tonsillar abscess during sleep, resulting in suffocation ; by the violence of the inflammation causing infiltration of the neighboring parts, which, extending to the larynx, produces oedema of the glottis ; and by erosion of the walls of one of the large arteries ac^acent to the tonsil, followed by fatal haemor- rhage. Several instances of the first and third accidents are upon record. An instance of the second has been observed by the writer. In a vigorous man, accustomed to yearly attacks of tonsillitis, what seemed an ordinary quinsy suddenly became unusually severe. In the course of a few hours the existence of oedema of the larynx be- came evident. It was temporarily relieved by free scari- fication, but soon relapsed, and the writer was hastily summoned to perform tracheotomy, only arriving in time to see the patient expire, although a tracheal tube was instantly inserted and artificial respiration was persist- ently maintained. Treatment.-In all forms of tonsillitis the treatment, to be effective, must be both general and local. General Treatment.-Since acute tonsillitis is almost invariably attended -with constipation, the first and most important measure is the administration of an effective purgative, preferably a saline, and the continuance of mild purgation throughout the course of the attack. This holds true for all varieties of the disease. With regard to general therapeutic measures directed toward the disease itself, innumerable plans have been proposed and countless drugs have been lauded as speci- fics. In almost every instance they have proved valueless. Some, however, have survived the test of practical ex- perience, and have gained for themselves a fair reputa'- tion for usefulness. Before referring to them in detail it must be explained that the effect of drugs upon tonsillitis varies greatly in different individuals, and that the same drug which may be almost a specific for one, seems with another to be inert. Why this should be so is not clear, unless we may explain it upon the ground that the ton- sillitis is fundamentally due to a diathesis or special sys- temic condition, which condition is itself acted upon favorably or otherwise by the remedy. That this is true of the arthritic diathesis seems almost beyond question. It is needless to say that, to be effective, general treat- ment must be instituted as soon as possible after the commencement of the attack. For a simple case in an adult the best plan is to administer, alternately, every fifteen minutes, half a drop of tincture of aconite (Flem- ing's) and half a drop of tincture of belladonna, watching carefully for indications of the physiological effects of the drugs and stopping the medicine upon their appear- ance. This method promises much better results than the administration of opium in the form of a ten-grain Dover's powder, or of a large dose of sulphate of quinine, although both of the latter are occasionally serviceable. In the cases which seem to be of rheumatic origin three remedies have been highly recommended. These are sali- cylic acid, guiacum, and the bicarbonate of soda. Of these, the first is, in the experience of the writer, the most reliable. A convenient form for its administration is in capsules, each containing five grains of salicylate of soda, with a small quantity of quinine, generally about one grain, one such capsule to be taken every two, three, or four hours, as the case may require. The use of guia- cum in tonsillitis is more popular abroad than in this country. In England several of the best authorities re- gard it as a specific. It is best administered in the form of the guiac lozenge, which contains two grains of the drug; or of the ammoniated tincture, one drachm of which, combined with syrup, mucilage, or milk, consti- tutes a dose, to be repeated once every four to six hours, as the case may demand. The use of bicarbonate of soda, taken internally and also applied locally to the tonsil, has gained many supporters. In all forms of tonsillitis iron is invaluable. While there are many preparations of greater elegance, none is so effective and reliable as the tincture of the chloride, which not only acts constitutionally, but, in the process of deglutition, is applied locally to the surface of the tonsil, where its aseptic and astringent effects are most salutary. It may be administered most conveniently in glycerine, in the proportion of three parts of the latter to one of iron. From half a drachm to one drachm of the mixture to be given, as the case may require. The ad- dition to the dose of the iron and glycerine mixture of about one ounce of cold Vichy water, makes a decidedly palatable drink, and prevents the iron from staining the teeth. Quinine should also be given in tonic doses, and the nutrition of the patient must be carefully maintained. During convalescence the administration of bitter tonics and iron will materially hasten recovery. Local Treatment.-The employment of well-selected local measures in the treatment of acute affections of the tonsils is of the utmost importance. It is not too much to say that there is no case of tonsillitis, whatever may be its nature or its degree of severity, which cannot be benefited, and the more distressing symptoms palliated, by means of applications made directly to the affected parts ; and while the use of local applications cannot do away with the necessity for the constitutional treatment of the general condition underlying a given attack, the two should go hand in hand, each being essential to the successful working of the other. Local applications may be made either to the neck, in the region of the tonsils, or directly to the glands them- selves. If the onset of the attack be recognized at an early period in its history, much may be done to abort it 134 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tonsils. Tonsils. by the use of cold applied to the neck over the region of the tonsils. The application may be made in one of several ways. The old-fashioned plan of dipping a folded handkerchief in Cold water, wringing it out, and tying it over the neck in the neighborhood of the tonsils by two or three turns of a flannel bandage, is often pro- ductive of good results. Lennox Browne gives excellent directions for making a wet compress for the throat, and advises as follows : Take a piece of lint twice as large as may be required to cover the desired area-that is, from angle to angle of the jaw-or a piece of linen four times as large, the former to be folded twice, the latter four times. Saturate this with cold w'ater, apply it over the region of the larynx (or tonsils), and cover it with a piece of oiled silk, rubber tissue, oiled paper, or other water- proof material, which must be at least half an inch larger than the compress in every direction. By lining the oiled silk with flannel, greater adaptability is obtained. Secure by means of a handkerchief tied twice around the neck. Far more convenient is spongio-piline, as commonly made and sold in this country. By means of this most convenient dressing, applications of either heat or cold can be made, and with the least possible annoy- ance to all concerned. In the later stages of suppurative tonsillitis, poultices of linseed meal or spongio-piline, are often of great bene- fit. The application to the throat of dry cold is a value- able therapeutic measure in a large variety of inflam- matory conditions. The writer has been for several years in the habit of employing it in certain cases of diphtheritic tonsillitis, by partly filling a small bladder with pounded ice and laying it over the neck so as to cover the space adjacent to the tonsils. "Leiter's tem- perature regulator " is made of a series of coils of metal piping arranged to cover the part to which heat or cold is to be applied, and connected with a vessel filled with ■water of the required temperature, which is allowed to percolate through the tubing and escape from its distal end. For cold applications a temperature of 60° to 68° F. is often sufficient to abstract heat. That of 50° to 55° F. gives an effect equal to ice in ice-bags, while a tempera- ture of 35° to 40° F. may produce complete anaesthesia. Even a temperature of 50° F. cannot be endured long, and requires a layer of flannel between the coil and the applied surface. A temperature regulator has lately been made in this country, which is less expensive and far superior in every respect to the Leiter apparatus. It is called " Sitwell's improved surgical water banclage," and, being made of the best quality of soft india-rubber, is ex- tremely light-weight and elastic, and hence remarkably adaptable, convenient, and comfortable. Browne urges, in favor of the temperature regulator as applied to the neighborhood of the air-passages, that: 1. The effect is strictly local. 2. The temperature is constant-warm applications do not become cold, nor cold applications warm. 3. Moisture, with all its attendant inconvenience, is not necessary, but, if indicated, can be applied by this method, the required temperature being maintained. 4. The apparatus is cleanly, light, and not liable to get out of order. 5. Ice is not required, the ordinary temperature of the w^ater as drawn generally being sufficient. 6. Finally, the apparatus is so inexpensive and so read- ily adaptable to other uses, that there need be no hesita- tion in urging its general use. For outside application the use of pigments, counter- irritants, and leeching is, as a rule, not to be recom- mended, since they are far more likely to increase than to diminish the discomfort of the patient. When re- quired, a simple stimulating liniment of ammonia well answers the purpose, while the use of cold, as already described, early in the attack, or of warm poultices later, will be found both grateful to the patient and beneficial. When excessive secretion is an annoying feature of the case, some advantage may be derived from the external application to the throat of belladonna liniment. Internally, the use of inhalations of steam and of hot sprays has of late become unpopular. Much better is the following process : Let the patient lie upon his back, partly fill the mouth with hot water, turn the head until the face is uppermost, and thus allow the water to gravi- tate toward and upon the affected parts. This will suc- ceed as well as any ordinary act of gargling, and with little or no discomfort. It may be repeated as often as necessary. It is generally productive of so much com- fort that the patient soon realizes its value and will desire its repetition. This is true even of children. If desira- ble, the fluid may be medicated, the addition of a small proportion of borax being especially helpful in facilitat- ing the removal of the viscid secretions common in such cases. It must be remembered, however, that an extensive area lies behind and above the tonsils, which may be more or less filled with irritating secretion, and which washes, applied as above, cannot reach. For cleansing these parts, no method is more satisfactory or more gen- tle than the careful injection of spray, through the ante- rior nares and backward into the pharynx. This maybe done by the patient himself, or by an attendant, by means of any good hand-ball atomizer throwing a horizontal jet, and when properly employed is capable of giving the greatest relief. The same spray may be used through the mouth, directly toward the tonsils and pharynx. The use of the post-nasal syringe in acute inflammations of the tonsils and pharynx is dangerous, and should never be allowed. While in chronic conditions harm has prob- ably very seldom been done by the use of this instrument, in acute cases it has been beyond question the cause of serious middle-ear inflammation. In one instance, seen in consultation by the w'riter, the result was a mastoid ab- scess which nearly proved fatal. Severe pain followed immediately upon the injection of the naso-pharynx with a solution of salt-water, a drop or two of wlpch seemed to have entered the Eustachian tube, and within a few hours all of the signs of acute middle-ear inflammation appeared. Applications to the tonsils of medicated fluids may be made to the best advantage with the hand-ball atomizer. One of the best solutions for use in simple and follicular tonsillitis is composed of chloride of zinc, gr. ij. to iij.- § j. For purposes of cleansing and disinfection, an alkaline solution containing some good disinfectant will be most useful. Dobell's solution, if employed at all, should be largely diluted with w'ater. A good mixture, and far more elegant than the former, is composed as follows: IJ. Borax, 3 jss. " Listerine" (the principal ingredient of which is thymol), glycerine, aa 3 iij. ; water, enough to make § viij. In suppurative tonsillitis, as in the formation of absces- ses in other parts of the body, the most important consid- eration is the early recognition of the formation of pus, and its speedy evacuation. A tonsillar abscess left to run its own course will, without doubt, and in due time, break. The question of surgical interference, however, must be considered, and for two reasons : First, because there is a remote possibility of danger from the sudden rupture of a large abscess during sleep, such an accident having more than once caused the immediate death of the pa- tient. Second, and far more important, because by a timely incision the abscess may be evacuated, the prog- ress of the disease cut short, and the patient saved per- haps many days of extreme suffering and depression, and, possibly, the danger of blood-poisoning. The comfort given to the patient by the incision of such an abscess, is best attested by the fact that adults accus- tomed to recurrent attacks of quinsy wall almost invari- ably beg to have the abscess lanced at the earliest possible moment, confident from farmer experiences of the relief to come. In the use of the knife in such cases, certain rules should be observed and precautions taken : 1. Scarification of the surface of an inflamed tonsil, while sometimes beneficial, is generally irritating, and not likely to afford more than a questionable amount of temporary relief. 2. In quinsy incision is indicated when, from the pres- ence of distinct fluctuation, the spot at which the abscess 135 Tonsils. Tonsils. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. is pointing may be evident; or, when the tissues are swollen and boggy, and there is reason to believe that pus may underlie them. The instrument most conven- ient for the purpose is a common scalpel, of medium size, the blade of which should be protected to within half an inch of the point, so that not more than the above amount of the cutting surface is exposed. In selecting the point at which incision should be made, it must be remembered that the abscess may be quite superficial and in the sub- stance of the gland, or deep and involving more the connective tissue outside the tonsil. In the former case, it is best to enter the tonsil itself, making the incision horizontally and from without inward. When the abscess lies more to the outside of the tonsil, palpation of the gland may fail to demonstrate any sign of point- ing. If, in such a case, the finger be applied to a point opposite the tonsil, outside of the anterior pillar of the velum (Fig. 3939, 9), it will often be possible to detect distinct fluctuation ; the space between the palato-glossus and the palato-pharyngeus muscles being covered simply with mucous membrane. If, now, the knife be entered at this point, although at no great depth, pus may be found and the abscess opened, when incision of the tonsil itself would have failed. In such a case the line of incision should be from above downward and slightly outward, following the direction of, and parallel with, the anterior pillar. In cases where the swelling of the tonsils is so great as to threaten suffocation, and where simple incision does not seem sufficient to evacuate the abscess or reduce the tumefaction, one of two surgical procedures may be resorted to. Either the tonsil may be excised and its inflammed and swollen tissue removed, or tracheotomy may be performed. Intubation is, of course, inadmis- sible, since the obstruction is not in the larynx, but above and outside of it. The writer has seen two cases in which a timely tracheotomy would have saved the pa- tient's life. On the other hand, where the tonsils them- selves are enormously enlarged and the tissues around them not too greatly infiltrated, where the abscess is evidently in the substance of the gland or immediately in its vicinity, and where there is danger of septic infec- tion, excision offers an effective, speedy, and tolerably safe means of relief. In acute exacerbations of tonsilli- tis, particularly in children whose tonsils are chronically hypertrophied, instances are not wanting in the ex- perience of most specialists in which a tonsillotomy, promptly performed, has averted a dangerous issue. 3. When, as is often the case in chronic hypertrophy of the tonsil, the patient suffers from recurrent attacks of quinsy, excision of the tonsil is of the greatest value, and in many instances the operation will effect a radical cure. As a rule, tonsillotomy should not be performed while the gland is in a state of acute inflammation. 4. In some cases the tonsils are sufficiently enlarged to admit of excision only during an acute attack. In these it is better to operate at once, and at the beginning of the acute inflammation. Thus the redundant tissue may be more thoroughly removed, the present attack cut short, and future trouble avoided. Pain is greater from such an operation, and haemorrhage is more likely to be active. Experience, however, proves its value. Chronic Inflammation of the tonsils, although generally associated with more or less hypertrophy, is sometimes observed as a disease of the crypts of the gland, the so-called chronic lacunar tonsillitis-an annoy- ing, and often an obstinate, condition of disease attended with inflammation, dilatation, and obstruction of these follicles. Excellent results may be obtained in such cases by direct application to the crypts of strong solu- tions of iodine, nitrate of silver, or chromic acid, or best of all, the galvano-cautery. Chronic Hypertrophy.-Etiology.-Hypertrophy of the tonsils is sometimes congenital. It is often noticed when the child is but a few months old. Sometimes it becomes developed about the age of puberty, owing, as some erroneously suppose, to a sympathetic connection between the sexual organs and the tonsils. In the expe- rience of the writer, many cases owe their origin to diph- theria, an attack of which has left the throat inflamed and highly sensitive to irritating influences, in which state the tonsils become permanently enlarged or liable to recurrent attacks of acute inflammation, through which hypertrophy takes place. Scarlatina, measles, or small- pox may serve as a starting point for it. and syphilis, congenital or acquired, may also be its chief cause, while many cases seem to result from recurring attacks of quin- sy. More often, however, the disease is due to an indo- lent catarrhal inflammation, associated with a cachectic condition, of the system, especially when the latter is caused by the strumous diathesis. Morell Mackenzie believes that sex is not without some influence in producing the affection, for of 1,000 cases tabulated, 673 were males, and 327 females. My own observations, however, do not accord with this, for of 260 cases recorded at the Demilt Dispensary, 167 were females, and 93 males. Age is said to play a most important part in chronic hypertrophy of the tonsils, as may be inferred from a study of the following tables. The first is an analysis of 1,000 cases seen by Morell Mackenzie at the Hospital for Diseases of the Throat, London. 5 to to '.'.' i8i (Under 10 yenrs 206 From 10 to 20 years 382 " 20 to 30 " 219 " 30 to 40 " 103 " 40 to 50 " 27 " 50 to 60 " 3 " 60 to 70 •* 1 1,000 Of 260 cases seen by the writer at the Demilt Dispen- sary, the following is the analysis : Males. Females. Under 5 years 14 21 From 5 to 10 years 16 30 " 10 to 15 " 30 60 " 15 to 20 " 16 31 " 20 to 30 " 8 20 " vO to 40 " 4 3 Over 40 " 3 4 91 169-260 Or, Under 10 years 81 From 10 to 20 years 137 " 20 to 30 " 28 •• 30 to 40 " 7 Over 40 " 7 260 Thus, if we are to be guided by the above statistics, it appears that the tendency to enlargement of the tonsils is in direct relation with the general activity of the gland, and that, active at birth, the susceptibility increases rap- idly until, at the time of puberty, it is at its height. From this time there seems to be a decline, which be- comes progressively rapid, until, beyond thirty, the dis- ease is more and more uncommon. Hence it has been the custom from time immemorial to advise against sur- gical interference, and to allow the child to "grow to his tonsils," the confident expectation being that at pu- berty they would atrophy, and thus cease to be a source of annoyance. According to statistics this view would seem to be correct. It has occurred to the writer, how- ever, that deductions made upon the basis of the above tables are totally unreliable and misleading. From a careful and somewhat extensive study of the question, he is convinced that, while atrophy may and does occur at or about puberty in a few instances, in quite as many cases tonsils hitherto normal become enlarged ; and that hypertrophy may take place in them, not only at the time of puberty, but at any period within fifteen years or even more after the age of adolescence. Thus it not uncom- monly happens, in the case of an adult, that tonsils which have been slightly enlarged, but yet not sufficiently irritated to cause perceptible trouble, begin to increase in size under the impulse of an attack of diphtheria or quinsy, until they attain a condition of typical hyper- trophy. If, therefore, it be true that even a healthy tonsil may become chronically hypertrophied after pu- 136 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tonsils. Tonsils. berty, how much more probable is it that one already enlarged in childhood may continue in that condition, tradition to the contrary notwithstanding. Again, there are two additional sources of fallacy to which consideration has not been given. The places from which our statistics have been taken are London and New York, cities in which intelligent medical advice is remarkably accessible to all classes of patients. We do not find in these statistics as many cases of enlarged tonsils at thirty as we do at fifteen, for the same reason that the number of cases of club-foot or of hare-lip which exist in those cities at twenty will not begin to equal the number to be seen at one or two years of age. With the present unlimited facilities for the relief of these con- ditions, few children thus deformed escape the observa- tion of the intelligent parent on the one hand, or the zeal of the surgeon on the other, so that for such a case to reach maturity without relief is at the present day most unusual. Just so is it with hypertrophy of the tonsils. Either the difficulty will be recognized by the parents and relief by operation be early sought and obtained, or else the child, arriving at the age of intelligence, will be led by the dictates of common sense to accept the advice offered, or be forced by the constant annoyance and distress of the condition to the limit of his endurance, and be thus induced to beg for the suppression of the trouble through the removal of the offending glands. Finally, the number of children whose lives are indi- rectly sacrificed through the presence of enlarged tonsils is probably great beyond conception. Diphtheria, scarla- tina, bronchial and pulmonary affections, various disor- ders of nutrition-all these and many others are seriously complicated by the disease in question, and often directly due to it. If, therefore, we add to the statistics the case's operated upon before the age of twenty, eliminate from them those who will die before twenty, and those in whom the disease has developed after puberty, a more accurate conclusion as to the true history of the disease may be gained. And when the three factors above de- scribed are fairly considered, the prospect of the child " growing to his tonsils" will not seem flattering. Symptoms.-The symptoms of tonsillar hypertrophy are usually so pronounced that a diagnosis may be made from the expression of the patient's face and from the tone of his voice. The impression made upon the gen- eral condition of a young patient by this disease will de- pend to some degree upon the power of resistance of the individual, upon his surroundings, and upon the care which he receives. Thus, with a good constitution, good climate, plenty of exercise and fresh air, careful attention to dietetics, and finally, intelligent medical aid, the influence of the disease may be scarcely felt, where- as, with the opposite of the above conditions, the results may be most disastrous. While among children living in the country such extreme cases are rarely met with, to those familiar with city-bred patients, and particularly those of the poorer classes residing in tenement houses, the description about to be given will not appear over- drawn. In a well-marked case the first signs to which atten- tion will be called are those seen upon the countenance of the patient. The complexion is pale, cachectic, and transparent, the veins standing out in distinct relief; the lips are often dull pink, or even blue ; the eyes are heavy and lifeless and their lids are drooping; the mouth is partly open, and often the upper teeth project forward. When the child is stripped his body is seen to be emaci- ated, and his muscles flabby, the intercostal spaces are retracted, and the breast-bone is prominent. It will readily be perceived that all of the above- described appearances are due to the influence of the dis- ease upon the general system, and that they are mainly caused by the mechanical effects of the enlarged glands in obstructing respiration. Voice.-Another of these mechanical effects is the alteration in the voice, .which in such cases is generally thin, nasal, and lacking in resonance. The explanation of this lies in the fact that the pharynx and the air-cavi- ties above act in the production of tone as resonators. This is particularly true of the lower pharynx, where, probably more than in any other region, tone-quality is determined and controlled. Mechanical obstruction would exercise the same influence here as in the case of a wind-instrument, interference with the calibre of which would tend inevitably to impair the fulness and richness of its tone. Just as the tone-quality of a cornet will be interfered with by the introduction of a foreign body of considerable size into the bell of the instrument, so with singers, hypertrophy of the tonsils will, mechanically, di- rectly injure the timbre and even, possibly, the range of the voice. Moreover, the tone-waves are prevented from properly reaching the resonating spaces which lie above the tonsil, and thus again the full production of the normal overtones is prevented. Finally, the voice is in- jured by the effect of the tonsillar inflammation upon the soft palate, which in such cases is generally relaxed, and hence unable to fulfil its functions in a proper man- ner. In consequence of this articulation is interfered with, the patient speaking with thick utterance, and the palatal consonants being in particular mispronounced. When we add to the above the injurious effects upon the laryngeal mucous membrane of the catarrhal in flammation often associated with, and aggravated by, chronic hypertrophy of the tonsils, the deleterious influ- ence of this condition upon the voice may be fully ap- preciated. Respiration.-Respiration can never be normal where any considerable hypertrophy of the tonsils exists, for not only does the inspired air pass over an unhealthy surface, but the pharyngeal space is greatly narrowed, and the entrance of air from the nose and through the upper pharynx is seriously obstructed. The inevitable conse- quence of this is that the child becomes a mouth-breather, and still worse, if possible, even when breathing takes place through the mouth, the amount of air admitted is often entirely insufficient for the proper aeration of the lungs. A patient suffering in this manner almost invari- ably gives a history of respiratory difficulty, particularly well marked during sleep, at which time the mouth is widely opened and respiration is noisy, and nearly always accompanied with loud snoring; sleep is restless and broken, the patient being feverish and tossing about and dreaming incessantly, often muttering or talking, and sometimes, it is said, indulging in somnambulism. In severe cases intense reflex phenomena manifest them- selves, among which a not uncommon symptom is for the patient to be awakened by sudden attacks of dyspnoea, so severe in some instances as to threaten suffocation, and attended with severe exhaustion and alarm. The subject of enlarged tonsils awakens after such a night feeling dull and tired, and often with a headache. The throat is dry and parched, the breath fetid, and the appetite impaired. No more eloquent appeal for fresh air could be given than is manifested in such a case; nearly every detail being the same that would be ob- served in a healthy person sleeping in a close and badly ventilated apartment. Again, the evils of tonsillar hypertrophy, as a cause of mouth breathing, cannot be too earnestly emphasized. In the first place, the respiratory function of the nose being abolished, the air in its passage to the lungs is neither moistened, warmed, nor freed from impurities. In consequence of this the respiratory passages are ren- dered abnormally dry, the lungs are subjected to the danger of irritation from cold, and the whole tract, from the tonsils themselves downward, is made liable to the effects of whatever foreign matters may be inhaled. Thus not only is the patient unusually exposed to all of the external influences which produce inflammatory af- fections of the respiratory tract, but the tonsils them- selves, particularly susceptible in their irritable state to the acute morbid processes which may affect them, are so situated as to offer the best possible resting-place for any germ which may enter. The effect of enlarged ton- sils upon nasal respiration is such as to exert an impor- tant influence upon the nutrition and development of the nose itself. From experiments upon rabbits it has been found that occlusion of one nostril in a growing animal 137 To 11 Hi Is. Tonsils. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. is followed by an under-development of the occluded side. This results in distortion, asymmetry, and impair- ment of function. Without question, a proper supply of air and the normal exercise of the part are necessary for its proper and complete development. Hence it is, as seems probable to the writer, that deformities of the bony structures of the nose, so commonly found in those who have suffered from enlarged tonsils, are caused by the effect of the latter upon nasal breathing, and that asymmetry of the nasal cavities and, indeed, of the su- perior maxilla itself, may be due to the same influence when exerted unilaterally. In many children in whom the tonsils are large and the local secretions excessive, there will be noticed a marked effort on the part of the walls of the chest to com- plete the act of respiration, the intercostal and infra- clavicular spaces sinking inward with each attempt. Under such circumstances persistent obstruction to res- piration leads to serious changes in the thoracic parietes. In 1828, Dupuytren called attention to the frequency with which deformity of the walls of the chest was found associated with hypertrophy of the tonsils. Later, Mr. Shaw, of London, suggested the connection between en- larged tonsils and the condition commonly known as " pigeon-breast;" while to Lambron is due the credit of having most accurately noted the various morbid changes, and of having explained their causation in a thoroughly rational manner. According to the latter writer, the characteristic malformation of the thoracic cavity met with in such cases, is a circular depression of the walls of the chest at about the junction of the lower and mid- dle third. The thorax seems as though it had been con- fined by an unyielding ring, which, while contracting its growth in this situation, gives an appearance of ab- normal bulging to the upper part of the cavity. This circular depression corresponds with the attachment of the diaphragm internally to the osseous framework of the chest, and is evidently due to the constant energetic contractions of that muscle in its effort to overcome the obstacle to free respiration. In childhood the bones yield easily to such influences, and when the difficulty in breathing, which occurs where there is any considerable hypertrophy of the tonsils, especially during sleep, is considered, its pernicious effects upon the respiratory ap- paratus will be readily understood. In addition to the organic alterations in the bones of the chest, other evils are brought about, and Chassaignac well observes that, although increased efforts of the diaphragm to a certain extent neutralize the impediment to respiration, there are frequent intervals when the powers of the muscle be- come temporarily exhausted, and the oxygenation of the blood is very incompletely performed. The vital forces are in consequence very much lowered, the patient lives in a state of constant ill health, and easily succumbs to any acute attack of disease, particularly if affecting the respiratory organs. Hearing.-The effects of enlarged tonsils upon the hearing are highly injurious. They are exerted in two different ways, each of which is capable of producing marked results. It was at one time supposed that com- pression of the orifice of the Eustachian tube, by the presence of a large tonsil, played an important part in the production of deafness. Later the view has been advanced that the tonsils grow in the direction of the mouth, and not upward, and that the result is an undue patency of the Eustachian orifice, which, combined -with an extension into the Eustachian tube of the catarrhal inflammation commonly present in the pharynx of such a patient, produces a general chronic swelling and con- gestion of its mucous membrane, with thickening and retraction of the drum-membrane and loss of hearing. On the other hand, it seems reasonable to suppose that this same retraction of the drum-head is caused in certain cases by the mouth-breathing habit, the upper pharynx not being properly supplied with air. This opinion is sustained by the fact that after removal of the tonsils the hearing distance is often greatly increased, and with as much promptness as it is after the use of the Politzer in- flator. The danger to the auditory sense from hyper- trophy of the tonsils is decided, and its importance cannot be overestimated. When, therefore, there is reason to suspect that deafness may be due to it, or to the allied condition of hypertrophy of the adenoid tissue at the vault of the pharynx, the necessity for the thorough in- vestigation of these organs becomes strongly emphasized. Smell and Taste.-Owing to the catarrhal inflamma- tion present in hypertrophy of the tonsils, the senses of smell and taste are often impaired or altogether lost. In the case of olfaction the diminished special sensibility is also due to the occlusion of the pharynx and to mouth- breathing, by reason of which the odoriferous particles are prevented from reaching the olfactory region. On the other hand, the constant presence of fetid discharges makes itself apparent to the patient himself and those about him, by causing him to be constantly annoyed by disagreeable odors and sensations of taste, and by impart- ing most unpleasant qualities to the breath. Having considered the mechanical effects of hyper- trophy of the tonsils, it will be •well to study the in- fluence of the disease upon the gland itself, and the results of the condition, both local and general, other than mechanical, upon the patient. As has been sug- gested before, enlargement of the tonsils, and chronic catarrhal inflammation of the neighboring mucous mem- brane, are usually associated. While it may be urged, and with reason, that both are due to an underlying gen- eral cause or diathesis, it is still true that removal of such tonsils will be followed, in most instances, by marked amelioration in the catarrhal symptoms, the improvement commencing immediately after the opera- tion, and perhaps continuing more or less steadily for months. The irritating influence, therefore, of enlarged tonsils upon a sensitive pharynx must be considered, and its importance not under-rated. Again, while in health, the tonsil furnishes a secretion of its own of value in the various actions in which it takes part; in its diseased state, this secretion becomes greatly increased in amount, and it, together with the abundant supply of mucus given off by the neighboring membrane, is a source of much disturbance. Not only does the pharynx become tilled with it, by -which respiration is rendered more difficult, but when swallowed it is apt to give rise to decided in- digestion. Again, through failure to enjoy it, the act of eating is accomplished rapidly, and the food is swallowed in large masses without having been properly masticated. Thus the nutrition of the child is directly attacked ; for, through loss of taste and smell, and through the depress- ing influences of a lack of oxygen, the appetite is gen- erally impaired at the outset, while, by reason of the faulty mastication and of the dyspepsia, even the food ingested is not properly utilized. When it is remembered that loss of oxygen, loss of sleep, and loss of nourishment may all arise from the disease under consideration, its influence upon the gen- eral health cannot but be recognized. Before closing with the consideration of the symptom- atology of enlarged tonsils, attention must be called to the nervous phenomena to which they may give rise. Of these, the most important is the occurrence of attacks of dyspnoea, generally during sleep, which seem to be due to a veritable spasm of the glottis, and in the course of which the pa- tient is awakened suddenly from a sound sleep to find himself choking. For a few seconds inspiration is almost impossible, and efforts to accomplish it are accompanied by loud, stridulous breathing, and intense apprehension and alarm. It may be urged that such accidents might arise from the presence of a deposit of thick, tenacious mucus in the larynx, and such, no doubt, is often the ex- planation of them. However, in certain instances, ob- served by the writer and others, there can be little doubt as to the spasm being of a purely neurotic nature. Severe spasmodic cough, due to reflex irritation from enlarged tonsils, is sometimes seen in children and in young adults. It is generally dry and hacking in char- acter, and in some cases is almost incessant. Again, chorea is sometimes observed in children suffer- ing from enlarged tonsils, and is apparently due to reflex irritation from their presence. The influence of enlarged 138 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tonsils.. Tonsils^ tonsils upon the circulation is a matter of importance, deficient oxygenation of the blood not being the only re- sult which may be traced to them. Anaemia is a com- mon symptom, and one which is often particularly well- marked in these cases. Some believe that enlargement of the heart by dilatation may be directly due to this im- poverishment of the blood. Disturbed cerebral circula- tion, as a result of pressure from the enlarged glands, has been suggested by Chassaignac; while a recent writer states that he has found epistaxis to occur frequently in children suffering from hypertrophy of the tonsils, and maintains that the haemorrhage is due to continuous press- ure upon the veins of the neck, producing chronic en- gorgement above, with perhaps chronic alteration in the walls of the vessels. Pathology.-Chronic enlargement of the tonsils is a true hypertrophy or hyperplasia, in which, according to Vir- the lymphatic follicles are increased in number and size, the stroma is not markedly augmented. Such a tonsil may be removed easily and, as a rule, without pain. In the other variety the surface is smooth and often glazed, the color is pink or even dull gray, the consistence firm and unyielding ; while the mouths of the crypts are apt to be partly occluded, and the crypts themselves filled with broken-down excreta. Microscopically, the most striking feature of the section will be the remarkable proliferation of the fibrous stroma, which may be found more or less thickened at the periphery, and in the inte- rior of the gland may be so greatly increased in amount as to encroach extensively upon the adenoid elements. The writer has in his possession several specimens in which the stroma occupies fully one-third of the substance of the tonsil. In performing tonsillotomy in such a case, great resistance to the knife or the tonsillotome may be experienced, and considerable pain caused by its passage through the tonsil. Again, the main blood-vessels ramify in the stroma. When the latter is normal or not exces- sive in amount, the walls of the vessels, when divided, easily close and bleeding is stopped. In fibrous tonsils, however, the excess of connective tissue surrounding the blood-vessels makes it difficult for the latter to undergo the normal process of retraction when divided, so that bleeding after the removal of such a tonsil is apt to be more prolonged than in the case of the first-mentioned variety. The fibrous form is found during childhood, but is more common in adult life. Indeed, the older the pa- tient the greater is the amount of fibrous tissue generally present. Hence the greater liability of the adult to haemorrhage after tonsillotomy, the rule being that in patients under twrenty years of age the operation is almost absolutely devoid of danger. Diagnosis.-The diagnosis in chronic hypertrophy of the tonsils may usually be made with the greatest ease, the history of the patient, his general appearance, and his symptoms pointing almost invariably to the source of the trouble. Any doubt may be dispelled by the simple in- spection of the pharynx. Upon opening the mouth and looking into the throat, the tonsils will appear extending beyond the normal limit and toward the median line, and their relative size, their nature, and the condition of the crypts may be ascertained. During easy, deep inspira- tion the tonsils w'ill assume their normal position behind the anterior pillar of the velum, a minimum of their vol- ume being projected toward the median line. If now the patient be made to gag, the tonsils will be rotated forward and thus brought out from behind the velum and into plain view. Any doubt which may exist as to the real size of the gland may be removed by placing one forefinger just below the angle of the jaw externally, and the other behind the tonsil, when the whole extent of the enlargement may be recognized. Prognosis.-Hypertrophy of the tonsils may exist to a considerable degree, both in children and in the adult, ■without giving rise to serious symptoms. In some cases its presence may pass unnoticed. Usually, however, the contrary is the case. It may be said, in general, that the younger the child the more injurious is the effect likely to be. While the tonsils may sometimes regain their nor- mal condition at puberty, the occurrence of this atrophy is uncertain, as has already been pointed out in the sec- tion relating to the etiology of the disease. Meanwhile the general health of the patient may be undergoing seri- ous injury, and irreparable damage may be inflicted upon adjacent parts. The prognosis, therefore, in pronounced cases of tonsillar enlargement is unfavorable as to the ul- timate subsidence of the difficulty, and although cases are not infrequent in which the symptoms of disease have disappeared toward middle life, the writer believes that in a considerable number of instances the contrary is true. As to the effect of enlarged tonsils upon the life of the patient, there can be no question that they may be an indirect cause of death ; that their presence should ever be immediately fatal seems improbable, and, in the opin- ion of many observers, impossible. Other authorities, Fig. 3943.-Hypertrophied Tonsil. Enlarged drawing. (Luschka.) chow, there is not only increase in volume of the gland, but an actual multiplication of all of its constituent parts. The epithelium covering the tonsil usually shows little change, but the papillae underneath are often more nu- merous and less elevated than in the normal state ; while, in the crypts, there seems to be a tendency for the mem- brane to become thinner as the bottom of the crypt is approached. The substance of the gland may show one of two vari- eties of alteration. Either the lymphoid elements alone may be increased in amount, the stroma of the gland be- ing little affected, or the fibrous tissue which constitutes the stroma may be greatly in excess of the normal de- gree. In the latter condition the lymphoid elements may be in excess, or there may be a condition of general atrophy present. The external appearance of the tonsil in the first-named variety of disease is quite character- istic, the surface being rough and irregular in outline, dark red in color, and the substance of the gland being soft and compressible. The mouths of the crypts are usually more or less open, and the whole organ is deeply congested. Microscopical examination shows that while 139 Tonsils. Tonsils, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. however, are of a different opinion. In order to gain as much light upon the subject as possible, the writer has sought the views of a number of physicians of wide experience in the observation of tonsillar disease. Al- though many of them had never seen or heard of such a case, there were several who believed that it might occur. In a communication to the writer, the late Professor Elsberg wrote : " I have seen many cases of tonsillar hypertrophy in which the symptoms were urgent and threatening. I have heard from parents that they have lost children under such circumstances, and of physicians who attended such cases with fatal result. Although I have never had a death of the kind occur in my own practice, I feel sure that in a number of cases a fatal issue has only been averted by timely operation." Similar testimony was given by others, while a case has come within the observation of the writer, which seems to prove clearly that death may be directly due to the above- mentioned cause. A boy two and a half years of age, ■of remarkably healthy and vigorous-looking parents, and himself sturdy and well nourished, considering the amount of difficulty in the throat, was seen at the throat clinic of the Demilt Dispensary, New York. The par- ents said that the child's tonsils had always been large, and that from early infancy he had been a mouth-breather. His general condition, however, had been excellent, and he had seemed to thrive as well as any other healthy baby. Within a few weeks of the visit to the dispensary the tonsils, already very large, had seemed to increase in size. Meanwhile there was a free secretion of mucus. Finally, the child was attacked with paroxysms of choking and suffocation of such severe character that the parents be- came alarmed and sought advice. On examination of the throat there appeared a pair of tonsils so enormously en- larged that they seemed to completely fill the pharynx, meeting in the median line. The uvula was much thick- ened and elongated, and still further occluded the already contracted pharyngeal space. The pharynx was bathed with a thick, tenacious mucus, such as is often seen in hypertrophy of the tonsils in children, and evidently de- rived from hypersecretion of the tonsillar crypts. The child's respiration was labored, the entrance of air to the lungs being evidently obstructed, and with any increase ■of the mucus present inspiration wtjs almost impossible. The attacks of dyspnoea were thus readily explained. Although careful examination was made for retro- pharyngeal abscess, for abscess of the tonsils, and for any other cause which might have produced the symp- toms complained of, nothing whatever except the con- dition of the tonsils and uvula above described could be found. The necessity for an immediate tonsillotomy was urged upon the parents, who declined to allow it until they had consulted with their family physician, who had told them that an operation was unnecessary, and that the child would " grow to his tonsils." They were directed to employ means for keeping the child's throat free from mucus, and to bring him back for opera- tion with the least possible delay. This they failed to do. Four or five days later, a physician was sent for in haste, who found the child dead. It had suffered re- peated attacks of urgent dyspnoea, and finally, in the midst of one of more than usual severity, had succumbed. As the child had one of these paroxysms while in the presence of the writer, there was no doubt as to their existence or nature. Such a case, fortunately, is extremely rare ; but it is worthy of record if for no other reason than to prove the possible danger of the condition, and to emphasize the folly of temporizing with it. Treatment.-The treatment of chronic lacunar disease of the tonsils, in which the degree of hypertrophy is slight, is a matter of some difficulty, and in the case of the large majority of practitioners is but imperfectly under- stood. Considerable service may be rendered by cleans- ing the affected crypts of the cheesy excretion which they contain, and then cauterizing them thoroughly with nitrate of silver, chromic acid, or the galvano-cautery. Such measures in some cases are productive of excellent results. In a majority of instances, however, they are ineffective, and recourse must be had to such constitu- tional measures as may be suitable for the case in hand. No better advice has ever been given than that proposed by Mr. Lennox Browne, namely, that whenever, as is almost certain to occur in these cases, active inflam- mation causing enlargement takes place, it is to be en- couraged rather than arrested, and the gland is then to be removed. It is in these cases, also, that the galvano- caustic method, as advocated by C. H. Knight, is of the greatest value. No case should be abandoned as incura- ble. In cases of moderate hypertrophy of recent stand- ing, where there is little deposit of fibrous tissue, and where the enlargement depends upon an increased vascu- larity and dilatation of the crypts, much good may be done by general and local hygienic measures and by local medication. Careful attention should be paid to the dietary, exercise, and general surroundings of the child, and any diathesis discoverable should be diligently treated. As many of these cases are associated with a strumous condition, the administration of the iodide of iron and of cod-liver oil will be found beneficial. Externally, a valuable measure is the habitual application, every morn- ing, of a cold bath of salt-water. This should be applied to the neck and throat by means of a sponge, the water being at a temperature sufficiently low to produce a re- action, but not so cold as to shock the patient. Mean- while, the throat should be well rubbed, and special attention paid to the region over the tonsils, which, by a process of massage gently applied, may be successfully stimulated, and the blood-vessels caused to act with greater liveliness and tension. The application of mas- sage directly to the tonsil has been recommended, and commends itself as a useful expedient. In applying it, the tonsil should be supported by one hand of the oper- ator, laid against the neck immediately under the angle of the jaw, while with the forefinger of the other hand, introduced into the patient's mouth, gentle interrupted pressure from below upward upon the tonsil is made. The application to the inflamed tonsil of the constant galvanic current is a measure deserving of attention, and one which promises to yield good results. Local applications of a solution of the tincture of the chloride of iron or of the perchloride of iron ( 3 j.-ij. to ? j.) are sometimes useful, as are those of powdered alum or tannin. Morell Mackenzie recommends that the latter be rubbed into the crypts by means of a small spatula, simply dusting the powder over the surface of the tonsil not being sufficient. Tincture of iodine is not recom- mended. These measures, however promising they may seem, are generally ineffective, and sooner or later, in the vast majority of cases, their futility will be recognized and surgical measures accepted. Removal of the tonsils has been practised from earliest times. For its accomplishment several methods have been employed, and, since some of them are still in vogue and others not without certain elements of use- fulness, it will not be out of place briefly to enumerate them. According to Mackenzie, to whom we are indebted for this historical sketch, extirpation of the tonsils must have been commonly practised at a very early period, for although the first clear mention of it is made by Cel- sus, about the year 10 a.d., that writer speaks of excising the tonsils as if it was evidently considered an ordinary and trifling procedure. He says: "Tonsils which re- main indurated after inflammation, if covered by a thin membrane, should be loosened by working the finger around them, and then torn out. When this is not prac- ticable they should be seized by a hook and excised with a scalpel."' Aetius, a.d. 490, the next writer who gives an account of the operation, speaks of it in much more cautious terms. "The portion," he says, "which pro- jects, i.e., about half the entire gland, may be removed. Those who extirpate the entire tonsil remove at the same time structures which are perfectly healthy, and in this way give rise to serious haemorrhage." Paulus JEgineta, a.d. 750, instructs us as to excision of the tonsils very 140 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tonsils. Tonsils^ precisely. He does not approve of operating upon them when inflamed, and describes them as being most fit for removal when they are "white, contracted, and have a narrow base." In operating he advises that the head of the patient be held by an assistant, his tongue held down by a spatula, and the tonsil, being seized and drawn in- ward by a tenaculum, "cut out by the roots." Albu- casis, a.d. 1120, gives nearly the same directions as the last-mentioned author, excepting that he is more cau- tious and dreads haemorrhage. Subsequently to this pe- riod the operation seems to have fallen into disuse, and, having become almost obsolete and traditionary, suc- ceeding writers either omit all mention of it or approach the subject with such timidity as to show that they had had no personal experience with it. Thus, even Am- broise Pare, in 1509, counsels tracheotomy when serious enlargement of the tonsils exists, and hints also at the possibility of applying a ligature to them, but does not mention excision. Guilleman, a pupil of Pare, did not resort to tracheotomy unless the patient's mouth could not be opened. According to circumstances, he ligated or cut away the diseased masses, but he was opposed to the removal of the whole gland. In 1637 Severini, dur- ing an epidemic at Naples, the principal symptom of which consisted in great swelling of the tonsils, re- moved large portions of the glands, when sessile, by caustics, and when pedunculated, by means of a hook and a semicircular knife. Nevertheless, for a century afterward excision of the tonsils was almost entirely dis- countenanced, although a few surgeons had recourse to the ligature. The authorities of this time all feared to excise the tonsil and condemned the operation, and con- tented themselves with removing parts of the gland by means of the ligature or cautery. The opinion of Heister, expressed in 1683, is worth quoting, as his surgical trea- tise was perhaps the most popular text-book during the first half of the last century. He says : " This operation is not only too severe and cruel, but also too difficult in the performance, to come into the practice of the mod- erns, because of the obscure situation of the tonsils." After 1740, however, the operation by means of the tenac- ulum and bistoury was again much practised, and the credit of the revival is principally due to Meseati and Wiseman. The practice of the latter surgeon was first to ligature the tonsil and then to cut off the projecting part. In 1757 Caque proved indisputably that the great dread of haemorrhage which existed was chimerical, and that the resulting wound healed readily in a short time. From this date excision of the tonsils became one of the recognized operations of surgery, and practitioners began to devise new instruments and invent new meth- ods for performing it. It is unnecessary to describe here all the various hooks, forceps, bistouries, etc., which were devised during the last century for the excision of the tonsils, as almost every eminent surgeon made some modi- fication of the instruments used for the purpose by his predecessors or contemporaries ; the method most gen- erally in favor was perhaps that of Louis, who employed a blunt-pointed bistoury or pair of scissors, the blade or blades being sometimes preferred straight and sometimes curved. The patient was placed with his face toward the light, and directed to open his mouth widely ; an as- sistant then pressed down the tongue with a spatula or with his finger, while the surgeon seized the tonsil with a vulsellum, and, drawing it as much as possible toward the median line, cut off the superfluous part on a level with the pillars of the fauces. After a time the scissors gave way to the bistoury, wTith which instrument many surgeons operate up to the present day. Thus it will be seen that the surgical treatment of this condition extends backward for many centuries. When we add to this the fact that the disease is common, and that it has been extensively studied in recent years, it will also appear that our present knowledge of the subject is based upon the views of a vast number of dis- tinguished and highly experienced authorities. Of the methods for removing the tonsils most commonly used at the present time may be mentioned cauterization, by chemical or electrical escharotics ; ecrasement, by means of the galvanocaustic loop or of the cold wire ; abscis- sion, by means of some modification of the knife or scis- sors. Both the tying off of the tonsil by means of a ligature, and the injection into its substance of various supposed absorbents, only need be mentioned to be con- demned. The practice of enucleating the tonsil with the finger has been lately revived in some quarters. It is of questionable value and propriety. As escharotics, chromic acid, London or Vienna paste, and the galvano-cautery may be used. They rank in- versely to the order given, the galvano-cautery, as advo- cated by Voltolini, being by far the most desirable. In very young children the use of this method will often be found impracticable, except under general anaesthesia. In short, as has been pointed out by Knight, the galvano- cautery should be reserved for a comparatively small proportion of cases, including those in which the ha?mor- rhagic diathesis is present or suspected, those in 'which vascular anomalies may be recognized, those in which the anatomical conditions prevent a sufficiently thorough extirpation of the organ, and those in which the use of the knife is positively declined. In applying the cautery a small-sized cautery-point is passed to the bottom of a crypt of the enlarged tonsil and the current then estab- lished. The operation may be repeated, but not more than three crypts should be cauterized at one sitting. Should the lacunae be obliterated, as sometimes occurs, the cautery-point may be pushed into the substance of the gland. The pain caused by the operation is usually slight, nor is inflammatory action often excessive. In from four days to a week the operation may be repeated, the in- flammatory reaction usually subsiding within that time. The application of cocaine to the crypts before operation will materially lessen the pain, while the subsequent sore- ness and irritation may be relieved by alkaline and disin- fectant sprays or gargles. If necessary, further applica- tions of cocaine may be employed. Concerning this method of treatment, it must be con- fessed that it is slow, and that the reaction which some- times follows it is annoying. Surgically speaking, both the galvano-cautery and the electrolytic method are in- ferior in every respect to tonsillotomy, and they should be substituted for it only in the cases mentioned above. ficrasement by means of the galvano-caustic loop is sometimes an effective and valuable method, although in simple hypertrophy, uncomplicated with malignant dis- ease, it will be found less convenient and far more pain- ful than other methods. In its use two precautions are necessary : The electric current should be employed in- termittingly, and traction should be made upon the loop only during the passage of the current. Thus haemor- rhage may be avoided and the danger of injury to the pillars of the fauces by diffusion of heat may be pre- vented. Any unevenness remaining may be removed by subsequent cauterizations. Inclusion of the greater part of the tonsil within the loop may usually be effected by dragging it inward by a forceps or by means of a trans- fixion needle. Local anaesthesia may sometimes be ob- tained by injecting into the parenchyma of the gland, before operation, six or eight minims of a ten per cent, solution of cocaine. The amount of tissue actually re- moved by the snare does not represent the total effect of the operation, since the parts remaining are cauterized to a considerable depth. In rare instances, in which the tonsil is very large and fibrous, and the patient is an adult, it may be desirable to use the cold wire ecraseur. By this means, as by the former, haemorrhage may be avoided. Ou the other hand, the operation is tedious and in many cases ex- tremely painful, and, unless performed under an anaes- thetic, it is not likely that it will be tolerated by any but a remarkably hardy patient. Tonsillotomy.-Of all methods hitherto proposed for the removal of enlarged tonsils, none can compare in general popularity, utility, thoroughness, and, on the whole, hu- manity, with tonsillotomy. As time has gone by the value of the procedure has become more and more com- pletely established. Meanwhile the instruments for its 141 Tonsils. Tonsils. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. performance have been carried to a high degree of per- fection, and although a few operators still prefer the old- fashioned forceps and bistoury, an overwhelming ma- jority, among whom may be included, almost without 'exception, the most distinguished specialists and writers of the day, strongly favor the use of the tonsillotome. The history of this instrument will be highly interesting to all American readers, for, of the two possible varieties, one was devised in the year 1827, by the distinguished Dr. Physick, of Philadelphia, and the other in 1832, by while it is safe to say that it has been applied in hundreds of thousands of cases, there is not a single instance on record, or referred to traditionally, in which a fatal re- sult has followed its use. For the convenient and successful performance of ton- sillotomy the aid of a trained assistant is almost indis- pensable. With adults and with children old enough to be under good self-control, he will be of use in steadying the patient's head and in supporting the tonsils ; while with young children the possibility of operating at all will sometimes depend upon the man- ner in which the patient is held. During the operation the patient should sit facing a good light, the op- erator with his back to it. By those familiar with the use of the head-mirror the latter, however, will generally be preferred. The patient, if an adult, should sit upright and well back in the chair, the head fixed against a properly adjusted head-rest or supported by an assistant. The latter should stand di- rectly behind the chair, and while hold- ing the head with both hands should place the fingers of each hand over the tonsillar region of the corresponding side, that is, immediately below the angle of the jaw. Thus the tonsils may be prevented from receding before the pressure of the tonsillotome when it is introduced, and the operation may be per- formed with greater accuracy, and, if necessary, with greater thoroughness. This plan was suggested by the late Llewellyn Thomas. It has been objected to by some as incurring the risk of cutting too deeply. The writer has made extensive use of it and has never known it to cause the above accident, and believes the objection theoretical and not proved by experience. In the case of a child the assistant should be seated in front of the operator, and the patient seated across one of his thighs, facing inward, so that the legs of the latter may be grasped and firmly held between the thighs of the assistant. The body of the child is partly turned so that he faces the operator, and his head is rested against the breast or the shoulder of the assistant, who controls the arms and body of the child by throwing one of his arms across the patient's chest, while with the other hand he steadies the child's head firmly against his own body. The use of a mouth-gag is unnecessary. The blade of the tonsillotome is now drawn backward and the instrument introduced flatwise and in the median Fig. 3944.-Fahnestock's Guillotine. (Modified.) In the variety above illustrated (Fig. 3944) the instrument consists of three principal parts : A, A ring made to receive the thumb of the oper- ator. and attached to a rod upon the end of which are the pronged forks D; C, a staff, at the end of which is a ring, E; B anil B, two rings made to receive the fore and middle fingers of the op- erator's hand, and attached to another rod which plays upon the staff C, and at the end of which is a ring-knife which rests within a groove in the ring E. In using the instrument the thumb piece A is pushed forward for a certain distance, when by the automatic releasing of a spring-catch the rod with the knife attached is drawn forward by the rings B, B, so that the tonsil, already engaged in the ring E, and drawn still further through it by the forks, is excised. Dr. Fahnestock, of Lancaster, Pa. Tiemann & Co., of New York, claim to have invented and manufactured a tonsillotome as early as 1828. The idea of the tonsillo- tome was undoubtedly suggested to Dr. Physick by the uvulatome, an instrument at that time in use in England, where the idea had been taken from the Danes, who, cen- turies ago, practised uvulotomy, it is said, as a religious rite, using for the purpose a ring-knife. From this latter principle was taken the idea of the tonsillotome. The in- struments of Physick and Fahnestock are, however, in one respect made upon exactly opposite principles. In the former the knife is pushed from before backward through the tonsil, and the instrument is so constructed that sec- tion is accomplished upon the principle of the scissors, the tissues of the gland being pushed before the edge of the knife and well crowded together before the final sep- aration takes place. In the Fahnestock instrument, or guillotine, as it is commonly called, a sharp ring-knife is drawn through the tonsil from behind forward, the di- vision being effected as by a knife. This instrument has been extensively modified by French and American sur- geons, and in one form or another is in general use throughout the world. It possesses several objectionable features, however, which render it not only unsatisfactory, but in some in- stances positively dangerous, and which should be understood before the instrument is used. These are: 1. The danger of haemorrhage, from the action of the blade being that of a knife and not of scissors. 2. The fact that in several recorded instances the forks have been drawn behind the ring in their passage through the tonsil, in which case the instrument has been firmly fixed by the ring-knife sliding forward against the forks. In this position the surgeon is able neither to advance nor to retreat, the only alternative being to cut the instrument away from the tonsil by dividing the latter with a knife or scissors. The po- sition of the patient, meanwhile, cannot be agreeable. 3. The guillotine is a complicated instrument, and as such is difficult to handle. 4. Finally, its workmanship is delicate and it is made up of a number of small parts, so that it is difficult to clean and liable to get out of order. In the Physick tonsillotome, as made after the pattern represented in Fig. 3945, a high degree of simplicity and perfection has been attained, and although many modifi- cations of this instrument are offered for sale, it is safe to say that, up to the present time, it stands unrivalled. In England it is generally employed, while in this country it is the favorite tonsillotome of nearly every recognized authority. It is absolutely simple in construc- tion, not liable to get out of order, comparatively easy to clean, and, what is far more important, it is a safe instru- ment to handle, the accidents to which the Fahnestock instrument is liable being with it impossible. The dan- ger of haemorrhage is also reduced to a minimum ; for Fig. 3945. - Physick's Tonsillotome. (Modified by Morell Mackenzie.) A stout handle, E, is attached to a steel plate, D, at the other end of which is a grooved ring, C; upon this plate D, the knife, or rather the curved chisel A B, slides forward to ad- mit the tonsil within the ring C, and backward, to cut it off. line, as if it were a tongue-depressor, as far back as the pharynx. It is then rotated, by raising the handle out- ward from the vertical to the horizon- tal position, until the plane of the blade becomes parallel with the plane of the desired incision. Following this comes one of the most important manoeuvres of the whole operation, and one to which too much attention cannot be paid, namely, the engaging of the tonsil in the ring of the instrument. In carrying the tonsillotome outward from the median line, the tendency is for the handle of the instrument to be carried out too rapidly. In other words, the angle of the mouth is used as a fulcrum against which the middle of the instrument rests, and while the handle is carried outward the other end is carried in the opposite direction, or inward, and away from the tonsil. The result is that, 142 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tonsils. Tonsils. instead of squarely grasping the gland at as deep a posi- tion behind it as before, the end of the tonsillotome slips over the back of the tonsil, and the operation results in simply slicing off a section from its top. To avoid this it is necessary to observe the rule, that the blade of the instrument must always be kept parallel with the median line, and that if any deviation is made it should be to carry its dislal extremity outward. Having engaged the tonsil in the ring of the instrument to the required depth, push the blade firmly and steadily through the included tissue, separate the fragment of tonsil, and withdrawing the instrument quickly, remove the excised gland adher- ing to it. Then with the greatest possible expedition- and before the patient realizes that there is a second op- eration-before bleeding sets in, and without giving him a chance to cough or clear his throat, reintroduce the ton- sillotome on the opposite side and remove the remaining gland. By this means both tonsils may be removed at one sitting, so that but one convalescence is to be endured. Few young patients will submit to a repetition of the op- eration. Several ingenious modifications of the Physick tonsillotome have been made, by which the handle may be reversed so that the operator may use it first in one hand and then in the other. A far better plan, however, is to gain through practice sufficient dexterity to change the instrument from one hand to the other, and to operate thus on both sides with equal facility. With a quiet and tractable patient the operation may be done very quickly, from ten to fifteen seconds being ample time in which to complete it. The use of anaesthetics is, as a rule, contra-indicated. In most cases the actual pain caused by cutting through the tonsil is very slight, the patient often complaining more of the introduction of the instrument into the pharynx and the consequent reflex, than of the operation itself. In the hands of the writer the injection into the tonsil of cocaine has proved ineffective. General anaes- thesia, from either chloroform or nitrous oxide, is ob- jectionable, not only because it is, as a rule, unnecessary, but because it is highly desirable to have the active co- operation of the patient in clearing the throat the moment that the operation is completed. To this rule, however, there are rare but positive exceptions. When a child is highly irritable, nervous, and timid, and when the operator may be tempted to abandon the case rather than subject the patient or himself to the inevitable struggle which with such children must be undergone, the adminis- tration of nitrous oxide or of a few whiffs of chloroform will prove of the greatest assistance. If the child is fairly well and strong, the best plan is to be frank with him, place him upon his mettle, and proceed with the opera- tion. If, on the other hand, he is delicate and easily frightened, it will be wise to consider to what extent he may be coerced without producing an undesirable degree of shock ; and, as chronic hypertrophy of the tonsils is apt to be associated with these very conditions of nervous- ness, such children should be managed with the greatest gentleness and consideration. According to most authorities, haemorrhage after the operation is usually slight and soon ceases spontane- ously. If not it may be readily checked, and, generally, by simple means. Of the latter the most effective is the direct application to the cut surfaces of a mixture con- sisting of one part gallic acid and three parts tannic acid, reduced to the consistency of cream by the addition, drop by drop, of a small quantity of water. This or the sucking of cracked ice will usually prove effective. The question of haemorrhage after tonsillotomy, how- ever, is by no means so easily settled as would appear from the above general statement, which, although in the main correct, is nevertheless subject to so many excep- tions that it has given rise to much spirited discussion. The view taken by most specialists is, that the operation is attended with little or no real danger. On the other hand, there are some practitioners who look upon it with dread. In studying the literature of the day, the fact becomes apparent that considerable looseness of expression pre- vails with regard to this matter. Thus, one writer says that there are several records of more than a thousand operations at the hands of the same surgeon without the occurrence of any serious haemorrhage. Another believes that profuse haemorrhage occurs perhaps once in five hundred times, while an alarming haemorrhage does not happen once in a thousand times. Sir Morell Mackenzie, whose experience in this direction undoubtedly exceeds that of any living operator, has only once met with a case in which bleeding actually appeared to endanger life. Elsberg, who claimed to have operated upon sev- eral thousand cases, stated that in only two of them had bleeding of an alarming character taken place. On the other hand, the statement is commonly met with that there are quite a number of cases of tonsilloto- my recorded in which the haemorrhage has proved fatal. Upon investigating the truth of this remark, we find that there are a few instances recorded by the older surgeons, in which death from haemorrhage has followed operation upon the tonsils. It should be explained, however, that in most instances these operations were not performed for simple hypertrophy of the gland, but for some dis- eased condition which required more or less deep dissec- tion. Again, at the time when these cases are said to have occurred, tonsillotomy was generally performed with the knife, the tonsillotome of Physick being then unknown. In an admirable paper upon the subject, by Lefferts (" Transactions American Laryngological Association," vol. iii.), the author thus summarizes his views : 1. A fatal haemorrhage after tonsillotomy is very rare. 2. A dan- gerous haemorrhage may occasionally occur. 3. A seri- ous one, as regards possible immediate and remote results, is not very unusual; and 4. A moderate one, requiring direct pressure or strong astringents to check it, is often met with. While fully agreeing with the last three propo- sitions, the writer is inclined to go further than Dr. Lef- ferts in regard to the first. For many years he has made diligent search, both by reading and by inquiry among the leading authorities of the day, in order to find, if possible, an authentic case of death from haemorrhage after tonsillotomy performed according to modern meth- ods. His efforts have not been rewarded by the discovery of a single instance ! And yet the operation must have been performed many thousands of times. The fatal causes alluded to are, therefore, traditional, and not fairly to be included in modern statistics. While the above is believed to be strictly within the bounds of reality, yet cases are not wanting in which hae- morrhage of an alarming character has taken place, the literature of 1887 in particular including several of them. In haemorrhage after tonsillotomy several varieties of bleeding may occur. These are : 1. Arterial: from the division of one or tw6 compara- tively large arterial branches. 2. Arterial: from the division of a large number of small arterial twigs. 3. Venous: from the division of the small plexus of veins which lies below and outside of the tonsil. 4. Capillary. 5. General: from the presence of the haemorrhagic dia- thesis. Of the above varieties, the first two seem to be decidedly the most common. Of eight cases which have come to the knowledge of the writer, all were in men, all were upward of twenty- four years of age, the youngest being twenty-four and the oldest thirty-four, and the average age was twenty-eight years. Age, therefore, plays an important part, and for the reason that, the older a tonsil is and the longer it has been the subject of hyperplastic disease, the greater will be the amount of fibrous tissue in it, and the larger and more dilated will be its vessels. Thus, in a typical case observed by the writer, the patient was aged thirty-four. The tonsil was small in size, firm in texture, and of a grayish color. Marked resistance was encountered in forcing the blade of the tonsillotome through it. Not more than two or three drachms of blood were lost im- mediately after the operation. Within an hour bleeding returned, and it continued increasing in severity until 143 Tonsils. Tonsils. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the patient was nearly exsanguinated, and that in spite of every possible effort to stop it. Microscopic examina- tion of a section of the tonsil, made through its base, re- vealed an unusually large amount of fibrous tissue sur- rounding and running through the substance of the tonsil in broad bands. In this fibrous tissue were seen large numbers of blood-vessels, many of which were of con- siderable size. By reason of their situation in the midst of the fibrous tissue, evidently, they had been unable to retract and close, and thus the bleeding had been allowed to continue. Cases of severe bleeding in children are extremely rare. The only one which has come under the observation of the writer, was one that occurred in a girl of seven, and was due to haemophilia. In children the haemorrhage is generally capillary. The sources from which tonsillar haemor- rhage may arise are obscure, since the blood-supply of the gland is derived from a considerable number of different arterial branches, which together ramifying through it, render it almost impossible in the living subject to trace the connection of any one twig with its parent branch. More- over, anomal- ies are com- mon, and while the ascending pharyngeal is probably in most cases the largest contributor, it is sometimes small, and precedence is then taken by the ascending palatine. It is safe to say that in all modern instances in which bleeding has taken place, it has been from some of these smaller arte- ries. There is nothing to prove that the internal carotid itself has ever been wounded, since the intro- duction of the tonsillotome, by the use of that instru- ment ; nor does it seem possible that it could be when the relation of that trunk with the tonsil is considered. In sev- eral cases in which the common carotid has been ligated for dan- gerous tonsillar haemorrhage, the bleeding has continued, and in the case seen by the writer, already referred to, firm and per- sistent holding of the common carotid seemed absolutely with- out effect. As stated by Lef- ferts, the generally received views are in favor of ligation of the internal carotid. Later au- thorities have expressed a pref- erence for ligating the common carotid, and several cases are reported in which this has proved successful. On the other hand, it has in other instances totally failed. It would seem that a careful study of the circulation of the neck would set at rest any question as to what should be done. In the first place, the objection some- times made to tying the common carotid, that it may unduly cut off the supply of blood to the brain, is not to be considered for a moment. Again, the internal carotid lies so far from the tonsil (see Anatomy, page 130) that to injure it directly, in ton- sillotomy done with the modern tonsillotome, is, theo- retically and anatomically, impossible. Moreover, the wounding of a vessel of such great size as the internal carotid would almost necessarily produce a haemorrhage of overwhelming severity, while in every case of severe bleeding which has been reported the haemorrhage has been distinctly of a different character, and plainly referable to the division of a smaller class of vessels. Not even these vessels can come from the internal carotid, unless they be branches of the ascending pharyngeal when that ves- sel, as sometimes happens, is given off anomalously from the internal and not from the external carotid. In point of fact, " the cer- vical portion of the internal carotid gives off no branch- es" (Gray). No branches, therefore, can be distributed to the tonsil, and in case of tonsillar hae- morrhage the bleeding can- not possibly come from that trunk. On the other hand, in nor- mal cases the branches which do supply the tonsil are, without exception, de- rived primarily from the external carotid, and al- though some of them anasto- mose with their fellows of the opposite side, as, for instance, the dorsalis linguae, they depend practi- cally entirely upon the carotid. To ligate the internal carotid, there- fore, would be uncalled for. To tie the common carotid would certainly result in shutting off the circulation in that artery and its branches, including the external carotid, from below. Why, then, should not compression or ligation of the common carotid result in absolutely checking tonsillar haemorrhage, instead of being followed, as has often happened, by complete failure? And why is it that in nearly every modern instance of severe bleeding, where the haemorrhage was not arrested by the occlusion of one or two spirting twigs by torsion or otherwise, all means have proved ineffectual, and the flow has only ceased when at last syncope has occurred ? The answer to these questions must be apparent when we consider the connections of the internal carotid with other important arteries, for, through the circle of Willis, it has direct communication with all of the great vessels of both sides which enter the cranium. Ligation of the common carotid, of course, cannot cut off the communi- cation between the external carotid and the internal. Moreover, with its circulation stopped from below, there is no reason why a very considerable supply should not be received from the arteries at the base of the brain, carried downward to the bifurcation of the common ca- rotid, and thence into the external carotid and its branches. Hence it is, apparently, that the results of tying the common carotid have not been good. The answer to the second question will depend Fig. 3946.-Arteries of the Neck. (Gray.) 144 Tonsils. Tonsils. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. somewhat upon the anatomical condition just de- scribed. Haemorrhage in general, it is unnecessary to say, is likely to cease during syncope. In bleeding after ton- sillotomy, the excitement of the patient and the conse- quent stimulation of the heart and activity of the brain, result in great increase in the general circulatory force and in the amount of blood actually carried to the brain. As long as this condition lasts, bleeding will continue, the tendency being for it to grow more, rather than less, severe, even although the common carotid may have been tied. When, however, the heart s action becomes weak and the brain anaemic through syncope, the circu- lation in the common carotid being now, as before, cut off, bleeding from the tonsil will cease. This circum- stance would, it seems, tend to confirm the view already expressed and to prove the futility of ligating the com- mon carotid at all. Plainly, then, no dependence can be placed upon the ligation of either the internal or the common carotid. It has been suggested by Lefferts to ligate both the common trunk and the internal caro- tid, and this, in case of an anomalous origin of the as- cending pharyngeal, would probably prove effective. In order to operate with the maximum certainty of success and the least possible surgical interference, it is to the external carotid that the ligature must be applied. And, since the supply sent to the tonsil by the ascending pha- ryngeal is usually considerable, pains should be taken to tie the carotid behind that vessel and between it and the bifurcation of the common carotid. True, Druitt ob- jects to the tying of the external carotid, "because of the uncertainty of origin of the vessels which supply the tonsil," while Gray states that it is rarely performed on account of the number of vessels given off from it, liga- tion of the common carotid being preferred. It does not seem as if these objections were valid, in view of the general necessities present in the cases which we have had under consideration. Fortunately, the occasions upon which such proced- ures will be called for are extremely rare, and in the less severe cases reliance may be placed upon simpler means. In general, it may be said that the operation of tonsillotomy should not be performed unless ample means are at hand for controlling any ordinary amount of haemorrhage which may occur, and although the chances of bleeding are infinitely slight, no surgeon is justified in incurring them unprepared. Since the amount of bleeding present may vary from the loss of a few drachms up to a haemorrhage of considerable importance, it follows that the means selected for its ar- rest must vary with the nature and severity of the case. In the vast majority of instances, the bleeding, even though sharp at first, will subside spontaneously within a few minutes after the operation. In these cases the patient should be directed to keep the head upright, as far as possible ; to refrain from making efforts at clearing the throat; to gargle the throat quickly, and several times in succession, with ice-water; or, upon the re- moval of the tonsils and, if possible, before bleeding has begun, the surgeon should apply at once to the wounded surfaces the tanno-gallic mixture already mentioned, the solution having been prepared and the brush with which the application is to be made having been satur- ated with it before the operation, so that there shall be no loss of time. By this means it is often possible to escape with almost no loss of blood at all. Should the bleeding continue, excellent results may be obtained by grasping a smooth, rounded piece of ice in a pair of long forceps and holding it firmly against the bleeding surface. Or the surgeon may wrap, somewhat tightly, a pledget of absorbent cotton around the end of a suitable rod, saturate it with the tanno-gallic mixture, and then press it against the wound. Should these means not succeed, the pharynx of the patient should be illuminated by the best attain- able light, the neighborhood of the tonsil diligently cleared of clots, the cut surface thoroughly exposed to view, and careful search made for the exact source of the haemorrhage. Sometimes this precaution will be rewarded by the discovery of one or two spirting points. These will generally be found low down in the pharynx, corresponding with the inferior part of the tonsil, in which the larger arterial branches seem to be received. Such points, having been discovered and precisely located, should be seized with long slender forceps, and thoroughly twisted ; or they may be touched with a small galvano-caustic point; or the tip of a probe upon which nitrate of silver has been fused may be pressed into them, the spot having previously been well cleared of blood. Such haemorrhage is apt to occur in cases where the incision has been carried low down in the pharynx, and may usually be arrested by the above means. Upon inspecting the thoroughly cleansed wound, however, there may appear not one or two bleeding points, but innumerable little vessels, none of which is large enough to be seized, but all vigorously engaged in the work of pouring out arterial blood. These are the cases in which the tonsil has been subject to hyperplastic enlargement, where the fibrous stroma containing the nutrient vessels is markedly increased and indurated, and the vessels themselves large and abundant. Encased as they are in fibrous tissue, it is difficult for them to contract ; hence the bleeding, abundant, persistent, and exceedingly dif- ficult to control. In these cases torsion is impossible. If the means first mentioned have been tried without effect, good may sometimes be accomplished by the application of pres sure, either through the medium of the fingers of one hand of the operator introduced into the pharynx and pressed against the wound, while counter-pressure is made from the outside with the other hand, or by means of a forceps-like instrument made for the purpose, and furnished at its distal ends with two pads of suitable size. Anyone who has tried to apply pressure in a case of lively tonsillar haemorrhage, with the patient gagging from the pharyngeal reflex and, from time to time, throwing off the blood which has found its way to the stomach-not to mention the other symptoms of distress and alarm usually present-will agree with the writer that it is by no means an easy resource, although at times it may prove effective and may not be attended with the difficulties described. Failing in this, one of two devices may be resorted to. If the removal of the tonsil has been thorough the surface of the wound may be seared with a large flat galvano-caustic point, or with the Paquelin cautery. If, on the other hand, enough tissue has been left to make such a proceeding possible, the stump of the tonsil may be drawn inward by the vulsellum, or hook, or else pierced at its base with two transfixion needles, and a strong ligature passed firmly around it. This method has been employed by Dr. E. W. Clark with success upon a case at the New York Hospital. Pressure of the common carotid may be maintained, al- though in the personal experience of the writer and of others it has proved useless. Meanwhile, several general measures of great value may be employed. Since the object desired is to quiet the circulation and allay nervous excitement, the administration of opium is decidedly indicated. Again, arterial tension may be relieved by shutting off a part of the supply of blood. This may be accomplished by constricting the patient's thighs, as is sometimes done in haemoptysis. Finally, in nearly every instance of tonsillar haemor- rhage of the class last described, known to the writer, the bleeding has continued in spite of all efforts to stop it until, at last, the patient has fainted. Upon the oc- currence of syncope the flow has promptly ceased, nor has it, with the return of consciousness, recurred. While, therefore, the means which seem best adapted to the case in hand are being applied, any tendency to fainting should be encouraged rather than repressed. Should the above means all prove ineffective, and the question of ligating one of the great vessels be entertained, it should be re- membered, as has already been shown, that ligation of the internal carotid is useless ; that ligation of the com- mon carotid has sometimes succeeded, but has often 145 Tonsils. Tonsils. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. failed ; and that the choice of a successful operation lies between tying the external carotid near the bifurcation of the common carotid, or the ligation of both the com- mon and the internal carotid arteries. The occurrence of a venous haemorrhage is unusual. The writer has seen one such case, following the use of the Fahnestock guillotine, in which the instrument, not being properly regulated, dragged the tonsil from its bed and, cutting completely outside of it, passed through a plexus of veins lying near its lower aspect. A profuse haemorrhage followed, which was checked without great difficulty by means of cold and pressure. Capillary haemorrhage may be stopped by the tanno- gallic mixture, by pressure, by cold, or, finally, by the gargling of water taken as hot as can be borne. Of a very large number of cases of tonsillotomy known to the writer, in only one has severe haemorrhage oc- curred in a child. This patient, a girl of seven, had haemophilia, and the Fahnestock instrument was used. Profuse bleeding followed, which was controlled by styptics, but it recurred twice within thirty-six hours, leaving the child almost exsanguinated. Recurrence was evidently caused by the swallowing of food. All food by the mouth was interdicted, and the patient was nourished by rectal alimentation for three days, with complete success. Finally, annoying and persistent bleeding may occur from the accidental wounding of the anterior pillar of the velum palati in the course of tonsillotomy. The ad- hesions which often exist between the anterior pillar and the tonsil should be broken up before the removal of the gland is attempted. It must not be supposed that all that is necessary in the way of treatment is to secure the healing of the pha- ryngeal wound. In the case of children, besides the general tonic treatment sometimes required, three points at least should be carefully attended to. First, a child who has been a mouth-breather from infancy may need some help to overcome the habit, even when the pharyn- geal obstruction has been removed. To this end he should be encouraged, while waking, to breathe through the nose, and when asleep should receive the benefit of some artificial help. For this purpose Dr. T. R. French, of Brooklyn, has proposed an effective method. Two bandages of cheese-cloth, about three inches wide, and long enough to tie around the head, are applied, the one under the chin and over the top of the head ; the other in front of the chin and around to the back of the head. The bandages are fastened to each other with safety-pins at each side of the chin, the whole forming a comfort- able and easy support. The after-treatment in tonsillotomy is exceedingly simple. The general condition may be estimated to equal about that of a patient suffering from a mild attack of tonsillitis. He should be kept quiet for two or three days. Solid food should be withheld for thirty-six hours, and then such articles selected as shall produce neither chemical nor mechanical irritation. A gargle of simple borax and water, or containing besides a trace of carbolic acid or thymol, or any other good disinfectant, should be used every few hours, unless it is painful to the throat, in which case the fluid should be used with an atomizer. Gum arabic, or better still, " marsh-mallow drops," may be occasionally dissolved in the mouth. The wound usually heals with rapidity and without accident. Some- times, however, in unhealthy subjects, it becomes cov- ered with a thick, whitish membranous deposit, which may even appear to be diphtheritic, and which may be associated with more or less constitutional disturbance. This, in the majority of cases, soon yields to local disin- fectant measures, and the internal administration of iron. Secondly, the defects of pronunciation commonly met with in the subjects of enlarged tonsils, become, like the mouth-breathing, matters of habit, and do not always disappear when the cause to which they are due has been removed. This matter should be explained to those hav- ing the child in charge, and suitable exercises in reading and pronouncing recommended. Finally, the deformity of the chest will in many cases need attention. Light gymnastics and, more particularly, the systematic prac- tice of chest expansion, will often bring about a surpris- ingly rapid and beneficial result. The results of tonsillotomy are immediate and marked. It is not uncommon for a patient to sleep quietly and without snoring upon the night following the operation, perhaps for the first time in his life. Locally, the symp- toms of pharyngeal irritation quickly improve, the ca- tarrh subsides, the hearing-distance is increased, the quality of the voice is at once altered for the better, the discomfort in deglutition and the loss of desire for food are removed, ami the ability to breathe through the nose is established. Nutrition is no longer interfered with, and the child, who was before weak, ill-nourished, and under-developed, will in many cases begin to grow with remarkable rapidity ; his whole appearance at the end of several months being greatly changed for the better. It is not easy to understand why a measure of such ob- vious necessity and advantage as the excision of enlarged tonsils should meet with the opposition which is brought to bear against it by some practitioners. Still less is it explicable when the ground of the opposition is explained. Among the principal objections urged against tonsil- lotomy are the following: 1. That the tonsils will atrophy spontaneously at pu- berty ; or, as some express it, that the child will " grow to his tonsils." 2. That tonsillar hypertrophy exercises a protective in- fluence against infections. Also, that it protects against bronchitis and phthisis. 3. That the removal of the tonsils will injure the voice. 4. That their removal will destroy the patient's virility. 5. That the tonsils will be likely to grow again. 6. That milder measures than excision will answer the same purpose. 7. That the operation should be indefinitely postponed because the patient may be weak. With regard to the first objection, the considerations discussed in another part of this article are a sufficient answer. The tonsils do not tend to atrophy at puberty, as statistics will show, and even were they to do so, the injury done the child meanwhile might be irreparable. The second objection is perhaps the most erroneous and pernicious one of all, for, as a matter of fact, exactly the contrary is true, and so far from protecting from dis- ease the condition in question renders the patient all the more susceptible to it. Thus, diphtheria is far more apt to attack an inflamed surface than a healthy one. Again, the larger the tonsil the greater the severity with which it may be attacked, and the greater the extent of surface which may be involved. A more difficult case to man- age can hardly be imagined than an attack of diphtheria in a child whose tonsils have undergone the enormous en- largement often seen in an acute exacerbation engrafted upon an already hypertrophied pair of tonsils ; and there are few practitioners, probably, who cannot recall in- stances in their own experience where such cases of diph- theria have been practically hopeless from the beginning, and where death has been the inevitable result. That they protect against pulmonary troubles is still less true. Children whose tonsils are enlarged are commonly the sub- jects of bronchitis. Deficient oxygenation and the addi- tional exertion thereby thrown upon the lungs are efficient factors in the production of bronchial irritation. Such children often die of lung disease. The ideas that en- larged tonsils will prevent phthisis, and that tonsillotomy will cause it, are at strange variance with fact. Patients who have suffered for years with enlarged tonsils do not contract phthisis on account of their removal, but be- cause, by reason of their presence, the constitution has been broken down and the general power of resistance to disease is diminished. The question as to the effect of the removal of enlarged tonsils upon the quality of the voice is one of real impor- tance to all singers, and one upon which they will always seek information. The tone-quality of the voice is largely determined in the pharynx, for, although the upper pharynx and nasal cavities play a part in the matter, the condition of the lower pharynx exercises a far more im- 146 Tonsils. Tonsils. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. portant influence upon it. Thus, a "throaty" quality, or one deficient in over-tones, is produced by contracting the walls of the pharynx. Just as in a cornet the bell of the instrument must be kept free from obstruction if the best tone is to be secured, so, in vocalization, a pure, mellow, rich timbre requires a wide and ample pharyn- geal space. Anything which tends to contract and nar- row this space will directly injure the quality of the voice. On the other hand, restoration of the normal capacity of the pharynx will improve the voice. The removal therefore of hypertrophied tonsils cannot possi- bly injure the voice, but, on the other hand, is certain to benefit it. It is said that Adelina Patti, without doubt the most brilliant singer of the day, submitted to tonsil- lotomy several years ago, with the result of decidedly im- proving her voice. Nor is it by mechanical interference alone that tonsillar hypertrophy may interfere with the production of tone. The condition is almost always at- tended with more or less catarrhal inflammation of the neighboring parts, and this, extending to the larynx, is certain to inflict more or less injury upon its tone-pro- ducing power. Finally, a relaxed and semi-paretic con- dition of the soft palate is often associated with enlarged tonsils, the effect of which upon the voice is to render its quality thin, sharp, and nasal. No singer, therefore, can do himself justice so long as enlarged tonsils con- tinue to obstruct his throat, nor can he depend upon the preservation of a voice exposed to such constant and seri- ous danger. The assertion that tonsillotomy will destroy the virility of the patient is constantly contradicted by the fact that, in numerous instances known to the writer and others, the fathers and mothers of large families have at some time in their lives submitted to the excision of enlarged tonsils. On the other hand, the fact that hypertrophy of the tonsils is almost certain to produce a general debility and weakening of all the bodily powers, will readily ex- plain why a person who has suffered from them should be sterile, even though they may have been removed at a late period of life. It is not the operation, therefore, but the results of the difficulty for which it was performed, to which the sterility is due. The influence of the organs of generation upon the tonsils has never been proved to be very intimate, and the absurd argument to the con- trary, based upon the fact that orchitis may be associated with mumps, fails when we remember that the latter dis- ease is an affection not of the tonsils but of the parotid gland. For a tonsil, of which sufficient has been excised at the outset, to grow again, is one of the rarest of accidents. The writer has seen one case in which this seemed to have occurred. The patient was the subject of hereditary syphilis, and suffered from extraordinary enlargement of all of the adenoid elements of the upper air-passages. Milder measures than excision are, in the opinion of authorities in general, in the vast majority of cases de- ceptive. Sooner or later, as a rule, in a given case, they will be abandoned and a tonsillotomy will be performed. They do not succeed in satisfactorily removing the diffi- culty and, in many instances, they inflict far more pain and annoyance than does the radical operation. Feebleness on the part of the patient is generally due to the effects of the enlarged tonsils themselves, and the shortest and most effective way of relieving it'is to re- move the cause. Far more in such cases is to be gained by promptness than by delaying what must inevitably come. Foreign Bodies in the Tonsils.-From their peculiar structure and their position in the pharynx, the tonsils are very prone to the arrest and lodgement of small pointed foreign bodies. These may be found fixed in one of the deeper lacunae or thrust into the substance of the gland itself. Their presence is characterized by a limited degree of pain at the seat of impaction of the body, and sometimes by slight dysphagia. Occasionally, however, the pain is referred to a point more or less remote from the seat of the trouble. Commonly, in tonsils which are the seat of chronic inflammation, the secretion of tin lacunae may be in- creased in quantity and retained within the crypts, several of which may be found thus occupied. The composition of this matter is found under the microscope to consist of the debris from broken down follicular glands, granular matter, epithelium, pus-corpuscles, cho- lesterin, and an abundance of the parasite known as the leptothrix buccalis. The presence of such deposits in certain of the crypts, is due to the fact that the latter are unusually deep, and their mouths are not sufficiently patent to allow of the free evacuation of their contents. They are invariably a source of irritation to the tonsil, and often the occasion of frequent and recurring attacks of acute inflammation, and even of abscess. These soft concretions, which are of a white or yellowish color and cheesy consistency, must not be mistaken for tonsillary calculi, which are entirely different both in character and composition, and which are actually of very rare occurrence. The composition of these concretions is principally phosphate and carbonate of lime. They are, therefore, not of gouty origin, as has sometimes been supposed. Besides the above-named salts, they contain small quantities of iron, soda, and potassa. Their pres- ence gives rise to few symptoms which may not be ob- served in any inflamed tonsils. A slight pricking sen- sation is often complained of, and, when the concretions are large, dysphagia. Sometimes small concretions are discharged spontaneously, and sometimes their presence predisposes to severe attacks of quinsy, in the course of which an abscess may form which may be very slow in healing. The presence of a tonsillar calculus may be determined by the discharge of pieces of the calculus, by inspection, a part of the calculus projecting from the lacuna far enough to be visible, or by direct examina- tion with the finger or a probe. In the treatment of these cases the concretion may be re- moved by means of a hooked probe, or small forceps. It will generally happen that the tonsil will be enlarged, and then the extirpation of more or less of the gland will be called for. Indeed, this is the simplest way of relieving the whole matter. The use of the tonsillotome may be impossible on account of the hardness of the calculus, in which case resort to the bistoury will be necessary. Parasites in the Tonsils.-Mackenzie quotes several instances in which certain parasites, such as hydatids and tricocephali have been found in the tonsils. Dupuytren relates the case of a woman twenty-one years of age, who for eleven months had suffered from attacks of inflam- mation of the tonsils. The left gland was considerably swollen, and the surgeon having diagnosed an abscess, plunged a bistoury into the tumor. As a result, nearly two ounces of watery fluid gushed out, and ultimately a large hydatid cyst, the size of a hen's egg, was extracted. The patient died soon after, and a hydatid cyst, the size of a child's head, was found attached to the left kidney. A similar case, excepting that the patient was a man, is reported by Davaine, and the same observer relates an instance in which a tricocephalus was found lodged in the left tonsil. The parasite had probably attained this situation through being expelled from the stomach dur- ing the act of vomiting. Syphilis of the Tonsil.-Chancre.-The occurrence of the initial lesion of syphilis upon the tonsil is less un- common than has been supposed. Since attention was first directed to it by Fournier, in 1860, and a year later by Diday, a considerable number of cases have been recorded, and the lesion is now fairly recognized and un- derstood. While chancre of the lips and buccal cavity is not uncommon, its occurrence upon the pharynx is practically unknown. The explanation of its appearance upon the tonsils is plain when the structure and po- sition of those organs is remembered, situated as they are at the most exposed part of the buccal cavity, and abounding in depressions into which the virus may read- ily be received, and by which it is easily absorbed. Most authorities agree that chancre of the tonsil is more com- mon in women than in men. Although it is doubtless commonly due to the causes to which it was attributed by the earlier waiters, there are many cases in which, without question, it has been innocently acquired. Thus, 147 Tonsils. Tonsils. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES the contagion has been conveyed by kissing, by means of instruments, table utensils, such as knives, forks, spoons, cups, and other household articles; of nursing- bottles ; of tobacco-pipes used by syphilitic smokers, and of cigars rolled by infected operatives; by nurses from syphilitic children, and by children from wet-nurses suf- fering with the disease. Wigglesworth tells of a med- ical student who put his mouth to that of an asphyxiated newly-born infant, and inflated its lungs several times. One month later a hard chancre developed upon his right tonsil. C. H. Knight also relates the case of a lady who contracted a chancre of the tonsil by using the same tooth-powder as her nephew, who was suffering from secondary syphilis. Formerly, chancre of the tonsil was observed among glass-blowers, whose custom it was to pass from mouth to mouth the tube through which the glass was blown. Several epidemics of buccal chancre occurred, when the matter was investigated by Guinaud, and further contagion prevented by each workman being provided with his own mouth-piece. While chancre of the tonsil is generally unilateral, it has sometimes been observed upon both glands. The diagnosis of chancre of the tonsil is apt to be dif- ficult, since the symptoms vary considerably, and the situ- ation of the trouble is so remote that it easily passes un- observed or unrecognized. R. W. Taylor calls attention to the fact that probably some cases of the syphilis d'em- blee or larvee of the French were instances of tonsillar infection. The signs of infection, of the tonsil generally begin with slight redness and swelling, and without perceptible induration. Soon there is pain in deglutition, increased redness, and hypertrophy, which is followed by a super- ficial erosion, having an indurated base, and more or less glandular involvement of the affected side. The hyper- trophy and general tumefaction of the tonsil itself is an important sign, and seems to be a constant accom- paniment of the disease. The second important symp- tom is the superficial erosion, increasing to an actively ulcerating surface, generally covered with a grayish-white coating of greater or less thickness, granular in character, and distributed over the surface of the ulcer in a some- what irregular manner. Sometimes the erosion is very superficial and ill-defined, while in other rare cases it has assumed the phagedenic form, presenting a deep, slough- ing ulcer, with a high degree of inflammation and tume- faction of the neighboring, parts. Again, induration of the base of the ulcer is always present, and presents here, as elsewhere, a most important diagnostic sign of its syphilitic character. It is said that the amount of induration will depend upon the degree of hypertrophy of the tonsil existing before the development of the chancre, the greater the hypertrophy the more marked the induration, and vice versa. As lias been com- monly observed in the case of hard chancres in other sit- uations, induration of the base may be the only symptom present which is characteristic of the primary lesion. Enlargement of the submaxillary lymphatic glands of the affected side is a constant symptom, the engorgement being hard, indolent, and sometimes extensive. Suppu- ration does not seem to have been observed. The dura- tion of chancre of the tonsil has been thought to be shorter than that of the same lesion in other places. There is generally more or less dysphagia, and when the ulceration assumes the phagedenic form, pain in swallow- ing may become very severe. The diagnosis of chancre of the tonsil is often by no means easy. It will generally be difficult to obtain a history of contagion, through either the reticence or the ignorance of the patient. The unusual situation of the lesion, its diversity of appearance and form, the absence of corroborative evidence, all render the case in many in- stances obscure. It is necessary to differentiate it from malignant disease, especially epithelioma; from tubercu- lous ulceration; from psoriasis of the mouth and from the so-called smoker's patches ; from mucous patches ; from the ulcerating gummata of tertiary syphilis; from diphtheria ; and, finally, from gangrenous ulceration of the tonsil. Donaldson, in his resume of this subject, with bibliog- raphy (The Medical News, August 15, 1885), gives the following summary of the differential diagnosis between chancre and cancerous disease of the tonsil: SYPHILIS. Functional Symptoms. Deglutition painful, but rarely impossible: freedom from pain when the parts are at rest. Physical Signs, Some hypertrophy, with early su- perficial ulceration in primary sore. The tertiary ulcer perforating, and con e-shaped. Com para ti vely. slight glandular enlargement, not painful, and subsiding with the cause of the irritation. Haemorrhage rare. Emaciation slight. Amenable to treatment. CANCER. Functional Symptoms. Difficulty and pain in swallowing the first and constant symptom, in- creasing until deglutition is impos- sible. Physical Signs. Great hypertrophy ; later, wide- spread ulceration. Considerable glandular enlargement and indura- tion, which become very painful, and do not disappear. * Haemorrhage frequent. Emaciation marked. Incurable. Difficulty may arise in distinguishing a chancre from an ulcerating mucous patch. The latter would lack the indurated base and would follow the roseola and other early manifestations of secondary syphilis, and would generally present appearances more or less characteris- tic. As a means of determining between a hard chancre and a mucous patch, Diday advises that the ulcer be cauterized twice, within a period of five days, when, if it is a secondary ulcer, it will disappear ; if primary it will not. The differences between chancre and diphtheria are sufficiently obvious and lequire no special mention. Ulcerating gumma of the tonsil is distinguished from chancre by the previous history of the case and by the depth of the ulceration, the characteristic punclied-out appearance of the edges, and the absence of induration. The prognosis in chancre of the tonsil is good, except- ing in unrecognized and neglected cases of the phagede- nic form. Finally, it is often impossible to arrive at a decided conclusion until the development of constitutional phe- nomena, and the results of treatment unite in confirming the diagnosis. If a suspicious ulcer remain obstinate to all ordinary internal remedies, and to such local applica- tions as the nitrate of silver and the nitrate of mercury, for four or five weeks, we are, in the opinion of Morell Mackenzie, justified in suspecting the disease to be of specific origin. Again, as Donaldson has suggested, if the lesion upon the tonsil has been of slow, unilateral development, and is superficial, with grayish-white de- posit ; if there is a history or even suspicion of syphilitic exposure ; if there is glandular enlargement; if the ton- sillar sore has appeared from fifteen days to three weeks after exposure ; if the patient has not been subject to simple tonsillitis ; if the pain is on the affected side, has lasted foi' several days or weeks, and has not excited fe- brile reaction ; and if the whole is followed in due time by an outbreak of secondary syphilis, we are certainly justified in the diagnosis of chancre of the tonsil. The treatment, constitutionally, must depend upon the views of the practitioner with regard to the management in general of early syphilis. Should mercury be adminis- tered, the cyanide, one-sixteenth of a grain three times daily, as recommended by Morell Mackenzie, has been found especially valuable by the writer. In simple cases emollient gargles will answer every indication ; while, if the sore become phagedenic, cauterization with the acid nitrate of mercury and the application of antiseptic sprays or gargles will be indicated. Erythema of the tonsils is common in early syphilis. It may be general at first, but soon shows a disposition to limit itself by well-defined margins and to assume a symmetrical arrangement. Mucous Patch.-The occurrence of mucous patches upon the tonsil is very common, especially in cases in which the tonsils have already been hypertrophied and inflamed. They may be slight and barely perceptible, or large, well defined, and extensive, varying in color from an opalescent grayish-white to a dull yellow. In the latter case they are often mistaken for the exudation of follicular tonsillitis and for diphtheria, from which 148 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tonsils. Tonsils. they may readily be distinguished by their chronicity, their appearance, and by the history and coexisting signs of syphilis. The tonsils themselves meanwhile are gen- erally much enlarged and inflamed. Local treatment is best carried out by applications to the patches of solu- tions of iodine, and by sprays or gargles containing the bichloride of mercury (two grains to eight ounces of water). For the erythema an astringent spray will has- ten resolution. Gummy tumor may be recognized by the characteristic appearance of the ulceration; by the comparative free- dom from pain, which distinguishes it from cancer and from tubercle ; by the absence of the signs characteristic of tubercle in other parts of the body, including the high evening temperature; and by the fact that in the latter disease the ulcers are smaller and less deep. The best effects may be obtained from the internal administration of the iodide of potassium, while, locally, the progress of the ulcer can probably be checked by applications of the nitrate of silver or the acid nitrate of mercury. In- dolent ulcers may be stimulated by means of solutions of the sulphate of copper, or of the sulphate or chloride of zinc. Tubercular Ulceration. - Tubercular ulceration occurring primarily in the tonsil is rare. Consecutive to the appearance of the disease in other organs, it is not very uncommon, a fact which may be explained by the position and vulnerability of these organs. The appear- ance of the ulcer, when not too broken down, presents most of the following characters : The surface is uneven, pale, and devitalized ; it is granulated or often covered with yellowish-gray viscid or coagulated mucus; the edges are sometimes sharply cut, sometimes levelled, sel- dom elevated, everted, or undermined ; the surface is not usually very red, but often more reddened than the sur- rounding tissue ; there is little or no surrounding in- duration ; the shape of the ulcer is not constant, but it is usually ovoid; its depth varies, but it is usually super- ficial ; there is generally ulceration of some of the neigh- boring parts ; pain in swallowing is usually very severe. Microscopical examinations of scrapings from the surface of such an ulcer, made by the writer, revealed the pres- ence of a large amount of fine granular matter with an abundance of tubercle-cells and an occasional giant cor- puscle. There was also a small amount of the fibrous structure of the tonsil, with a little epithelium. But few pus-cells and no tubercle bacilli were present. Indeed, the apparent absence of the bacillus of tuberculosis is not uncommon. Whether this be from faulty methods of examination or not is difficult to say. It has certainly not been found in a number of cases in which the micro- scopic examination was entrusted to careful pathologists. While, therefore, the presence of the bacillus is proof positive of the existence of tubercular disease, failure to find it is no proof that the ulcer is not tuberculous. As to the local treatment of these ulcers, much will de- pend upon the stage of the general disease and the con- dition of the surrounding parts. Primary ulceration is best treated by the destruction of the infected area, either by scraping or by means of the galvano-cautery, this to be followed by applications of iodol or of a solution of iodine, the healing process being encouraged by any suitable means. Where the ulceration is second- ary to general tuberculous infection and to the develop- ment of ulceration in neighboring parts, less vigorous means will probably be indicated. In these cases, several of which have been seen by the writer (New York Medical Journal, May 14, 1887), the best results have been obtained by first spraying the sur- face of the ulcer with a solution of resorcin of a strength of two or three per cent., or with a weak dilution of Dobell's solution, and then applying to it lactic acid. If cocaine have been previously used the last application is painless. The strength of the lactic acid may be made to vary from thirty to one hundred per cent. In all cases the application of a four per cent, solution of cocaine will be found most effective in relieving the in- tolerable pain and dysphagia. The effects of an appli- cation of this drug usually last for five or six hours, and the patient may readily be taught to use it himself. Should the use of cocaine be impracticable for any rea- son, morphine may be substituted with happy results. Treatment, to be effective, must be carried out with great thoroughness and regularity, and the general nutrition of the patient must be maintained with care. If necessary, the process of deglutition can be much simplified by the use of a small-sized feeding-tube, through which food can be injected into the stomach. (Vide article Dysphagia.) Pharyngo-mycosis.-A parasitic disease which affects the tonsils rather more frequently than other parts. The condition is characterized by the presence of a peculiar deposit upon the surface of the tonsils and the mucous membrane in their vicinity. This deposit is white or yellowish in color, more or less hard, sometimes much in- durated, and either distributed in small patches or more or less confluent. Occasionally, the patches form pro- jections which are almost pedunculated, and they are generally situated at the orifices of the tonsillar crypts. The appearance of these deposits is attended with nei- ther local nor general inflammatory reaction, which fact distinguishes the condition from diphtheria and from follicular tonsillitis. The diagnosis may also be con- firmed by the microscope. The patches recur quickly upon being scraped off. A microscopical examination, made by the writer, of scrapings from a case observed by him, showed the presence of pavement epithelium, granular matter, pus-corpuscles, white blood-corpuscles, cholesterin, and finally, and most important of all, an abundant quantity of the leptothrix buccalis, filiform elements described by Frankel under the name bacillus fasciculatus, but long since known and recognized under the former term. This organism attacks not only the outer layers of the epithelium, but extends also to the deeper parts of the mucosa. This may explain the ten- acity with which, in many cases, the deposits cling to the mucous membrane, and the tendency to recurrence which they manifest. Sometimes, however, the deposit is but slightly adherent and easily removed by scraping. The chief characteristics of the affection are its long continuance, marked tendency to recurrence, aud the tediousness with which a cure is effected. As has been stated already, pharyngo-mycosis may be distinguished from acute follicular tonsillitis by th(j absence of the symptoms of acute inflammation, and by the rapid disappearance of the follicular exudation. It is true, nevertheless, that the leptothrix may be found in the white patches of the acute condition, while Emil Gruening has shown that in chronic disease of the crypts, attended with the formation of white or cheesy concre- tions, the basis of the foreign matter is not the remnant of the cast-off matter from the neighborhood, but the same leptothrix buccalis. (Vide section on concretions of the tonsil.) The successful treatment of this condition is accomplished only by long-continued and persevering effort. All authorities agree that, to be effective, the treatment must be radical and thorough. The best results have been obtained by first scraping away the deposit with a sharp curette or some similar instrument, and then applying a galvano-cautery to the site of the lesion. Meanwhile, the frequent application to the throat of gargles or sprays, containing either the bichloride of mercury (gr. j. to 3 iv. of water), or the biborate of soda, are beneficial. Care must be taken in the management of these cases to recognize, if possible, the origin of the bacillus ; and, since carious teeth are said to be a fruitful source for their production, the mouth of the patient should be examined, and any such condition remedied. Tumors of the Tonsil.-Benign.-Benign growths springing from the tonsil are somewhat uncommon. The varieties most frequently met with are papillomata, fibromata, lymphomata, lipomata, and angiomata. Papil- loma of the tonsil is similar to the same growth in other parts of the body. Such tumors are generally of small size. They are apt to spring from the upper part of the tonsil, and to be pedunculated, creating little or no dis- turbance by their presence until they attain dimensions sufficient to render them mechanically irritating. Their 149 TohkIIs. Tonsils. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. appearance is that of a warty growth, with irregular out- lines, their consistence is soft and yielding, and their color usually pink. Fibromata are very similar to the above, excepting that they develop from the peritonsillar connective tissue, appearing like polypoid growths, or, as happens occasionally, growing in the connective tissue of the gland itself. The surface of the tumor is smooth and glistening, and its consistence is firm. In the case of papillomas and fibromas which are pedunculated, the best treatment is to put the pedicle well upon the stretch and then divide it close to the healthy membrane by means of a galvano-cautery knife. Lipoma, or fatty disease of the tonsil, is rare. There are no gross features which particularly distinguish it, so that a diagnosis must be made by the aid of the microscope. Lymphoma, although histologically similar to simple hypertrophy, is generally associated with leucocythemia and general lymphadenitis. It is sometimes seen as a consecutive manifestation after the neighboring glands have become enlarged. Suppuration of the tonsils in this condition rarely occurs. When, in this condition, the tonsils attain such a size that they obstruct the pharynx and are otherwise annoy- ing, they may be excised. The advantages of the opera- tion, however, will be largely mechanical. Angiomatous tumors of the tonsil must be exceedingly rare, since, while several instances of this form of growth occurring in the tongue and pharynx, have been re- ported during the past four years, we are unable to find a single instance in which it has been referred to the tonsil. Malignant Growths.-Although not a favorite seat for the development of malignant growths, such tumors are occasionally observed in the tonsils, and occurring there they are, from their history and prognosis, of the utmost importance. Primary cancer of the tonsils is rare. Of the two principal types, sarcoma and carcinoma, the most com- mon is the round-cell sarcoma. In addition to this are found the spindle-cell sarcoma and the lympho sarcoma. The etiology of cancer of the tonsil is, like that of the disease in other parts, unknown. * Of carcinomas the squamous-celled or true epitheli- oma is the most common, while, on the other hand, the spheroidal- or glandular-celled variety is the most rare. While the sarcomas and spheroidal carcinomas generally form distinct and prominent tumors, growths of the epi- theliomatous variety break down more or less early in their course, and form deep and sloughing ulcerations. The symptoms of cancer of the tonsil are more pro- nounced in the carcinomatous varieties. In the latter, pain of an intermittent and lancinating character is usu- ally an early and pronounced sign. Dysphagia soon fol- lows. In some cases, however, pain is not experienced at the seat of the difficulty, but is reflected to other parts of the throat. In a case of primary epithelioma of the right tonsil in an old man, seen late in its history by the writer, the first symptom noticed was severe pain in the ear of the affected side. The pain was pulsating in character, and continuous. There was no pain in the tonsil and no dysphagia. The advice of a competent otologist was sought, who pronounced the case one of otalgia. Four weeks after the appearance of the pain there was noticed an enlargement of the right tonsil. One month later the hypertrophy had increased until the tonsil was one and a half inch in diameter. At this time ulceration of its surface and swelling of the glands at the angle of the jaw began. The patient lived six months. The writer has seen another case in which otalgia, due to reflex irritation from malignant disease of the pharynx, was treated locally for some time before atten- tion was directed to the difficulty in the throat. Whatever the nature of the disease, its progress is marked by infiltration of the adjacent structures, most often the soft palate or palatine arches. The course of the disease is rapid. The cervical glands are almost invariably involved, and early in the history of the case, both in sarcoma and carcinoma. This may be explained by the intimate relation which exists between the tonsil and the cervical lymphatic glands. . Cancer of the tonsil may be secondary to the appear- ance of the disease in other organs. In a case of exten- sive sarcoma of the tonsil operated upon by the writer, the disease was multiple. The tumor of the tonsil was large, smooth, and resisting, and so filled the pharynx and overhung the larynx that deglutition and respiration became impossible. It had been of slow growth and its removal was attended with marked and long-continued relief. Of six cases of primary cancer of the tonsil seen by the writer, four were in men and two in women. In three cases the patients were upward of sixty years of age. The youngest was in a man of thirty-eight. But- lin mentions three cases of sarcoma in patients under twenty years of age, and six others who were from thir- ty-four to fifty-three years of age. In several cases of sarcoma mentioned by him the immediate cause of death was haemorrhage, both in those not operated upon and in those which were recurrent. In other cases death is caused by exhaustion due to dysphagia and discharge, or to a combination of various causes, among which the secondary involvement of other organs plays an impor- tant part. Haemorrhage from the ulceration of an epitheliomat- ous growth is not common. The diagnosis of malignant growth of the tonsil is, generally, not difficult. It is unusual before middle life, whereas ordinary hypertrophy of the tonsils almost in- variably occurs before that time. It is unilateral, while chronic hypertrophy is, as a rule, bilateral. Pain, either local or reflex, and enlargement of the glands at the angle of the jaw, are almost constant symptoms. As be- tween epithelioma and sarcoma, the diagnosis is not al- ways easy. In the former, however, pain is apt to occur earlier in the progress of the disease, and to be more se- vere, while the tendency to ulceration rather than to the formation of a considerable tumor distinguishes epitheli- oma from sarcoma, which at the same time is slower in growth, much more firm in consistency, and likely to at- tain a much larger size. In the treatment of these cases, both the sarcomatous and the carcinomatous, an early diagnosis is of the first importance ; and this is particularly the case if the dis- ease of the tonsil be primary. For, while removal of the tonsil by the natural passages is by no means a diffi- cult operation, the reverse is true of the extensive oper- ation required for its removal from the outside. The prognosis is more serious, of course, where glandular in- volvement has taken place, or where the neighboring structures have become infiltrated. The prognosis is bad, especially in epithelioma, as few patients live more than a year, and the majority are car- ried off within nine months from the beginning of the disease. Treatment. Aside from palliating the condition, little can be expected from any course of treatment which is not surgical in its nature. The local application of as- tringents and the internal administration of various drugs calculated to delay the progress of the disease, can only succeed in a slight degree in accomplishing the desired result. From the hopelessness of other methods, as well as from the discomfort and danger which often attend the presence of the tumor, the propriety of surgical in- terference will generally be discussed. For the removal of the tonsil several methods have been proposed. The one selected must depend mainly upon the character of the disease, and the presence or absence of involvement of the lymphatic glands. The tonsil may be removed either from within the mouth, or through an opening in the side of the neck. When the lymphatic glands are enlarged, removal of the organ through the mouth can only be regarded as palliative. Removal through the mouth is more applicable in the treatment of sarcoma than of carcinoma, because in the former disease the tumor is apt to be more prominent, 150 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tonsils. Tonsils. and the involvement of the adjacent parts is less. In operating the patient should be anaesthetized through the medium of a tube or some similar apparatus, introduced at the side of the mouth or through the nose ; the mouth must be widely separated with a gag, and the patient's head should be slightly raised and turned toward the best light obtainable. Excision of the affected tonsil may be best accom- plished by means of a galvano-caustic knife, a galvano- caustic loop, or a cold wire ecraseur. Of these methods, the galvano-caustic ecraseur will probably prove most useful in the majority of cases. While the cold wire may be used with almost no haemorrhage, the galvano- caustic ecraseur accomplishes as much and possesses be- sides several advantages over it. The amount of tension required for the latter is small, so that the loop is not apt to be dragged from its place, and fixation needles, if they are used, are not torn from the tumor by the pres- sure of the wire. The effect of the cautery upon the tissues of the wall of the pharynx is beneficial, in that any remnant of the growth left behind is apt to be de- stroyed at the time of the operation, and the chances of recurrence are thereby lessened. If the tumor be sessile and any difficulty is experienced in engaging it within the loop, much aid may be gained by the use of one or more transfixion needles. A means which the writer has found simple and ef- fective for passing the wire of the ecraseur around the tumor is to run the wire through a soft English catheter, about number eight, and, using this as a shield, pass the catheter around the tumor and under the transfixion needles, being sure, if possible, that it is well outside of the growth. Then, if the catheter be withdrawn and the wire left in position around the base of the tumor, the latter can be fastened to the cautery handle and the op- eration proceeded with. Care should be taken not to allow the temperature of the wire to rise too high, for the slower its progress the less will be the liability to haemorrhage. In a large majority of cases, however, bleeding is slight. Instead of the methods just described, the enlarged mass may sometimes be efficiently removed by means of the finger of the operator. While, as has been said, the haemorrhage following such operations is usually slight, the reverse sometimes happens. In cases of severe haemorrhage, and where there is considerable obstruction of the larynx from the effects of the tumor, immediate or remote, the perform- ance of tracheotomy may be necessary. Without ques- tion, no such operation should be undertaken without the means necessary for tracheotomy being at hand. Whether or not a tampon-cannula should be used must be determined by the necessities of the case in hand. Where the larynx is obstructed to any extent by the growth, or where the rima-glottidis has been narrowed by oedema or otherwise, the wisest course will be, probably, to per- form a preliminary tracheotomy. Too great emphasis cannot be laid upon the importance of consuming no un- necessary time in inserting the tracheal tube. The writer has more than once seen the chances of the patient effect- ually destroyed by a tedious and clumsy performance of the preliminary operation. Should bleeding occur the best haemostatic is the galvano-cautery. In operating upon such cases the writer has obtained great assistance in illuminating the pharynx from time to time during the operation, by means of a small, one-candle-power incandescent electric light, electricity for which may be readily obtained from any cautery battery suitable for heating the wire of the ecraseur. This may be intro- duced within the mouth and carried as near to the desired point as may be required, and by its aid exact conclusions may be arrived at as to the origin of bleeding, the character of tissue, and the extent of the growth. In- deed, the, importance of such assistance is not inconsid- erable, for with the best possible light, either of the sun or artificial, reflected by the head-mirror, there will generally be localities almost impossible to illuminate, and where bleeding is apt to occur or the presence of doubtful tissue to be suspected. By the use of the small electric light the whole character of the operation may be in some cases changed and the safety of the patient greatly enhanced. Even in cases where the disease of the pharynx has ex- tended beyond the tonsils to the soft palate and base of the tongue, the operation through the mouth with the galvano-cautery may be employed. In advanced cases, where the cervical glands are involved, the above opera- tion can only be palliative. Removal of the tonsil through an incision in the neck was first proposed and practised by Cheever, of Boston. It is not as formidable as it would appear. The opera- tion consists in making an incision, about three or four inches in length, along the anterior border of the sterno- mastoid muscle, from the level of the ear to below the level of the tumor. A second incision, at an angle to the first, is made along the body of the inferior maxilla ; the dissection is carried carefully down through the in- tervening textures, drawing the vessels and nerves aside, until the tonsil is reached, when it is removed with as little cutting as possible, preferably by means of the gal- vano-cautery. Tracheotomy may be performed if re- quired, and the patient after the operation must be fed through a tube. (See article Dysphagia.) Czerny has proposed an operation which, while far more formidable than Cheever's, seems to offer no especial ad- vantages over it. A tampon-cannula having been intro- duced into the trachea, an incision is made downward and outward from the angle of the mouth to the anterior border of the masseter muscle, and beyond it to the level of the hyoid bone. Through this incision the lower jaw is exposed and sawn through, between the second and third molar teeth, in a direction downward and outward, and the two fragments of the bone are held apart. Thus the tumor is laid bare, and to remove it it may be nec- essary to divide the digastric, stylo-hyoid, and stylo- glossus muscles, the hyo-glossal, glosso-pharyngeal, and gustatory nerves, as well as the lingual and other vessels. The tumor is then cut or torn out and the bleeding points touched with the galvano-cautery. The wound is treated antiseptically. The fragments of the lower jaw arc brought together by means of a silver wire passed through the middle of both, a second wire is twisted around the second and third molar teeth, and the external wound is closed with sutures except at the points where it is nec- essary to insert drainage-tubes. The opening in the mu- cous membrane within the mouth may also be brought together with sutures, if it is desired to hasten healing or prevent discharges from getting into the stomach or lungs. For the first few days after the operation the patient may be fed through a tube twice a day, and the tracheotomy tube may be retained. Both it and the feed- ing tube can be discontinued after a few days, and the silver wire removed from the molar teeth in the course of a fortnight. If the wire through the fragments of bone cause no irritation, it may be left permanently. Mickulicz has operated still more radically. He makes an incision from the mastoid process downward and for- ward, as far as the greater cornu of the hyoid bone. He then raises the soft parts from the jaw bone, avoiding, if possible, the facial nerve, and separates the periosteum from the outer and inner aspects of the lower jaw just above the angle. The jaw is then sawed through beneath the periosteum, the tendon of the temporal muscle di- vided, and the ascending process of the bone resected. He then draws aside, with strong hooks, the body of the jaw, the masseter, internal pterygoid, digastric, and stylo- hyoid muscles, when the surface of the wound is found to correspond as nearly as possible with the surface of the tonsil. By dividing the lateral wall of the pharynx, access is obtained to the palate, the base of the tongue, and the posterior wall of the pharynx, as far up as the naso-pharynx. By dividing the digastric and the hypo- glossal muscles and the hypoglossal nerve, the entrance to the larynx can be reached. By this proceeding the lymphatic glands may be removed if necessary, and the operation completed without opening the cavity of the mouth and pharynx. Mickulicz claims for this operation not only ease in reaching and removing the disease, and in dealing with 151 Tonsils. Torticollis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the lymphatic glands, together with the advantages which have just been mentioned, but, further, that the whole wound communicates freely with the outside, and can be dressed antiseptically. The resection of the ascend- ing angle of the jaw offers an advantage, for when the operation has involved the palate and base of the tongue, there results, in cases in which the resection has not been performed, so considerable contraction of the scar as seri- ously to affect the movements of the lower jaw. After the resection of the process, however, this contraction is not experienced. Butlin has collected twenty-three cases in which opera- tions have been performed for the removal of sarcoma- tous or carcinomatous disease of the tonsils. Of these, three died of causes due to the operation, which, in two of them, was pharyngotomy by Mickulicz's method ; in the third, the growth was removed from within the mouth. In this case, in which the operation was performed by Velpeau, the patient died of purulent infiltration on the eighteenth day after operation. Mickulicz lost one of his patients, between one and two hours after the opera- tion, from collapse and the entrance of blood into the air-passages. Kuster, operating much in the same man- ner as Mickulicz, lost his patient on the eighth day, from pneumonia and suppuration in the posterior mediasti- num. The patient, however, was sixty-one years of age, and the operation lasted two hours and a half. Considering the severity of many of the operations, the relations of the parts removed, the age of the patients, and the danger of primary and secondary haemorrhage, Butlin does not regard the mortality as excessive, amount- ing, as it does, to about fourteen per cent. Comparing the relative mortality of the operations performed through an external incision with that follow- ing operations performed within the mouth, Butlin finds a great difference. The number of pharyngotomies was ten ; of operations from within, thirteen. Two of the former proved fatal, and only one of the latter. The mortality of the pharyngotomies, therefore, is twenty per cent., that of the internal operations 7.69. While a larger number of cases might alter somewhat the relative figures of the above statistics, it is not probable that the change would be material. The removal of malignant disease from the mouth is less dangerous than it would appear to be, for not only is the haemorrhage, as a rule, slight, but the results of an extensive use of the galvano-cautery are, in the experi- ence of the writer, recovered from with surprising quick- ness. Butlin also suggests that one condition of many of the sarcomata has not been sufficiently recognized and employed, their relation, namely, to their surroundings. It is not uncommon for them to be so loosely attached to the bed in which they lie that, an incision having been made through the capsule, they can be shelled out with comparative ease. While such a process may not be radical, it is a question whether the more severe opera- tions are justified by the greater probabilities which they offer of permanent success. The general results of the twenty-three cases collected by Butlin are as follows : Three of the patients died of causes connected with the operation ; three were lost sight of after their recovery ; ten were dead or dying of recurrence of the disease ; in nearly every instance the recurrence and death took place within a few weeks or months after the removal of the tumor ; two were dead or dying of affection of the lymphatic glands without actual recurrence in the tonsil; two died at the end of three and seven months respectively, the former of a cause not reported, but probably from recurrence or secondary growth of the disease, the latter of apoplexy ; three of the patients were alive and well at periods of four, twelve, and twenty-four months after the perform- ance of the operation. Of these last-mentioned cases not one had attained the three years' limit, so that the ultimate success is not proved. It is worthy of note that in each of them the diseased tonsil was removed through the mouth, and that external incision was only used in one of them, for the excision of affected lym- phatic glands. In the most successful of the three the glands were not affected. Two of the three tumors were lympho-sarcomas. Butlin believes the very obvious proposition that here, as in malignant disease in other parts of the body, the rule seems to hold good that opera- tions of minor severity are the most successful, and that the best chances of success lie in the removal of the dis- ease before there is any involvement of the glands, and not in the removal of the primary tumor and the dis- eased gland by an extensive and dangerous operation. The results of pharyngotomy have not thus far proved satisfactory. In one case, operated upon by Mickulicz, the patient was free from the disease for about two years. It recurred, however. As to whether relief is afforded by the operation, the answer must be, in a large majority of cases, in the affirmative. The duration and degree of relief, how- ever, will depend upon the nature and extent of the disease and upon the operation employed. In two in- stances which have come under the notice of the writer, in which masses have been removed from epithelioma- tous tumors of the tonsil, the condition of the patient has seemed to be even worse after the operation than before. In most cases where the tumor is prominent and accessible through the mouth, as is not uncommon in the case of a lympho-sarcomatous growth, great relief to both dysphagia and dyspnoea may be gained by its removal. From what has been said the following general con- clusions may be drawn : The prospect of permanent relief by operation in any case of malignant disease of the tonsil is very small, even if there can be said to be any. Pharyngotomy has hitherto proved a dangerous pro- cedure, and has not yielded as good results as operation through the mouth. , Removal of the disease through the mouth does not appear to be dangerous. While no case of cure by operation through the mouth has been reported, several cases are on record hi which relief for a longer or shorter period has been gained. Pharyngotomy, judging from the results thus far ob- tained, is an unjustifiable proceeding. D. Bryson Delavan. TORMENTIL {Rhizoma Tor mantilla, Ph. G. ; Tor- mentille, Codex Med. The root or rhizome of Potentilla sylvestris Neck., Potentilla {Tormentilia, D. C.), order Ro- sacea, Potentillea). A perennial European herb with an oblique, crooked, knotted, when old red or brown, rhi- zome about as large as, and a little longer than, the little finger ; slender, straggling stems twenty or thirty centi- metres long, bearing alternate compound (3 to 5 parted) leaves and regular, yellow flowers. It looks very much like our native Potentillas, and has indeed the same prop- erty, namely, astringency, upon which its value depends. Tormentil contains a considerable quantity of tannic acid and a variable amount of a red coloring matter, Tormen- til-red, associated with or derived from the tannin. Allied Plants.-Argentine, Codex Med., from two other species of Potentilla, and several Potentillas grow- ing wild in this country, have the same constituents ; so do many others in this sub-class of the Rosaceae. Black- berry, Raspberry, Strawberry (roots), Avens (Genus), etc. Allied Dkugs.-Besides the above, Rhatany and the other astringents. See Catechu, etc. IK. P. Bolles. TORONTO. The accompanying chart, representing the climate of the city of Toronto, Canada, and kindly ob- tained for the writer by the Hon. H. Beaumont Small, of Ottawa, is here introduced for convenience of reference. Attention is called to the fact that the data of all the col- umns, except column B, are based upon the observations of a single year (1883), and the bearing of this fact upon the interpretation of the figures-especially those in col- umns J, E, and F-should be borne in mind. In column LL the term ' ' fair " is to be understood, not in the techni- cal sense applied to it in column L of the larger United States station charts, but in the equally technical sense at- tached to it by English observers, among whom it signifies merely the absence of rainfall or snowfall. 152 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tonsils. Torticollis, Climate of Toronto, Canada.-Latitude 43° 39', Longitude 79° 23'.-Period of Observations, January, 1883, to December, 1883.-Elevation of Place of Observation above the Sea-level, 350 feet. A A A n C n E F 11 Mean temperature of months at the hours of Average mean temperature de- duced from Column A. Mean temperature for period of ob- servation. 1840 to 1883. Average maximum temperature for period. Average minimum temperature for period. Absolute maximum temperature for period. Absolute minimum temperature for period. Greatest number of days in any single month on which the tem- perature was 32° and below. Greatest number of days in any single month on which the tem- perature was 62° and upward. January.... February... March 7 A.M. Degrees. 15.33 16.78 17.29 3 P.M. Degrees. 20.59 24.07 26.72 11 P.M. Degrees. 16.58 19.10 21.02 Degrees. 17.50 19.98 21.67 j Highest. Degrees. 32.69 30.33 37.11 Lowest. Degrees. 12.75 10.16 19.92 Degrees. 25.10 27.41 31.24 Degrees. 9.35 11.34 11.85 Highest. Degrees. 40.5 44.1 46.1 Lowest. Degrees. 2.1 16.3 13.1 Highest. Degrees. 27.4 31.9 29.1 Lowest. Degrees. -7.8 -10.5 -5.8 31 28 31 April May 34.48 44.48 36.07 38.34 ! 48.75 34.23 46.77 29.61 64.6 29.2 43.1 11.9 19 3 45.69 55.14 47.33 49.38 58.10 46.55 58.32 40.16 72.7 48.5 52.1 31.1 2 12 June 59.90 68.61 58.74 62.41 67.29 56.45 71.22 52.55 78.9 60.4 61.3 39.2 29 July 63.40 72.23 61.68 65.77 75.80 63.92 74.72 55.87 83.4 67.0 65.3 46.1 31 August 59.85 71.26 59.71 63.60 70.24 63.59 72.92 54.13 82.7 63.8 62.3 46.3 31 September.. October 50.90 42.02 61.01 50.02 52.06 43.93 54.65 45.32 67.83 54.79 53.39 41.82 63.51 52.15 45.55 37.63 75.1 71.0 49.1 40.0 I 57.1 51.7 33.4 27.1 "i 10 10 November.. December.. .35.56 24.58 41.46 29.23 36.60 26.15 37.87 1 26.65 41.87 34.29 27.54 17.24 44.57 33.06 29.71 18.45 60.1 48.7 23.3 14.8 46.5 35.5 13.4 -4.0 15 28 Spring Summer.... Autumn.... Winter Year :::::: :::::: 50.04 61.34 36.61 19.71 41.93 56.06 69.46 40.49 29.69 47.09 47.05 61.24 32.37 16.77 40.77 :::::: 1 .... .... J K LL O R S Range of temper- ature for period. Mean relative hu- midity. Number of fair days. Rainfall. Prevailing direc- tion of wind. Average velocity of wind, in miles, per hour. January Decrees. 84 13 Inches. 0.150 From N. 73 W. 12.63 February 54.6 80 10 1.010 N. 88 W. 12.15 March 51.9 74 17 0.050 N.70 W. 10.94 April 52.7 69 18 2.080 N. 9.52 Nfay 41.6 69 12 4.300 N. 15 W. 10.41 June 39.7 77 16 4.964 S. 22 W. 7.38 July 37.3 73 17 5.573 S.73 W. 8.32 August 36.4 70 23 1.830 N. 65 W. N. 23 W. 8.18 September 41.7 16 2.377 8.96 October 43.9 77 17 0.965 N. 55 E. 8.83 November 77 13 2.085 S. 70 W. 12.41 December 52.7 82 9 0.350 S. 68 W. 11.21 Spring 67.0 72 46 11.344 11.91 Summer 50.0 73 56 9.780 8.49 Autumn 75.0 79 39 3.400 10.82 Winter 56.6 79 40 1.210 11.91 Year 93.9 77 181 25.734 N. 77 W. 10.08 NOTE.-Ail the columns refer to 1883, except B named in heading. which includes the years II. R. muscles, and is unable to move the head in any direction. The head is inclined to one side, and usually slightly ro- tated in the opposite direction. The pain is not severe while the head is at rest, but is excited by the slightest motion, and so great is the dread of movement that the child screams with apprehension if anyone approaches the bed. The affection usually subsides in from a few hours to a few days, without any treatment other than rest and protection from cold. If seen early, a brisk saline purgative often shortens the attack. Another form, usually less painful and of shorter duration, is sometimes seen to occur after a sound sleep, during which the neck has been held in a constrained position. Of the two permanent conditions usually designated by the term torticollis, one is tonic the other clonic in character. In the former the deformity is due usually to a permanent retraction of the sterno-cleido-mastoid muscle, though the trapezius or other muscles may be concerned, either alone or conjointly with the sterno-mas- toid. The following description will be understood to apply to the more common form, dependent upon retrac- tion of the sterno-cleido-mastoid muscle, and the varying positions of the head when caused by retraction of other muscles will be afterward described. The deformity is usually congenital, or, at least, is first noticed during early infancy, but may, when due to paralysis or other causes, arise at any age. It is progressive in character, becom- ing more and more apparent as time advances. This is due not so much to continuous increasing contraction of the affected muscle as to the fact that it fails to keep pace with the growth of the other parts. The deformity is characteristic and easily recognizable. The.head is inclined toward one or the other shoulder, more fre- quently the right, while it is rotated in the opposite di- rection, the chin, instead of being in a line with the ster- num, pointing toward the clavicle of the other side. The sterno-cleido-mastoid muscle of the side toward which the head is inclined is prominent and tense, and may be seen standing out like a tightly stretched cord beneath the skin. Sometimes only one portion of the muscle seems to be concerned ; this is usually the sternal por- tion ; though, when this is divided, it is frequently discov- ered that the clavicular portion is also retracted and re- quires division before the head can be returned to its normal position. There is not infrequently some de- formity of the clavicle resulting from the constant pull- ing of the muscle upon its sternal end. The corresponding side of the chest may be deformed from the same cause. TORTICOLLIS. Syn.: Wry Neck, Caput Obstipuin ; Fr., Cou Tors, Torticolis; Ger., Schiefkopf, Schiefer Hals. A deformity characterized by lateral flexion of the neck in one or the other direction, usually accom- panied with rotation of the head toward the opposite side. This condition may be due to any one of a num- ber of causes, the distinction between which it is impor- tant to recognize, since upon this recognition depends in great measure the success of the therapeutical manage- ment. Acute wry neck may be either symptomatic or inflam- matory. The symptomatic form is caused by reflex contraction of any or all of the muscles upon one side of the neck, due to the presence of adenitis, abscess, or sometimes a severe angina. It may also be caused by the transitory paralysis occasionally met with in tuber- cular meningitis. As it is purely symptomatic, the treat- ment is that of the primary condition. Acute inflam- matory stiff neck occurs frequently in children, and occasionally also in adults, as a result of myositis of the sterno-cleido-mastoid or other muscles of the neck. Its onset is usually sudden. A child in apparently perfect health is suddenly seized with severe pain in the cervical 153 Torticollis. Torticollis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. In most cases there is a slight degree of compensatory lateral curvature of the spine, resulting from the curve of the cervical vertebrae. In long-standing cases there is a very appreciable degree of atrophy of one side of the head and face, which atrophy may, if treatment of the deformity have been too long deferred, remain as a per- manent condition, though usually it disappears in the course of time. Broca asserts that this atrophic condi- tion exists also in the cerebrum, and De Saint-Germain states that he has generally found the subjects of torti- collis to be intellectually backward. Hueter regards sco- liosis and torticollis as similar conditions, and cites this hemiatrophy of the face in support of his theory that lateral curvature is due to an unequal development of the two lateral halves of the vertebral column and thorax. The deformity in children is not usually very great, though as age advances it may become excessive. In some cases the lateral flexion of the neck is so extreme that the hand can barely be passed between the head and the shoulder. The accompanying figure, from Vogt, represents very well the appearance presented in a typi- cal case of wry neck of moder- ate degree. Besides the symp- toms mentioned, there may also be strabismus, and some- times there are alterations in the voice, induced by the changed relations of the parts about the larynx, in cases in which the lateral flexion of the neck is extreme. Sensation is but little affected. Some observers have found a pretty constant elevation of temperature on the convex side of nearly one degree Fahrenheit over that on the inner side of the curve. In a large proportion of cases, torticollis is a congenital affection ; though perhaps it might more correctly be re- garded as of traumatic origin, if, as first maintained by Stromeyer, and later by Dieffenbach and Blachez, the muscular retraction be due to an injury received by the child at the time of birth. It is claimed by these writers, and by others, that the sterno-cleido-mastoid muscle is ruptured during the extraction of the head in breech- presentations, or in the cases of head-presentations in which delivery is accomplished by the forceps. The in- jury causes a transient myositis, sufficient, however, to re- tard the growth of the muscle during the period of rapid development following birth, thereby giving rise to the deformity under consideration. Hueter states that he found but two cases of congenital wry neck in which the parents asserted positively that the children were not born by the feet or breech. Acquired torticollis may arise from any cause which induces a permanent retraction of the sterno-cleido-mas- toid muscle of one side. Among these causes may be mentioned chronic muscular rheumatism, traumatic my- ositis, syphilitic or other tumors, and purulent collections within the sheath of the muscle. Long-continued main- tenance of the head in any position, whereby the two ends of the muscle are approximated, will in time cause a permanent retraction ; this may result from cicatricial contractions following a burn of the neck. Several cases have been recorded in which hereditary influence seemed to be an important etiological factor. The deformity may also arise in paralyses of various kinds, as in the transitory paralysis sometimes occurring in tubercular meningitis, in that from apoplexy, or from other cerebral troubles. It occurs also from contractures following meningeal or ventricular haemorrhages. Finally, it may exist as a secondary condition in lateral curvature of the spine. The pathological changes noted in the rare autopsies which have been made on the subjects of torticollis are such as one would expect to find corresponding with the clinical features of the deformity. In a post-mortem ex- amination made upon a woman, the subject of congenital torticollis, dying at the age of twenty-two years from typhoid fever, Bouvier found the sterno-cleido-inuscle on the affected side shortened nearly one-half. The muscular fasciculi were in great part replaced by fibrous tissue, those which still remained being of a pale color and inextensible. The sternal portion was chiefly af- fected, its division allowing a nearly perfect reposition of the head, complete replacement being possible, how- ever, only after section of the clavicular portion. The cervical vertebrae were normal, with the exception of the axis, the body of which was considerably thinned on the side corresponding to the shortened muscle. In another autopsy, made by the same surgeon on an old man who had a traumatic wry neck dating from his eighteenth year, the changes in the cervical vertebrae were marked. There was motion at the two lower vertebral articula- tions in the neck, and also, in very slight degree, between the atlas and axis, but the intervening vertebrae were firmly soldered together by a new growth of osseous tis- sue, which offered an absolute resistance to any reduc- tion of the deformity, even after complete section of the retracted muscles. The atrophy of the vertebral bodies on the inner side of the curve is not usually so marked as it is in lateral curvature of the lower portions of the spinal column, and is confined chiefly to the upper vertebrae. The sheath of the sterno-mastoid muscle is also shortened, and some- times offers resistance to reposition of the head after the tendon itself has been divided. Secondary degenerative changes may occur in the other muscles, owing to the long-maintained approximation of their extremities. The vessels on the shortened side of the neck are tortuous ; the carotid, especially, is bent, in which fact lies the prob- able explanation of the accompanying hemiatrophy of the head and face. The position of the head in true torticollis, due to re- traction of the sterno-cleido-mastoid muscle, is so charac- teristic that there is usually but little difficulty in arriving at a correct diagnosis, yet it is sometimes so closely sim- ulated by the deformity dependent upon other conditions that, unless the differential points are borne in mind, the surgeon is liable to fall into error. In spondylitis of the upper cervical vertebrae the position of the head is often very like that of wry neck. In spondylitis, however, the sterno-cleido-mastoid muscle is less prominent than in true torticollis, and it is not alone affected, but all the muscles of the neck are more or less actively or poten- tially tense, becoming contractured upon any attempts at passive motion of the head. In torticollis it is usually possible to exaggerate the deformity without any discom- fort to the patient; in spondylitis motion is limited by reflex spasm in every direction, and any attempt to alter the position of the head generally causes pain. The pres- ence of an abscess may sometimes help to clear up the diagnosis. In Pott's disease of this region there is usu- ally more or less pain in the occipital region. If the pa- tient be brought profoundly under the influence of an anaesthetic, the contracture due to vertebral caries will yield, while the retraction of wry neck is persistent. A lateral flexion of the neck may be due to a congeni- tal or rachitic inequality of growth in the bodies of the cervical vertebrae. In this osseous form the muscles on the side of the concavity are simply shortened from ap- proximation of their origins and insertions, and cannot be seen and felt as hard cords beneath the integument. The attempt to reduce the deformity is met by a resist- ance which is more gradual and yielding than in torti- collis ; the stoppage is less abrupt and absolute. In the torticollis secondary to lateral curvature the rotation of the head is less marked, the sterno-cleido- mastoid muscle is not especially prominent, but all the muscles upon one side are retracted. Inspection of the en- tire spine will show that the primary curve is in the dor- sal or lumbar region, and that the cervical deformity is compensatory. In wry neck, due to cicatricial contractions, the cause is evident and the diagnosis plain. The same is true of torticollis from syphilitic, purulent, or other tumors, or from adenitis. When the deformity is due to paralysis of the muscles Fig. 3947.-Torticollis. 154 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Torticollis. Torticollis. on the opposite side, there is usually the history of an- tecedent cerebral or spinal cord trouble, or the existence of paralysis in other parts points to the true nature of the condition. In cases of recent torticollis from paral- ysis the neck can be readily straightened by the hand, but the head gradually returns to its former position as the sound muscles recontract, from want of any opposing force on the paralyzed side. There is a want of tone and a flabbiness of the muscles on the convex side of the curve, and they cannot be felt to contract when the pa- tient tries to raise the head. The head is sometimes drawn to one side and rotated in tetanus, but here the true condition is readily recognizable. Hysterical or neuromimetic wry neck may simulate true torticollis very closely. The history, however, will show that the deformity is of recent origin and due to no apparent cause. Persistent, steady, manual pressure will not infrequently be successful in reducing the distortion, and an anaesthetic will remove all doubt as to its nature. The malposition may even, though not always, be cor- rected during sleep. It will sometimes be found that the position of the head is changeable, the contraction at one examination being to one side, while at another time the head may be inclined in the opposite direction. The pa- tients are often of a distinctly nervous temperament, and frequently a history of similar antecedent troubles may be elicited. There yet remain a few words to be said upon the va- rious positions assumed by the head when other muscles than the sterno-cleido-mastoid are retracted. When the upper portion of the trapezius is affected, the head is in- clined to one side, the chin raised slightly, and rotated in the opposite direction. Contraction of the complexus extends the head slightly and rotates it to the opposite side. The levator scapulae, when the scapula is fixed, inclines the head backward and laterally. The scaleni, anterior and posterior, when acting together cause slight lateral flexion of the neck. The splenius causes exten- sion and lateral flexion of the neck and rotates the head to the same side. Finally, the platysma myoid muscle may be retracted, causing a simple lateral inclination of the head, with a peculiar appearance of puckering of the integument on that side. Other muscles whose retrac- tion might occasion lateral flexion and rotation, singly or combined, are the recti antici, the longus colli, the obliqui, the semi-spinalis colli, and the trachelo-mastoid. The writer has never seen wry neck due to retraction of any of these last-named muscles, however, nor have any such cases, as far as he knows, been recorded by other observers. It is important to remember that a malposi- tion of the head may be due to the retraction of no single muscle, but of two or more acting together, and the af- fected muscles may even be on opposite sides, as, e.g., the sterno-cleido-mastoid on one side, and the splenius on the other; in such a case the rotation of the head is extreme. The prognosis of torticollis as regards life is never serious -patients never die in consequence of the malposition of the head-and if treatment is undertaken at an early age, the deformity itself is usually easily cured. The hemi- atrophy of the face disappears in the course of time, when the lateral flexion of the neck has been overcome. If treatment is neglected, how'ever, the deformity steadily progresses, the head becomes pulled down upon the shoulder, the features are distorted, and often an incu- rable scoliosis of the lower part of the spine is produced, the resulting deformity being even greater and more hideous than that of primary progressive lateral curva- ture. It is seldom, however, that even neglected cases reach this degree, though the treatment is so simple that the hope of an arrest in the progress of the ^flection would never warrant its postponement or abandonment. In true torticollis, due to actual retraction of the muscle, a spontaneous cure never takes place. In young children in whom the deformity is very slight a cure may sometimes be obtained by apparatus, without tenotomy, but in cases of long standing or of marked deformity a division of the retracted muscle is necessary. Although the sternal portion alone of the muscle may seem to be concerned, it will usually be found necessary to divide the clavicular attachment as well, before complete rectification of the deformity is possible. Sometimes a resistance to reposition of the head, even after complete division of the tendons, is. offered by the contracted sheath of the muscle. In such a case a series of short, forcible jerks will usually suc- ceed in tearing the sheath. Care is, of course, to be ob- served in practising this manoeuvre, and the operator must be satisfied upon what the difficulty rests before he employs it. Tenotomy should not be performed until the apparatus which is to be worn subsequently is ready, for it is necessary to restore the head to its nor- mal position at once, and to retain it there until repair of the tendon is complete (see article Tenotomy). The head being held by an assist- ant, so as to put the muscle to be divided as strongly as possible upon the stretch, the tenotome is to be inserted beneath the tendon, about half an inch above its clavi- cular or sternal insertion, entering from the outer side. It is better to use the blunt-pointed instrument after the incision through the integument has been made with a sharp-pointed knife. The knife is now to be turned to- ward the tendon, and the latter divided in a direction to- ward the skin. Both insertions of the muscle may be severed, if occasion require, without withdrawing the knife, thus obviating all danger of air entering the wound. The section of the tendons should be made at a point not higher than that indicated, otherwise the op- erator will run great risk of wounding some of the ves- sels of the neck. For the same reason, also, it is necessary to introduce the knife as close as possible to the tendon. Some care may be required to avoid cutting the integu- ment as the last fibres of the tendon are severed. Immediately after the operation an appliance of some sort must be used to retain the head in its normal posi- tion. This may consist of a collar made of leather, felt, or plaster-of-Paris, fitting accurately over the shoulders and base of the neck, and well padded in its upper part to receive the head (see Fig. 3948). The head is better supported, however, by an apparatus similar to that used in the treatment of cervical caries, as shown in Fig. 3949. It con- sists of two spinal uprights supported by a hip-band, surmounted above by the conventional Taylor chin-piece, as modified by Shaffer ; this modifica- tion consists in the addition of a ball- and-socket pivot (Fig. 3950) by means of which the head can be secured in any position, or be moved in any di- rection, from day to day, according to the indications. A webbing strap is attached to the extremities of the occipital uprights E E, passing around the forehead, thus retaining the head firmly in the apparatus. The retention-brace should be worn for several months after a cure has been obtained by ten- otomy, otherwise a relapse will almost inevitably occur. In those slight cases in which tenotomy may not be imperative, the support to be employed is the one last described, as by it the position of the head can be readily changed, without the necessity of remoulding the appara- tus. The instrument shown in Fig. 3951 may be em- ployed when it is desired to treat the compensatory lat- eral curvature of the spine at the same time with the Fig. 3948.-Leather Cravat for the Treatment of Torticollis. Fig. 3949.-The Taylor Spinal Support, with Chin-piece attached. 155 Torticollis. Trachelorrhaphy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. torticollis. The dorsal curve may usually with safety be ignored, as, unless of long standing, it will ordinarily disappear as soon as the primary condition is removed. Another condition which also bears the name of torti- collis is that of clonic unilateral spasm of one or more of the muscles of the neck, usually the sterno-cleido- mastoid. It ranks properly among the neuroses, bearing an analogy, in its clinical symptoms at least, to histrionic spasm and writer's cramp. It is supposed to be due to an irri- tation of the spinal accessory nerve ; in some cases this nerve has been found to be hyper- trophied. It is a disease more especially of adult life, though it has been observed to occur in infants during dentition, and in older children as a sequela or lingering symptom of chorea. The head is drawn to one side and rotated in the opposite direction by a series of jerks, sometimes ten or twenty occurring in rapid succession, and then being followed by a period of rest during which the head resumes its normal position. After the disease has existed for a considerable time a permanent distortion may remain, even in the intervals of spasm. The affection usually, though not always, in- creases in severity with time ; it seldom, if ever, disap- pears spontaneously. There may be pain of a dull, ach- ing character in the muscles of the neck. The spasms are generally more severe if the health of the patient be- come impaired and if he be laboring under nervous ex- citement, though sometimes a nervous shock or any sud- den emotion may be curative in its effect. The faradic excitability of the affected muscles is increased, as is also their electrical sensibility. Cases have been ob- served in which both sterno-mastoid muscles were affect- ed, the spasmodic contraction occurring alternately in one and the other. The spasms usually, though not invariably, subside during sleep or while the patient maintains the recumbent position. The prognosis in confirmed cases is unfavorable; the spasms are very persistent, and unless the treatment is begun very early in the course of the disease a cure is seldom obtained. The general health is usually unaffected, though it may become impaired through insomnia or mental despondency. Cures have been obtained by the persistent application of electricity -the continued current to the af- fected muscles and the induced current to their antagonists. My- otomy has been recommended, but has seldom been of benefit. In cer- tain cases very successful results have followed the use of hypoder- mic injections of morphine contin- ued for a considerable length of time in increasing doses; but the practitioner should weigh well the possibility of establishing the opium habit before resort- ing to so dangerous a remedy. Massage of the affected muscles is useful. Attempts have been made to restrain the movements of the head by mechanical support, but have been unavailing, the irritation of the apparatus seeming even to increase the spasmodic contractions. (Ionium may be found an efficient remedy in some cases. Whatever plan of treatment be pursued, in order to be successful, it should be adopted in the very incipiency of the disease and persistently followed up. Finally, in cer- tain rebellious cases which had resisted all other methods of treatment, a cure has been obtained by resection of a portion of the spinal accessory nerve close to the point where it enters the muscle. Stretching of the same nerve has been recommended, but the operation of resection would seem preferable. Thomas L. Stedman. TRACHELORRHAPHY ; HYSTERO - TRACHELOR- RHAPHY. By hystero-trachelorrhaphy we mean a plas- tic operation devised by Thomas Addis Emmet for the restoration of a lacerated cervix uteri. The operation is termed by some authors " tracheloplasty," but it is prob- ably better to adhere to the term by which it is more generally known. Although the operation, as performed by Emmet and his pupils, has varied very little from the original method, others have introduced some modifica- tions in the operative details. No endeavor will be made in this article to describe all the methods of operating adopted, but those only will be considered which, accord- ing to the writer's experience, have yielded the most sat- isfactory results. Preparation of the Patient.-The general prepar- atory measures to be adopted are the same as those nec- essary for all operations of any importance. The pa- tient should be confined absolutely to the bed for one or more weeks, as circumstances indicate. The bowels should be evacuated by saline laxatives for several morn- ings before the day set for the operation. It is, how- ever, a mistake to have the contents of the bowel in a liquid state the morning of the operation, for obvious reasons. On the morning of the operation an enema should be given to unload the rectum,and a vaginal irriga- tion of -rutt sublimate solution should be made. When the patient has been anaesthetized and placed on the table, the vagina should be again thoroughly cleansed with absorb- ent cotton, and a n,1^ sublimate solution should be in- jected until it returns quite clear. This is most easily done with the patient on the back and with a Simon speculum introduced-the position in which the opera- tion is now generally performed. As regards the anaesthetic, ether is the most universally used in this country. In one respect, however, trache- lorrhaphy differs from other operations upon the female genitals, in that it can be done without an anaesthetic, and without the patient experiencing much pain. The cervix uteri is not, when uninflamed, a sensitive organ, and the pain inflicted during trachelorrhaphy is chiefly that produced by the speculum, and the prolonged cramped position of the patient. The writer has oper- ated several times without an anaesthetic, especially in unilateral lacerations; but it is not to be advised, as the patient suffers very much from shock and fright as well as from the causes above mentioned. It must also be borne in mind that a delicate patient, sensible of what is going on, and in a state of mental depression from fear and anxiety, will tolerate very little blood-letting with- out suffering from alarming syncope. This same pa- tient, while profoundly under the stimulating influence of ether, and unconscious, will surprise us by the large amount of blood she will lose without apparent cardiac depression. The room in which the operation is performed should be carefully chosen. Any surgeon who has done a trachelorrhaphy in a dark, ill-ventilated, small room, soon realizes his error. The operation should be done at that time of day when the light is best; but the sun must not be allowed to glare directly on the part, as it is very annoying. The arrangement of the operating-table should be as follows : The ordinary kitchen table, 4 x feet, will answer the purpose well. Place this endwise to a win- dow with the best light in the room. Let there be suffi- cient space between the table and the window to permit a chair to be placed conveniently for the operator. At the right of the operator there should be a small table, covered with a towel, on which the instruments needed are to be placed, and under this table is a small stool or box, supporting a basin of boiled w'ater, for the purpose of enabling the operator to cleanse his hands of dried Fig. 3950.-The Ball-and-socket Joint, and Chin-piece. (After Shaffer.) Fig. 3951.-Apparatus for the Correction of Torti- collis complicated with Scoliosis. 156 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Torticollis. Trachelorrhaphy . blood from time to time. On the left of the operator is placed a chair, on which the nurse who holds the speculum sits. Behind We may occasionally meet with cases in which a cer- vical laceration exists of greater or less extent, but in which, for several reasons, we do not feel called upon to advise operation. In these cases we have no erosion, eversion, or fibro-cystic disease involving the glandular and interglandular structure, no hyperplasia of the body of the uterus, and no haemorrhagic endometritis. If, however, the patient has become morbidly impressed with the fact that she has a " torn womb," and will not be at rest until it is restored, the writer looks upon this mental condition as a reasonable indication for the operation. Up to the present time, and in accordance with the literature of the subject in text- books, we have been accustomed to asso- ciate exclusively the term "trachelor- rhaphy" with the procedure origin- ally devised by Emmet. To make, however, the subject more com- prehensive and practical, the writer will describe also an operation devised by Carl Schroeder, of Berlin, for the relief of extensive ero- sion resulting from laceration or other causes. Of these opera- tions we shall describe first that known as Emmet's, or the restoration o f the injured cer- vix to a condi- tion and shape nearest approaching its original state; and then that known as Schroeder's, or complete exsection of the dis- eased cervical mucous membrane and adjacent tissue, and replacing these parts by the outer cov- ering of the portio vaginalis. Emmet's Method.-The instruments necessary for performing the operation are as follows: 1 Sims broad speculum (for patient on side). 1 Simon short-blade speculum (for pa- tient on back). 1 depressor. 2 steel tenacula. 2 Emmet curved scissors (right and left). 1 Russian stout needle-holder. 1 Munde counter-pressure hook. 1 Emmet twisting forceps. 1 Sims shield. 1 stout wire scissors. 1 or 2 dozen assorted lengths of trocar- pointed needles (nickel-plated). Pure silver wire, Nos. 27 and 33. 12 metal sponge - holders, and fine sponges cut up. 1 Simpson sound. In regard to the specula made use of in this operation, it is necessary to say that the Sims instrument will be used only when the operation is performed with the patient on the left side. And it will be found a great advantage to have one with Munde's flange, to aid in supporting the right buttock. When, however, the operation is performed with the patient on the back, then a Simon perineal retractor will be required. In this position sponges and holders are done away with, and the constant irriga- tion apparatus is used instead, which offers a very obvi- ous advantage. It will be necessary also to have a knee- Fjg. 3952.-The Operation of Trachelorrhaphy. The operator is placed to one side in order to show the field of operation. the nurse is placed the irrigator on its stand. It should contain one or two gallons of fluid. The stream is con- trolled by the nurse's left hand (Fig. 3952). As regards assistants, an expert operator requires only the one in charge of the anaesthetic, and the nurse to manage the speculum and irrigator stream. In fact, the fewer the assistants at this simple operation the better. Every extra one increases just so much the liability of infection. The operator should see to it beforehand that everything that he may need is within easy reach. It has always seemed to the writer that the surgeon who felt the necessity of an extra assistant at each side of him has mistaken his calling, and should never have at- tempted an operation of this kind. Indications for Operation.-It is an exceedingly difficult matter to lay down definite indications for the performance of trachelorrhaphy. Surgeons differ widely in regard to the necessity of performing the operation in every case of cervical laceration. The best general indi- cations which the writer can give are those of Munde, as follows: "The mere existence of a laceration of the cervix does not call for the radical operation ; the indication for that measure depends entirely on the depth of the rent, on the degree of eversion, and the amount of erosion and hypertrophy of the torn lips ; on the intensity of the symptoms, unquestionably or probably, depending on it; and on the improbability of these symptoms being permanently cured by other than radical treatment." Should a patient have a lacerated perineum as well as a lacerated cervix, the question may arise in the surgeon's mind regarding the advisability of doing the operations at one or at two sittings. When the principles of modern antiseptic surgery are carefully observed, the perform- ance of the two operations at the same sitting would not in any way weaken the patient's chances of recovery or endanger the good results. It is here understood that the double procedure is done with such rapidity and care that the patient is not kept unduly long under the anaesthetic. The writer has, for some years, performed both opera- tions at one sitting, generally using catgut for the cervix, and has never had indifferent results. Fig. 3953.-Skene's Hawk-bill Scissors. 157 Trachelorrhaphy. Tracheotom y. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. crutch, or Beinhalter, to hold the patient in the proper dorsal position. Details of Operation.-Matters having been arranged as above described, and the patient being placed upon the table, the knee-crutch is to be attached. The strap of this instru- ment should be passed over one shoulder and under the other (so as to avoid strain upon the nucha), and then braced well up so as to tilt the sacrum, as it were, partly off the table. The vagina is then cleansed thor- oughly, and made aseptic by means of irrigation with sublimate solution of n/oj strength. This having been accomplished, the Simon speculum is introduced and given to the nurse ; the anterior lip of the cervix is seized with a single-toothed vol- sella, and held forward and upward by the nurse. The lower lip is now drawn forward in a similar way, and approximated evenly to the upper lip. By this manoeuvre the exact angle of the laceration will have become ap- parent on each side, and an inci- sion is then made with a sharp scal- pel from that point to the apex of each cervical lip. The upper and lower seg- ments of the cer- vix are now sep- arated slightly, and a corresponding incision of denuda- tion is made on the inner side of each opposing lip from the angle to the apex. This is repeated on the laceration, as it affects the other side of the cervix. This mapping out of the position and shape of the intended denudations causes little loss of blood and very materially aids the operator in carrying out the next very important proceeding, viz., that of removing with the scissors the cicatricial edges and angles of the laceration (Fig. 3954).* The sutures are now introduced at a distance from each other of somewhat less than a centimetre (| inch), and about half a centimetre from the denuded margin. The sutures are twisted or tied, according to the material used (Figs. 3955 and 3956). During the op- eration the irrigator should be kept almost constantly playing upon the bleeding parts. The contents of the irrigator may be plain boiled water at 120° F., or-nHnny so- lution of corrosive sublimate at or near the same tempera- ture. Very hot water un- doubtedly has a most excel- lent aseptic effect upon freshly made wounds by causing instantaneous con- traction of the opened ves- sels, and thereby lessening the liability to the entrance of in- fected matter. Instead of using vaginal injections night and morning for the following ten days during conva- lescence, the writer tampons the vagina with carefully shaped disks of sublimated cotton, saturated in a 1 to 40 solution of carbolic acid and glycerine, and well dusted with iodoform or hydronaphthol. This dressing is al- lowed to remain undisturbed for a period varying from five to eight days. It is then removed through a Sims speculum, and the vagina is washed out. The sutures are removed, if other mate- rial than catgut is used, on the tenth day. Should menstruation supervene, they can be left un- touched until the period has passed. Patients who have undergone this opera- tion should not be allowed to resume their usual duties under two months, and during that time should have the iodoform and glycerine treatment once or twice a week. If this is neglected, the parts will become congested, the old cellulitis will return in a subacute form, and the patient, in many cases, will declare to her surgeon that she is worse than before the operation was performed. The operation next to be described has given more sat- isfactory results, in the writer's experience, in the majority of cases of cervical laceration. Schroeder's Meth- od. - The uterus is drawn down in the man- ner just described, and the lateral walls of the cervix are split with a pair of straight scissors as far as the vaginal junction. The lower lip is then drawn some- what forcibly backward, and divided with a scal- pel transversely, at its base, more than half-way through its entire thick- ness. This incision is immediately met by an- other, from the apex of the cervix downward by longitudinal transfixion. In this way the whole of the erosion is exsected, and can never be replaced, as the mucous membrane in its entirety has been removed (Fig. 3958). The anterior lip is treated in the same way, and the sutures are introduced in the manner shown in the cuts (Figs. 3958 and 3959). When the sutures have been removed and the parts have entirely healed, it will be found that the vaginal covering of the cervix has been turned in to line what has now become the cer- vical canal (Fig. 3959). Of these two methods, Schroeder's has given the writer the better results in all cases of cervical laceration accompanied with hyperplasia and ero- sion. And the only cases considered suitable for Emmet's method are those in which the lesion is of recent date, and no change has taken place in the nutrition of the parts. Schroeder's opera- tion is somewhat more difficult to perform, on account of the skill Required in passing the sutures. And to add to the difficulty, there is more free haemorrhage, necessitat- Fig. 3954.-Trachelorrhaphy. Emmet's method. Fig. 3955.-Trachelorrhaphy. Emmet's method. Fig. 3958.-Trachelorrhaphy. Schroe- der's method. Fig. 3956.-Trachelor- rhaphy. Sutton's method. Fig. 3957. - Trachelorrhaphy. Sutton's method. Fig. 3959.-Trachelorrhaphy. Schroe- der's method. * Dr. Skene, of Brooklyn, has devised a special scissors, shaped as shown in Fig. 3953, for exsecting at a single stroke the cicatricial corners. Dr. Sutton, of Pittsburg, has devised the plan of denudation, as shown in Fig. 3957, whereby a large amount of diseased tissue is removed and still the patency of the cervical canal is maintained. 158 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Trachelorrhaphy. Tracheotomy. ing quick work on the part of the operator. The after- treatment in Schroeder's operation is the same as that de- scribed for Emmet's method. 2'. Johnson Alloway. TRACHEOTOMY (Bronchotomy, Laryngotomy, Thy- rotomy, etc.). The term tracheotomy is used in general to signify an opening made from without into the wind- pipe in any part of its course. The term bronchotomy, originally and more properly used in this sense, has gradually fallen into disuse, and is now rarely met with. The term tracheotomy, in its exact sense, is applicable only to an opening made into the trachea proper ; while thyrotomy, cricotomy, and laryngotomy, singly or in combination, may be used to describe openings made into the larynx only, and laryngo-tracheotomy and crico- tracheotomy those involving both larynx and trachea. History.-The practice of tracheotomy may be traced back to considerable antiquity. According to Sprengel,1 Asclepiades, of Bithynia, b.c. 90, was the first to per- form it with success, saving the lives of many persons thereby. The theoretical fear that incisions through cartilage would not heal caused the operation to be rejected by his immediate successors. But Antyllus, a.d. 125, ac- cording to Paul of H^gina,2 both did the operation and taught the indications for it and a method for its performance, advising that the windpipe be opened at about the third and fourth rings, by a transverse incision between two rings, in- volving only the mem- brane connecting the cartilages. Though the knowl- edge of the operation was preserved by the Arabian writers, no record of any actual case of its performance is given by them, and the procedure remained merely a literary curi- osity for fourteen hun- dredyears. Benivieni,3 of Florence, who died in 1502, is commonly cited as the first who actually did the opera- tion in its renaissance; but a critical examination of the account given by him shows that he simply incised a high-lying abscess of the neck that was compressing the air-passage. A genera- tion later, Brassavola,4 of Ferrara, in his commentaries on the " Rules of Diet in Acute Diseases," published in 1543, states that he had himself incised the trachea of a patient expiring from cynanche, and that recovery was obtained thereby. After which, in many other instances, the same means in his hand had been attended with suc- cess. Close upon this came the powerful support and advocacy of the great teacher of anatomy and surgery at Padua, Fabricius of Aquapendente.8 In his own surgi- cal works, published in 1617, and earlier through the work of his pupil, Casserius,6 on " The Organs of Voice and Hearing" (1600), he eulogized the operation as capa- ble of saving life, and gave a detailed description of the technique to be employed. These surgeons, however, are not yet emancipated from the traditional fear of cut- ting the cartilages of the trachea, and still recommend the transverse incision between two rings. Casserius gives quite full historical references, con- siders the objections raised to the operation, and refutes them, and finally describes his method of operation with illustrative plates. The accompanying cut, reproduced from his work, showing the location and manner of making the first in- cision, and the instruments needed for the operation, will be found to have present as well as historical value. During the seventeenth century the operation was fre- quently done, and the names of Habicot,7 Severinus,8 Nicolas Fonteyn,9 Rene Moreau,10 Purmann,11 Dionis,19 and Verduc 13 are especially to be noted in a recital of the literature of the subject. Moreau is the first to sug- gest that the air to be respired by a tracheotomized pa- tient be made warm and moist. Cases of gangrenous angina (diphtheria) were the most frequent subjects of the operation; but Habicot (1620) performed it also for the relief of a case in which suffocation, from the press- ure of a foreign body impacted in the pharynx, was im- minent, and in another case where the trachea was filled with a large blood-coagulum, the consequence of a wound of the larynx. Four names are especially worthy of mention in connection with tracheotomy during the eighteenth century. These are Junker,14 of Halle, who first advocated longitudinal incisions of the trachea in cases of foreign bodies in the air-passages ; Martin,16 of the English Navy, w'ho recommended a double tube, " that the innermost might safely and easily be taken out and cleaned when necessary, without any molestation to the patient;" Louis,18 of Paris, who was an enthusiastic partisan of the operation, and who contributed to the "Memoirs of the French Academy of Surgery" the most complete article on the subject that had yet been written; and Richter,17 of Gottingen, wdio, both in his " Ob- servat. Chirurg." and his "Anfangsgriinde," discussed at length and advocated warmly the operation. Three indi- cations for the opera- tion had been pro- posed : 1. Violent cy- nanches threatening suffocation. 2. F o r - eign bodies in the air- passages. 3. The re- suscitation of the drowned by insufiia- tions practised through a tracheal opening. This latter indication had as its advocates some eminent authorities (Dethard- ing,18 Junker,14 Heister 19). The operation for any cause remained, however, a rare procedure. Louis, in his me- moir, recounts twenty-eight instances of foreign bodies in the trachea, in which the surgeons refused to avail themselves of tracheotomy. The death of twenty-five of these cases is used by him to enforce his views as to the value of the operation in such cases. The celebrated memoir of Home,20 of Edinburgh, on " The Nature, Cause, and Cure of Croup," which ap- peared in 1765, should be mentioned as the first clear and positive description of that pseudo-membranous ac- cumulation within the larynx which has since become the most frequent of the conditions for which trache- otomy is done. Home was of the opinion, even then, that, when the deposit had acquired a certain degree of consistence, an incision into the trachea with a view to attempts at extraction of the membrane was the only means of any value remaining. John Andre, a surgeon of London, is credited with having been, in 1782, the first to practise the operation successfully for the relief of membranous croup, though some have questioned whether his case was not rather one of oedema of the glottis, or of phlegmonous laryngitis. The case is related by Borsieri,21 as follows; "Jacob Locatellius, a physi- Fig. 3960.-Tracheotomy according to Casserius, a.d. 1600. 159 Tracheotomy. Tracheotomy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. cian of great promise, has communicated to me by letters dated at London a case of tracheotomy successfully done upon a boy suffering from this kind of angina (croup), which he saw performed by a most expert sur- geon of London, Andre, after the following method : He first divided the skin by a longitudinal incision, three fingers' breadth in length, extending from the thyroid gland to the top of the sternum. The trachea then having easily been exposed, he cut through the mem- brane which joined its second and third rings, then made another like incision between the fourth and fifth rings, so that two rings were included between the two transverse incisions-out of the anterior portion of these he cut a quadrangular piece by two lateral incisions. By this procedure lie established an opening sufficiently large both for the inspiration and expiration of the air, and for the expulsion of the membranous exudation which was threatening suffocation. From this opening continuously issued no small amount of pus, but no true membranous exudation. The boy was perfectly re- covered within fifteen days." Andre22 himself, in a letter written in 1813, states, however, that it was a mistake about his having taken away the quadrangular piece of the trachea, he operated after the ancient method. Valentin23 relates, on the authority of Rush, in a letter, dated September 16, 1808, that Dick, of Alexandria, Va., performed tracheotomy in 1800 upon a girl of nine or ten years, who was in extremis from membranous croup, and who expired as the first cut was made. Artificial respiration was unsuccessful in resuscitating her. Also in 1803, in Boston, Mass., John Warren performed tra- cheotomy on the sixteen months old child of his col- league, Jonathan Ellis, but without success, the child dying five or six hours after the operation. In 1813, Bliss,35 at the New York Hospital, tracheotomized an adult who was suffering from croup, with the result of prolonging, but not finally saving his life. Neither the advocacy of the operation by Home, nor the successful case of Andre, was sufficient to popularize the operation in Europe. When, in 1807, the eldest son of Louis Bonaparte died from croup, a prize of 12,000 francs was offered by the Emperor for the best memoir upon the nature and treatment ofcroup. One only of the contestants, Caron,24 recommended tracheotomy, and the verdict of the commission to whom the contesting memoirs were referred for adjudication was, that trache- otomy was dangerous, useless, and could serve only to add a new evil to the one already existing !25 At the beginning of the nineteenth century, therefore, tracheotomy had little standing as a surgical procedure. Its uselessness in the case of the drowned had been generally recognized ; in cases of foreign bodies in the' air-passages it was rarely resorted to, and as a measure of any value in cases of croup it had received the con- demnation of the highest authority. In Great Britain, Chevalier,36 in 1814, Carmichael,31 in 1820, and Hume,38 in 1824, obtained recoveries after tracheotomy in cases of croup, and finally, in 1826, with the appearance of Bretonneau's treatise on diphtheria,26 tracheotomy began to become firmly established as a recognized and justifiable procedure. Bretonneau, per- suaded of the value of the operation, began to perform it in cases of croup ; his two first patients died, but his third, Elizabeth de Puysegur, recovered. This was in June, 1825. This favorable case established his faith and caused him to urge in his treatise that tracheotomy' "should be resorted to as a measure which entails no danger in itself, and which will not only open a free passage to the air, but will also favor the expulsion of the false membranes and permit access to the air-pas- sages for the application of medicaments." Bretonneau operated seventeen times, saving five of his patients. His views were taken up and advocated with vigor by his pupil Trousseau,21 and the general prevalence of diph- theria throughout much of Europe during the succeeding years served to multiply greatly experience in the value of the procedure. Lovett and Munro,28 in 1887, were able to compile 21,- 853 reported cases of tracheotomy for croup, excluding groups of less than five, of whom 6,135 recovered (twenty- eight per cent.); and of these, 9,242, with 1, 851 recoveries, were from French sources alone. Following close upon the general adoption of trache- otomy in croup came a more favorable reception of it for cases of foreign bodies in the air-passages, until finally, as the result of the elaborate discussion by S. D. Gross,29 in his work on " Foreign Bodies in the Air-passages," 1854, a general agreement among surgeons as to the propriety of the operation in cases of this kind wras effected. As early as 1694 Dekkers30 proposed to simplify the operation by using a trocar and cannula with which to pierce at one thrust from the cutaneous surface into the trachea. This suggestion, in some form, has been fre- quently revived even down to within a few years, but has never secured any general adoption. As none of these methods could be mentioned otherwise than with disap- probation, no other reference to them will be made in the further portions of this article. At the close of the eighteenth and beginning of the nineteenth centuries French surgeons busied themselves with methods of gaining access to the air-passages other than through the trachea alone. Vicq d'Azyr,31 Four- croy ,32 and Bichat33 suggested division of the crico-thy- roia membrane; Desault,33 thyrotomy ; and Boyer,34 crico- tracheotomy. Bretonneau and Trousseau, however, adopted the longitudinal tracheal incision, preceded by systematic division of the superjacent parts, the proced- ure still most frequently used by operators of experience. The most important improvement introduced by later operators is in the use of the movable shield for the can- nula, suggested by Roger,36 of Paris, in 1855. The literature of the twenty-five years past has been very prolific in contributions upon the subject of trache- otomy ; the field of its usefulness has been extended, special instruments to meet particular technical indica- tions have been devised, and many profitable suggestions as to operative details and as to the after-care of operated cases have been made. Whatever of these appears to the author to be of value will be found in its appropriate connection further on.37 Indications.- The object of a tracheotomy may be either to furnish a new aperture for the respiratory cur- rent when the natural one is no longer sufficient, or to afford access to the interior of the tracheal canal for local therapeutic purposes, or for the removal of foreign bodies lodged within it. In these cases it is a remedial measure. In addition, it may be indicated also as a preventive measure, as a preliminary to some surgical operations in- volving the cavity of the nose, pharynx, or larynx, to render possible tamponnade of the larynx, and to facili- tate the administration of anaesthetics. Any affection, laryngeal or supra-laryngeal, which is causing or threatening asphyxia, is an indication for remedial tracheotomy. These conditions may be classi- fied into : 1, Traumatic conditions ; 2, inflammatory con- ditions ; 3, neuroses ; 4, neoplasms. Some consideration of each of these classes is neces- sary : I. Traumatic Conditions.-The first under this head come wounds of the larynx. When, as the result of such a wound, blood is flowing abundantly into the trachea, and Inemostasis by ordinary means cannot read- ily and speedily be accomplished ; also, when the wound has partially severed the epiglottis so that it falls upon and occludes the glottic orifice-in these cases immediate opening of the trachea is imperative. Tracheotomy may also become necessary later in the history of a wound of the larynx in consequence of infiltration of the sub- mucous laryngeal connective tissue, and of the epiglottic folds, by blood, serum, pus, or air, causing the symptoms of oedema glottidis. Glottic emphysema, demanding tracheotomy, may be caused by extension of a general emphysema of the neck, when inadequate means to re- lieve such emphysema have been employed, but it is more frequently a localized air-infiltration of the aryteno- epiglottic folds from a penetrating wound of the larynx with contracted external opening. Local scarifications of the tumefied tissues, whether caused by fluid or by air- 160 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tracheotomy. Tracheotomy. infiltration, practised through the mouth, may suffice to afford relief in some cases, when time and opportunity can be had for them; but in all cases where the suffo- cative symptoms are urgent or the conditions are not favorable for making such local scarifications, immediate tracheotomy should be done. In these cases it would also be justifiable for a person provided with the neces- sary instruments, and skilled in their use, to try in- tubation after the method of O'Dwyer. Burns of the larynx and pharynx, the result of swallow- ing hot fluids or caustic agents, or of the inhalation of steam, are liable to be followed by oedema sufficiently great to require tracheotomy. Fractures of the larynx are likely to involve conditions making tracheotomy necessary. Displacement of the cartilages may in itself produce sufficient occlusion to become an indication. Consecutive oedema may result, as in the case of incised and punctured wounds of the larynx above considered ; phlegmonous purulent infil- tration is likely to develop ; blood-infiltrations are to be expected ; in some instances paralysis of the glottic dila- tors, from injury to the laryngeal nerves or their com- pression by displaced cartilages or inflammatory effusions, may supervene-any of these conditions indicate trache- otomy. Cicatricial contractions may result from loss of sub- stance attending any of the above-mentioned traumatisms of the larynx, and may produce stenosis of a high de- gree. More or less occlusion may also result from ad- hesions between soft parts following the cicatrization of wounds of the larynx or trachea, and from the healing in abnormal situations of displaced cartilaginous frag- ments or flaps of soft tissue. In either of these con- ditions tracheotomy is indicated as soon as any consider- able embarrassment in breathing is experienced ; it serves both for the relief of the dyspnoea and to facilitate measures for the dilatation of the stricture. Recent re- ports by O'Dw'yer38 would indicate that intubation may become a substitute for tracheotomy in some of these cases. Foreign bodies in the air-passages are to be classed among the traumatic conditions that indicate tracheot- omy. In all cases in which suffocative symptoms per- sist, and are urgent or frequently recur, as the result of the presence of a foreign body in the air-passages which cannot be speedily and readily removed through the mouth, immediate incision of the trachea is imperative. In a very large proportion of cases the first violent spasms of dyspnoea provoked by the entrance of the foreign body soon subside, and a period of calm follows, which may, indeed, last indefinitely. To be able to oper- ate during such a period of calm is highly desirable, for it can then be done with deliberation and with proper attention to those precautions which will prevent the operation itself from adding any new dangers to those already present. The present absence of urgent symp- toms should not induce the surgeon to indefinitely post- pone operation, in the hope that spontaneous expulsion may occur, notwithstanding the frequent instances in which such spontaneous expulsion is finally effected, for the foreign body is a constant menace to life as long as it remains in the air-passages, and is liable to produce sudden death at any time, even in the act of expulsion. According to the statistics compiled by Weist,39 out of 599 cases of foreign body in the air-passages which were not operated upon, 139 (twenty-three per cent.) died from the immediate or remote effects of the retention of the body ; 314 of the 599 were instances in which such smooth and comparatively unirritating substances as grains of corn, grains of coffee, beans, watermelon and other seeds were the bodies inhaled ; 68 deaths in this class are reported. The causes of death in the fatal cases indicate the lines of danger opened up by the retained body. Asphyxia was the cause of death in 84 instances (sixty per cent.); pneumonia in 26 ; broncho-pneumonia in 7 ; abscess in 10; laryngitis in 5 ; consumption in 3 ; and exhaustion in 4. Out of 260 cases in which the for- eign body was removed through an incision in the trachea or larynx, 20 (7.7 per cent.) resulted fatally nevertheless. In 78 other cases that were operated on, the attempts to remove the foreign body were unsuccessfnl ; 73 of these (93.6 per cent.) died ; 5 recovered after later spontaneous expulsion. An instructive comparison of these different groups of cases is obtainable from the following tabula- tive statement: Percentage of recoveries. Cases operated on unsuccessfully ...... 78 6.4 Cases not operated upon 599 76.8 Cases operated on successfully 260 92.3 The immense mortality recorded in the cases in which attempts at removal of the foreign body were unsuccess- ful suggests an inquiry as to the causes of failure in these cases. These causes of failure are to be found : 1, In the lack of suitable instruments for searching after and grasping a deep-lying body; 2, in premature aban- donment of the operation on account of inexperience and timidity on the part of the operator, or the occur- rence in the progress of the operation of threatening shock, haemorrhage, or asphyxia; and, 3, the previous impaction of the foreign body in the bronchia at such a depth or so firmly as to be beyond the ability of the sur- geon to remove it by any prudent effort. The first two of these groups of causes of non-success are most frequently present in those cases in which the operation is one of emergency, being done with haste and without opportunity for preparation, on account of the urgently threatening symptoms presented. If time can be taken to obtain skilled assistance and suitable in- struments, and the operation can be conducted with de- liberation, the third group of causes alone ought to jus- tify failure, and the frequency in which this cause would be found to be insuperable would be greatly diminished. Asphyxia from the abundant entrance of blood, vomited matters, or fluids of any kind into the air-passages calls for tracheotomy and artificial respiration, together with the use of means to free the air-passages from the for- eign matter that embarrasses it. Asphyxia from the en- trance of blood is always to be guarded against in the course of operations about the cavities of the mouth and naso-pharynx, when full anaesthesia is required, and every arrangement for immediate tracheotomy should be at hand in those cases in which a deliberate prelimi- nary tracheotomy is not deemed advisable. A person attacked by vomiting while in a state of unconsciousness is in great danger that portions of the vomited material may enter the air-passages. The accident of being drowned in one's own vomit is by no means infrequent. It is to be watched for in all cases where general anaesthe- sia is induced, and when it occurs, demands immediate incision of the trachea and the quick employment of en- ergetic means to free the air-passages from the obstruct- ing material. The incision into the trachea not only supplies a new, more direct, and free opening for the en- trance of air and facilitates the emptying of the air-pas- sages by the compressions used in carrying on artificial respiration, but it affords an opportunity to readily intro- duce instruments for cleansing the passages. Little can be accomplished in such cases by suction through tubes of any kind ; but, by the forcible blowing of air into the lungs through a catheter or other suitable tube introduced through the tracheal wound, the ejection of fluids and semisolids from the air-passages by the return current of air may be quickly and readily accomplished. II. Inflammatoky Conditions. - Stenosis of the larynx of such severity as to demand tracheotomy may arise in the course of any of the inflammatory conditions to w hich the larynx is subject. In the course of an attack of acute catarrhal laryngitis, the rapid development of symptoms of severe dyspnoea, which are not relieved by an emetic or other antispas- modic treatment, indicates the supervention of cedema- tous infiltration of the aryteno-epiglottic folds and of the epiglottis. The suffocative symptoms produced by this condition may early become so immediately urgent that no opportunity for the use of ordinary therapeutic means is presented, and prompt surgical interference is the only possible thing that can avert a speedily fatal issue. In 161 Tracheotomy. Tracheotomy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. other cases a more gradual development of the oedema gives time for the employment of remedies, and many of these cases, though in great apparent danger for some time, ultimately recover spontaneously. Scarification of the supraglottic oedematous tissue has been successful in relieving some of these cases, and in yet others, more recently, the practice of intubation, after the method of O'Dwyer, has likewise sufficed to avert dan- ger. But tracheotomy must remain the resource most frequently available to the practitioner who may neither himself have the special technical dexterity in throat manipulations required to satisfactorily practise the first- mentioned operation, nor be able to call to his aid others who may have it. The results of tracheotomy, when done for the relief of acute inflammatory occlusion of the glottis, are very en- couraging, and, when the operation is done with the pre- cautions and after-cares to be described further on, very little, if any, additional hazard is added to the case by its employment. It is* impossible to make any satisfactory statistical ex- hibit of the results which have been obtained by trache- otomy in cases of acute catarrhal laryngitis. Durham40 reports thirty recoveries out of forty-nine operations ; but in most instances in which operations have been per- formed uncertainty remains as to whether the case was one of simple catarrhal inflammation, or one attended with pseudo-membranous exudation. The tendency has existed to classify all laryngeal in- flammations which resist treatment and progress to the development' of threatening stenosis as cases of mem- branous croup. On the other hand, an equally confusing tendency has existed, in cases attended with demonstrable pseudo-membranous exudation, to make an arbitrary distinction into simple membranous croup and diphthe- ritic croup. The result of the whole is to render impossi- ble any reliable classification of the results of tracheot- omy for statistical purposes. From the stand-point of the indications for the operation this is unimportant to the surgeon ; the one supreme indication which he has to consider is that of severe and continued dyspnoea from laryngeal obstruction. The cause of this obstruction may influence prognostications as to the ultimate result, but does not affect the present indication as to immediate duty. In acute laryngitis the parts below usually remain comparatively unaffected, and after the relief to the ob- structed respiration has been afforded by the tracheal incision, the laryngeal inflammatory swelling so quickly subsides that the tube need be retained but a few days. The operation itself contributes to the shortening of the primary laryngitis by putting the affected parts at rest, and removing the source of irritation existing previously in the to-and-fro respiratory current. The question of chief importance to the physician who is charged with the responsibility of the care of an acute laryngitis is, what degree of urgency must the suffocative symptoms attain to justify him in opening the trachea ? He certainly should not wait until the patient is in ex- tremis, nor should he be precipitate in action, for spon- taneous recovery from very threatening conditions is not rare. At the same time, he is not to consider so much the idea as to whether the patient may not possibly re- cover without operation as he is to decide whether his chances of recovery will be made greater by the opera- tion. Tracheotomy is to be accepted as one of the thera- peutic resources at the command of the physician for the relief of dyspnoea from laryngeal obstruction, and when the dyspnoea is sufficiently great and prolonged to produce serious suffering, or much exhaustion, the operation is justifiable. The personal element of the skill and experience in the operation of the physician himself must also come into the equation, for, if the dan- gers inherent in the operation are great, it would be im- proper to subject a patient to them unless the dangers that were to be averted by the operation were already unmistakably greater and more imminent. Tracheot- omy, while often a simple procedure, at times develops conditions that tax to the utmost the coolness, adroit- ness, and command of resources of the most experienced surgeon. One who is thoroughly provided to control these difficulties would be justified in offering the opera- tion as a means of relief in circumstances less urgent than one without these qualifications. Loss of voice, frequent thin, metallic, muffled cough, difficult inspiration and prolonged expiration, the supra- sternal and epigastric tissues sinking in at each inspira- tory effort, great restlessness, suffusion of the face with bluish lips-these are symptoms that, if continued, will produce speedy exhaustion ; but in many cases of acute catarrhal laryngitis much of this respiratory difficulty is due to glottic spasm, which may be controlled by treatment, or may spontaneously disappear. If the severe symptoms of dyspnma are intermittent, if they are less- ened in severity and in frequency by treatment, if the general prostration is not great, and if the lethargy de- noting advancing defective oxidization of the blood is not marked, tracheotomy should be deferred. When, on the other hand, the dyspnoea is continuous, and is gradually and steadily increasing despite treatment, especially when symptoms of exhaustion are developing- as shown by pallor of the face, with cold perspiration- and when the benumbing effects of defective aeration of the blood is producing its anaesthetic effect-as shown by tendency to lethargy replacing previous restlessness- then tracheotomy should be resorted to without further delay. Pseudo-membranous Laryngitis.-Of all the causes which may possibly determine dyspnoea of sufficient gravity to require tracheotomy for its relief, the accumu- lation of a membraniform exudate upon the surface of the laryngeal mucous lining is the most frequent. When the accumulation of such a laryngeal exudate is second- ary to, or synchronous with, the same formation within the pharynx or upon the tonsils, early recognition of the cause of the laryngeal symptoms is made ; when the earliest manifestation of the exudate is within the larynx, a not infrequent occurrence, the condition cannot be distinguished with certainty from that attending acute catarrhal laryngitis in its severer forms ; it is only when, in the progress of the case, membraniform fragments become detached and are expectorated, or a membrani- form exudate forms in the pharynx or fauces also, or the presence of the exudate is demonstrated by incising the trachea, that an absolute diagnosis can be made. It is a common error to assume that severe and continuous dyspnoea arising in the course of acute inflammatory affections of the larynx is due to a membraniform ex- udate, and to denominate the case " membranous croup." This assumption has given rise to many erroneous con- clusions as to the value of medicinal treatment in cases of so-called membranous croup, for the catarrhal inflam- mation is much more amenable to medicinal agents than is the exudative. As long, however, as any doubt about the exact character of the case exists, it is wiser, from the stand-point of treatment, to assume that the more intractable disease is present and to guide the treatment accordingly. Such a principle of action will lead to an earlier resort to tracheotomy than would otherwise be the case. If the practitioner has positive evidence, or provisionally accepts the conclusion, that the larynx is becoming blocked by membraniform exudate, his course of action will also be likely to be influenced by his opin- ion as to the diphtheritic or non-diphtheritic character of the exudative process. As to the possibility of the development, upon the sur- face of the laryngeal mucous membrane, of a membrani- form exudate not due to diphtheritic infection, there is considerable evidence, consisting chiefly in the undoubted occurrence in localities of cases of membranous laryn- gitis at rare intervals during a long period of years before the prevalence of diphtheria in that locality. If such non-diphtheritic cases formerly occurred they may doubtless still occur ; but abundant observation has demonstrated to the writer that, clinically, it is impossible to distinguish such cases at the present time, and that the symptoms tabulated by systematic writers for estab- lishing the differential diagnosis between the two classes 162 Tracheotomy. Tracheotomy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. of cases are entirely unreliable, and their importance quite imaginary. The occurrence of membranous laryn- gitis in any community at the present time is always associated with the prevalence of other forms of diph- theria. The accompanying diagram (Fig. 3961) shows ryngeal diphtheria, and as such I shall consider them in what I may have to say further. The proportion of re- coveries from laryngeal diphtheria, without tracheotomy, is exceedingly small. Dr. Gay, in the article on Croup, in Vol. II. of the present work, has recorded that out of between forty and fifty cases of undoubted diphtheritic I croup that were treated by medicinal agents only, in the Boston City Hospital, during a period of nine years, every one died. Personally I have seen some recoveries from the use of medicinal measures only, in cases of undoubted diphtheria, with distinct symptoms of laryngeal involve- ment ; but these have been cases in which the obstructive symptoms never became so urgent as to strongly indicate tracheotomy. In no instance in which dyspnoea was quite marked, so that I have advised tracheotomy, and in which opera- tion was refused, have I known recovery to take place. Nevertheless, I am aware that cases have occurred in the experience of others in which, by the fortunate expulsion of extensive membranous casts, when the patient was in extremis, relief has been obtained, and ultimate recovery secured. Such events are very rare, and ought never to be taken into account in deciding as to the line of action to be chosen in any given case. In view, therefore, of the almost hopeless character of laryngeal diphtheria when left to pursue its course with- out surgical interference, when the exudate has assumed sufficient proportions to seriously embarrass the respira- tion, it becomes the duty of the surgeon to open the trachea as soon as the embarrassment to the respiration from the laryngeal obstruction is great enough to become a source of exhaustion to the patient; nor should the surgeon delay until the suffocative struggles are extreme, or the strength of the patient is exhausted by prolonged dyspnoea, or the narcosis of defective blood-oxygenation is far advanced. It is to be kept in view that the laryngeal obstruction is but a part of a general infective disease, for the struggle against which it is important that the general bodily strength be rallied and advanced to its highest possible point. From this point of view it is important to give to the lungs the most abundant and purest supply possible of air, and that with the least expenditure possible of muscular energy. The progress of a case from the first inception of symp- toms of hoarseness and slight embarrassment of breath- ing to the termination in death is usually rapid. Out of 1,760 cases of fatal croup in the city of Brooklyn, in chil- dren less than five years of age, fifty-seven per cent, died within three days from the onset of the croupy symp- toms, 159 died within twenty-four hours, and 22 died within twelve hours. Much time for deliberation is therefore not to be relied upon. In addition to the exhaustion produced by the unin- termitting violent efforts to respire, the deficient blood- oxygenation, and the continued depressing effect of the diphtheritic poison, the surgeon must also take into con- sideration the damage likely to be inflicted upon the lungs themselves during prolonged unrelieved dyspnoea. Pulmonary emphysema and oedema, and diffused capil- lary hypersemia, with subsequent bronchial catarrh, re- sult from prolonged dyspnoea, and form complications hindering recovery, should the dyspnoea finally be re- lieved by tracheotomy. Tracheotomy tends to prevent death in diphtheritic laryngitis by making possible free access of air to the lungs, and thus : 1, Relieving or pre- venting carbonic-acid poisoning and its sequelae ; 2, sup- plying the blood freely with the best of stimulants and tonics-oxygen-it assists in the struggle to eliminate the special blood-poison, and favors the limitation of the disease; 3, at once ending the cupping-glass action ex- erted upon the whole surface of the respiratory tract below the larynx by the inspiratory struggles, it lessens the danger of the occurrence of diffuse catarrh of the air- passages, of pneumonia, and of pulmonary oedema, and promotes recovery from these conditions when not al- ready too extensively developed ; 4, rendering respiration free and easy, it prevents exhaustion from excessive mus- cular exertion, and tends to relieve it if already present. It tends to prevent death by eliminating from the pos- Fig. 3961.-Showing comparative Prevalence of Croup and Diphtheria in the City of Brooklyn, 1870 to 1876. Croup, ; Diphtheria, .... graphically the relative prevalence of fatal diphtheria and laryngitis in the city of Brooklyn during a period of seven years, 1870 to 1876, inclusive. The statistics which form the basis of this diagram were compiled by me from a personal examination of the mortuary records of the Board of Health of that city, involving an inspec- tion of over 80,000 certificates of death. The continuous line in the diagram marks the course of fatality from inflammatory disease of the larynx of every kind, ex- clusive of those reported as diphtheritic ; a considerable, but undetermined, number represented in this line were doubtless non-exudative in character ; the remainder were exudative, but not recognized as diphtheritic ; nevertheless, the rise and fall of the croup line, pari passu with the diphtheria line, show's the close relation between the two processes. The year 1887 was again marked in the city of Brooklyn by an unusual fatality from diphtheria, the total deaths recorded from this cause being 950, an increase of 170 over the diphtheritic mortality of the preceding year ; an equal rise in the croup mortality likewise occurred, the number of croup deaths reaching 503, an excess of 100 over that of the preceding year. I feel justified, therefore, in emphasizing the teaching that any case of pseudo-membranous laryngitis is pre- sumably diphtheritic in its character, and that all cases should from the first receive the treatment appropriate to the diphtheritic condition. Practically, therefore, all considerations as to the treatment of pseudo membranous laryngitis resolve themselves into that pertaining to la- 163 Tracheotomy, Tracheotomy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. sible causes of death oedema glottidis, and occlusion of the glottis by a piece of loosened membrane, through the establishment of an opening for the entrance of air at a point between the glottis and the lungs. It prolongs life, and thus gives increased opportunity for the action of remedies, and for a rallying of the powers of nature suf- ficient to throw off the disease. By tracheotomy the surgeon is given ready access to the interior of the trachea, and is enabled to remove at once from it any masses of detached exudate that may be present, as well as the abundant pultaceous secretion formed by the mixture of membranous debris and muco- pus which often accumulates below the membrane proper, and is liable to be sucked back into the finer bronchial ramifications, blocking them up and carrying infection to the deepest parts of the lung-tissue. Through the tracheal opening local medication of the trachea and larger bronchia is facilitated, a more direct and accessible way being provided for the introduction of sprays and solutions, forceps and swabs, as the after- course of the disease may require. In any consideration of the character of the surgical interference to be adopted in cases of laryngeal diph- theria, the treatment of the local conditions, both pres- ent and to come, must be kept in view as well as the re- lief of the present dyspnoea. For this reason the writer rejects intubation entirely in laryngeal diphtheria, since it relieves only the glottic stenosis, and does not give the surgeon the access to the trachea, nor the control over its conditions, which tracheotomy does. Doubtless in- tubation is greatly to be preferred to dependence upon medicinal treatment alone, but it only partially answers the indications for surgical interference when a diph- theritic exudate has formed within the larynx and trachea, and therefore should not be considered as a substitute for tracheotomy in such cases. The choice of the point at which the trachea is to be opened should also be controlled by the facility with which intra-tracheal examination and treatment may be carried on through the incision. Without question an in- cision at some point below the thyroid isthmus gives the surgeon the most advantage in this respect, and for this reason should be chosen, notwithstanding that it demands more care and anatomical knowledge for its safe per- formance than an incision above the isthmus. When the one indication for tracheotomy is present, viz., laryngeal stenosis to such a degree as to be a source of danger either directly or indirectly, there can be no contraindication to the operation. Whatever the degree of septicajmia, if the stenosis is great enough to materi- ally intensify it, the operation should still be done. Coexisting pneumonia, bronchitis, exhaustion, even apparent death, instead of contraindicating, do the more distinctly indicate it. These and other complications render the prognosis more grave, but do not justify a refusal to operate. The literature of the subject abounds in instances in which, despite the gravest complications, recovery has been secured. The age of the patient is also a condition modifying the prognosis, but not to be considered in any case as a distinct contraindication. The recovery-rate in children under two years of age is comparatively small. Of 42 such cases at the Boston City Hospital (Lovett and Mun- ro 28), 3 recovered ; of 40 cases in Thiersch's Clinic, Leipsic (Van Arsdale 4I), 2 recovered ; of 27 cases in Rose's Clinic, Zurich (Hugonnai 6 recovered; of 1,093 cases col- lated by Monti,43 158 recovered, 11 of whom were under one year of age ; of 47 cases tabulated by Mastin,44 from reports of various American operators, 10 recovered ; of 3 such cases operated upon by myself, 1 recovered. About fourteen per cent., therefore, of recoveries in children aged less than two years may be expected with the aid of tracheotomy, a proportion which is just one-half the general average, twenty-eight per cent., as deduced by Lovett and Munro from the total of 21,853 cases of all ages compiled from all sources. This is a proportion of recoveries large enough to warrant the surgeon in resort- ing to tracheotomy for the relief of exudative laryngeal obstruction, however young the patient may be. In the opinion of the writer, notwithstanding the use of statistics just made, there is very little of practical value as a guide to the action of the individual surgeon in any mass of statistics relating to recoveries and deaths following tracheotomy done in diphtheritic laryngitis. The indications for the operation do not depend at all on the proportion of recoveries which it may assist in securing. The general principles which should guide the surgeon I have attempted to outline, and it is these, in my opinion, which should control his action in any given case. Laryngeal tuberculosis frequently develops conditions that indicate tracheotomy. Chronic cedematous infiltra- tion of the aryteno-epiglottic folds, by submucous puru- lent collections from perichondritis, with necrosis or ca- ries of the cartilages, or advancing tumor-like tuberculous infiltrations of the laryngeal or perilaryngeal tissues, may be the cause of the dyspnoea. The progressive stenosis resulting from these conditions is also liable to sudden aggravation by attacks of acute catarrhal laryngitis which precipitate operation. Paralysis of the dilators of the glottis, producing occlusion by the immobile vo- cal bands, may result from tuberculous invasion of the posterior cricoarytenoid muscles, or by compression of the recurrent nerves by enlarged glands or necrosed car- tilages. The sudden entry into the larynx of abundant or inspissated mucus may produce symptoms demanding operative interference ; also, when the epiglottis is ulcer- ated and immovable, or assumes a vicious position, so that deglutition is impeded and painful, and morsels of food penetrate into the larynx. Suffocative symptoms seeming to require tracheotomy may arise in the course of tuberculosis from other than laryngeal conditions, as in lesions of the cervical portion of the spinal cord and the medulla. Enlargement of the tracheo-bronchial glands in the mediastinum may com- press the air-passages below the larynx, and cause dysp- noea. Before operating, therefore, it is important to be assured that the obstacle to the passage of air lies in the accessible portion of the respiratory tract, and chiefly there. Judgment must be arrived at from the functional signs, such as the voice, respiration, cough, etc., and the physical signs obtained by inspection of the throat and neck by digital and laryngoscopic examinations. Opera- tion should not be delayed too long, but when pronounced dyspnoea shall have arisen and continues, or even when somewhat severe attacks of dyspnoea tend to recur fre- quently, tracheotomy should be done to preserve the strength of the patient, already undermined by his pre- vious disease. The more a patient has been affected by pulmonary disease, the earlier should the operation be done, if symptoms of suffocation occur; for if it is de- layed until asphyxia is imminent, the patient is apt to succumb despite the operation, because of inability to re- cover from the extreme prostration caused by insufficient oxygenation of the blood. The coexistence of advanced pulmonary tuberculosis is not necessarily a contraindica- tion to tracheotomy, although it may properly be taken into consideration in judging as to the benefit to be de- rived from the operation. If the suffocative symptoms are simply the final accident of a train of conditions that lead to speedy death, whether the laryngeal stenosis be relieved or not, the surgeon may be justified in declining to interfere. Syphilitic disease of the larynx may necessitate tra- cheotomy in its course on account of tumefactions of the laryngeal or perilaryngeal structures, either acute or chronic. Acute oedema of the glottis may supervene upon the laryngitis of secondary syphilis. Laryngeal gummata may produce laryngeal stenosis in their early history, or, later, through the purulent infiltrations of perichondritis. Paresis of the vocal cords may be produced by infiltra- tions of the dilating muscles with either inflammatory or gummatous products. Sudden suffocative attacks may arise from the loosening of cartilaginous sequestra, or the partial detachment of flaps of the softer tissues which may fall into and occlude the glottic orifice. It is important to distinguish between syphilitic and tuberculous tumefactions of the larynx in determining 164 Tracheotomy. Tracheotomy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the indication for tracheotomy, for in the former, rapid subsidence of the swelling, and consequent relief to the dyspnoea, may often be obtained by proper constitutional treatment, while in the latter there is little hope of relief to the obstructive symptoms except through tracheotomy. Phlegmonous inflammation of the pharynx, of the oesoph- agus, of the base of the tongue, and of the tonsils may each give rise to oedema of the glottis by extension of the inflammatory condition to the laryngeal structures, and so determine dyspnoea requiring tracheotomy. The volume of an abscess, forming among such supralaryn- geal structures (retropharyngeal abscesses, etc.), may itself be sufficient to occlude the glottic orifice, or, by the infiltration of the pus into the aryteno-epiglottic folds, there may be produced a true oedema of the glottis. When, in either case, the formation of the pus is well advanced before the development of severe dyspnoea, simple incision of the abscess will suffice to give im- mediate relief; but when the dyspnoea arises in the earlier stages of the inflammatory infiltration, tracheot- omy will be required. Phlegmonous laryngitis or laryngeal perichondritis, arising as primary affections, though exceedingly rare, must still be enumerated as among the possible causes of dyspnoea demanding tracheotomy. (Edema of the glottis may develop as one of the phe- nomena of a general dropsical tendency, as in the dropsies of renal and cardiac origin. If in such cases the dysp- noea is severe, and attempts at relief by scarifications through the mouth are ineffectual, tracheotomy is indi- cated. Erysipelas invading the larynx may occasion an oedema requiring tracheotomy for its relief. Measles, likewise, is sometimes complicated with a glottic oedema that rapidly becomes dangerous, and re- quires prompt operative interference. Small-pox may provoke an oedema of the glottis, re- quiring tracheotomy, at two different periods of its course ; first, at the eruptive stage, especially in the con- fluent variety, when the larynx is generally attacked with marked severity, and when death from the acute inflammatory oedema of the larynx may occur ; second, at a later period, from the formation of submucous ab- scesses, with possible necrosis of the cartilages. The laryngeal ulcers common in typhoid fever, though they generally do not in any way affect the ordinary course of the disease, in rare instances determine oc- clusion of the larynx, either by acute oedema or by sub- mucous purulent collections. Tracheotomy is the only resource in these cases. Chronic Laryngitis.-That form of chronic laryngitis in which there is hyperplasia of the submucous con- nective tissue, with consequent induration, thickening, and contraction, will ultimately require tracheotomy for the relief of the dyspnoea produced by the steadily ad- vancing stenosis which it produces. Chronic primary hypertrophic laryngitis is of comparatively rare occur- rence ; it does not differ essentially in its symptoms from the secondary chronic laryngeal inflammations due to tubercular, syphilitic, or other ulcerative affections of the larynx already referred to. Tracheotomy, in addition to its service in the function of respiration in these cases, is an important preliminary and aid to the later system- atic treatment of the laryngeal stricture by dilatation. Laryngeal Perichondritis.-Still more rare than the form of inflammation of the submucous connective tissue of the larynx just mentioned is primary inflammation of the perichondrium of the laryngeal cartilages. As a con- dition secondary to tuberculous, syphilitic, and typhous ulcerations, it has already been referred to. The second- ary form may arise also in the course of the invasion of ulcerating neoplasms. That it may arise, however, as a primary disease is well attested. Whatever its origin, the acute swelling of the surrounding soft parts, when it takes place within the larynx or at its entrance, almost invariably causes the highest grade of laryngeal stenosis and danger of suffocation, which compels the most speedy resort to tracheotomy. In general, it is only by the opening of a new air-passage that a possibility is secured for any subsequent repair of tlie inflammatory destructive processes in the larynx. Cicatricial Constrictions of the Larynx or Trachea of Inflammatory Origin.-Tracheotomy may become neces- sary for the relief of stenosis of the larynx or trachea produced by the later cicatricial contraction following ulcerative and destructive inflammatory processes in- volving these structures. Such constrictions are most frequently of syphilitic origin. As soon as attacks of serious dyspnoea begin to be experienced, tracheotomy should be resorted to. Unnecessary delay should not be entertained, for slight irritating causes may unexpectedly and suddenly provoke extreme aggravation of the dysp- noea at any time. Tracheotomy is not merely a pallia- tive procedure in these cases ; when followed by suitably directed attempts at dilating the stricture, it becomes the first step toward effecting a cure. III. Neuroses of the Larynx.-In the serious and sometimes threatening dyspnoea which may be deter- mined from either spasm or paralysis of the muscles of the larynx, tracheotomy may become indicated. Glottic Spasm.-Paroxysmal dyspnoea from muscular spasm is one of the common phenomena attending slight laryngeal catarrhal attacks in childhood constituting or- dinary croup. Though almost universally such attacks subside spontaneously, or are controlled by antispas- modic treatment, cases are recorded in which the spasm did not relax, but persisted until fatal asphyxia was pro- duced. It is true that relaxation may often occur at the very last moment, when suffocation seems inevitable; nevertheless, it is the part of prudence not to depend too much on such a favorable turn ; but, if the dyspnoea is great and continuous, and is not diminished by the proper remedial measures, and the lips and fingers are livid, and the skin is pallid and covered with cold sweat, indicating progressive asphyxia and exhaustion, to have recourse to tracheotomy. Paroxysmal spasm of the laryngeal muscles is a fre- quent complication of other laryngeal affections (trau- matic, inflammatory, inhalation of irritating vapors, etc.), and is often the active agent in precipitating symptoms of asphyxia that indicate immediate tracheotomy. Spasm of the glottis (laryngismus stridulus) due to pathological irritation of the recurrent laryngeal nerve or of the pneumogastric, or to causes of a more general nature, may require tracheotomy for its relief when suffocation is threatening. The rapidity with which fatal asphyxia is determined in glottic spasm of the highest grade will make the cases rare in which trache- otomy can be done quickly enough to avert the fatal issue. Spasm of the glottis arising in the course of general tetanus has been the occasion for tracheotomy. Astier45 gives five cases of this character. In one of them, oper- ated by Verneuil, ultimate recovery from the tetanus was obtained. It is true that in general the spasm of the laryngeal muscles is but a part of a general spasm of all the muscles of respiration. Whenever, however, asphyxia from the glottic spasm is a prominent symp- tom, the trachea should be opened for the relief of that symptom, in addition to the employment of general anti- tetanic remedies. Emotional causes may occasion glottic spasm of a high degree, requiring tracheotomy for its relief. Astier cites from Briquet (" Traite de 1'Hysterie") two cases of hysterical spasm of the glottis in which tracheotomy was done, in one case by Velpeau, and in the other by Michon. Epileptic convulsions as an indication for tracheotomy, first advocated by Marshall Hall46, in 1851, though ac- cepted by some for a time, are no longer so regarded by any teachers, notwithstanding that numerous good results in the relief of such convulsive attacks were at first re- ported from the use of tracheotomy. Glottic Paralysis.-The dyspnoea produced by total paralysis of the dilators of the glottis, the posterior crico- arytenoid muscles, is so urgent as always to demand tracheotomy to avert suffocation. Such paralysis may be sudden in its onset, or gradual in its approach. It may be due to central nervous lesions, to compression of 165 Tracheotomy. Tracheotomy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the recurrent laryngeal nerves in some part of their course by tumors and aneurisms, or to local changes in the muscle itself. Paralysis from the latter cause is one of the most frequent sequelae of laryngeal diphtheria, and is the immediate cause of difficulty in dispensing with the cannula in many cases in which life has been prolonged by tracheotomy. When any considerable degree of par- esis of the dilators of the glottis has developed from any cause, tracheotomy should be done as the first step in any course of treatment. IV. Neoplasms.-The neoplasms which may necessi- tate tracheotomy belong to two groups : Those which are without the larynx or trachea, but compress them ; and those which are growing within the interior of these passages and block them up. Extra-laryngeal Neoplasms.-Most frequent are the hy- perplastic tumors of the thyroid gland-goitres. These may surround the trachea and compress from all sides, may push the trachea to one side and cause a sharp obstruc- tive bend in it, growing downward behind the sternum may compress the trachea against the vertebral column, or may determine such softening of the cartilaginous tracheal rings that collapse of the air-tube is endangered by slight causes. Though the indication for tracheotomy may be very clear in these cases, the performance of the operation may be found to be attended with great difficulty and danger, and, after the trachea has once been opened, the use of specially long and flexible cannula?, like that de- signed by Koenig (Fig. 3973), will be necessary to derive any advantage from the operation. Aneurisms of the arch of the aorta may compress the trachea and determine suffocative symptoms requiring tracheotomy for their relief ; more frequently, however, aneurisms are likely to be a more indirect cause for tracheotomy, through stretching or compressing the re- current nerves, and so determining spasm or paralysis of the laryngeal muscles. The immensely hypertrophied cervical glands which characterize malignant lymphadenoma may compress the trachea and produce obstructive symptoms. Relief by tracheotomy is, however, problematical in such cases, from the probable coexistence of similar enlargement of the mediastinal glands which also compress the air-tube. The impaction of bulky masses in the oesophagus may compress the trachea to a degree necessitating trache- otomy for temporary relief, until the removal of the im- pacted body can be effected. Cancer of the oesophagus may likewise compress the trachea. Intra-laryngeal Neoplasms.-Tracheotomy may be indi- cated in the case of tumors seated within the larynx, for the purpose of relieving dyspnoea caused by their bulk and location, for gaining access to them for the purpose of removal, or as a preliminary procedure to render safer subsequent attempts at extirpation. In cases of malig- nant disease of the larynx, the trachea should be opened at the first appearance of serious respiratory embarrass- ment. The point chosen for the opening of the trachea should be as low as possible, in order to get as far away from the seat of disease as may be. The tracheotomy not only relieves the dyspnoea, but it sets the affected part at rest and also facilitates the use of palliative ap- plications to it. In cases of benign tumors, as every va- riety may be met with, the indication for tracheotomy will vary with the individual case. It is to be kept in mind that sudden and rapid changes in the capacity of the air-channel are likely to take place in any case of la- ryngeal tumor from swelling of the tumor, either from turgidity of its blood-vessels or from simple or inflam- matory oedema, and that change in the position of the tumor with impaction in the glottic chink, or glottic spasm, may likewise suddenly excite suffocative symp- toms. Whenever a patient with laryngeal neoplasm de- velops serious dyspnoea, unless a rapid removal of the obstructing growth by endolaryngeal manipulations is possible, tracheotomy must be done without delay. In small children with laryngeal tumors, in whom endo- laryngeal manipulations are impracticable, tracheotomy is the rule as soon as obstructive symptoms develop. When the attempt is to be made to attack a laryngeal or tracheal growth through an incision from without, the air-duct is to be opened at the point which will give the most ready and direct access to the growth. The inci- sion may divide the thyroid cartilage, the crico-thyroid membrane, the cricoid cartilage, or the trachea at any ac- cessible part, according to tlie necessities of the case. When the attack upon a laryngeal growth is likely to be attended with considerable haemorrhage, the trachea should first be opened at a lower point, and a cannula in- serted to insure against interference with the respiration in the use of necessary means to control haemorrhage. Tracheotomy as Preliminary or Adjunct to other Surgical Procedures.-The danger of the en- trance of blood into the air-passages in the course of sur- gical operations involving the cavities of the nose, mouth, and pharynx, has been referred to in connection with the traumatic conditions which might possibly require tracheotomy. The preliminary opening of the trachea, and the use of appropriate means to tampon the pharynx or the trachea, and thus to prevent the entrance of blood at all, commends itself as a device of great value, and worthy of being assigned an important place in the tech- nique of bloody and prolonged operations in the regions stated. The administration of an anaesthetic is also greatly fa- cilitated by such preliminary tracheotomy, since its unin- terrupted administration through the tracheal cannula is then possible, and the anaesthetizing apparatus is removed to a distance from the field of operation. The indirect advantages of preliminary tracheotomy are also great. It permits of deliberation and thoroughness by the surgeon in his work, while at the same time it enables him to press his work speedily and uninterruptedly to its full conclusion. Thus the loss of blood is lessened and shock is diminished. In the case of operations per- formed for the removal of malignant disease, the com- plete removal of all diseased tissue is less likely to be inter- fered with, and thus the ultimate benefit of the operations is more likely to be secured. It is especially true of ma- lignant disease of the upper jaw that the extent to which it may have involved neighboring structures is often much greater than the visible evidences would indicate, so that the surgeon, in undertaking any operation for the relief of such growths, should be prepared for the most serious conditions. In such extreme operations as resections of the upper or lower jaw, amputations of the tongue, removal of large growths from the fauces or pharynx, and extirpation of the larynx, a great element of danger in their course subsequent to the operation is the inspiration into the lungs of septic material from the operated surfaces and the consequent development of septic pneumonia ; an- other disadvantage is the general depression incident to the continuous breathing of air charged with the products of decomposition formed in the imperfectly cleansed wround-cavities. By the retention of the cannula in the trachea for whatever period of time the conditions of the individual case may seem to require, and the use of suitable tampons to shut off the trachea from the suppurating or necrotic regions, this contamination of the inspired air may be prevented. Michael,41 at the Congress of German Sur- geons, held in 1883, described a case in which such pack- ing around the tracheal cannula was borne for fifteen months. On the other hand, Schoenborn reported at the same congress a case in which the pressure of the tampon caused ulceration and gangrene of the trachea. This permanent tamponnade of the trachea must be used w ith discretion. It is true that by bringing the head of a patient be- yond the edge of a table and causing it to hang so far backward that its vertex points to the floor-Rose's po- sition-the inclination of the floor of the nares and of the mouth will be so altered that blood will flow out- ward away from the larynx. This device, however, has but a limited application. It is chiefly valuable for op- erations upon the palate and mouth in young subjects. Adults do not bear well prolonged retention of the head 166 Tracheotomy. Tracheotomy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. in such a position, and not infrequently patients begin to breathe badly when their heads are so placed. In cases of preliminary tracheotomy various devices have been suggested for tamponing the trachea. The one best known is that of Trendelenberg, who made use of an extra-long tracheal cannula, the intra-tracheal portion of which was surrounded with a thin rubber bag from which a small tube passed outward, through which the bag could be inflated after the cannula had been put in place ; the inflated bag, filling up all the vacant space between the walls of the trachea, would thus form a sufficient tem- porary tampon. Fig. 3962 shows the modification of Tren- delenberg's cannula devised by Dr. A. G. Gerster. The tube attached to the external end of the cannula leads to a suitable reservoir for amesthetics. In actual practice all such rubber-balloon armatures often disappoint the sur- lying between the body of the hyoid bone above and the upper margin of the sternum below, and bounded on either side by the decussating omo-hyoid and sterno- cleido-mastoid muscles. The skin here is thin, soft, and very movable. On account of this mobility it should be carefully steadied by the lingers of the operator as he makes the first incision for exposing the trachea. For want of such care I have seen an operator draw the skin unduly to one side in trying to steady it for the incision, and have the mortification of finding, upon relaxation of the tension, that his cut was so far away from the me- dian line that a second one was necessitated. The superficial fascia is easily separable into two lay- ers. The more superficial layer is continuous with the general superficial fascia of the adjacent regions, and contains a variable amount of fat. Surgically it is not to be separated from the skin, with which it forms the first layer, the division of which forms the first step of tracheotomy-a step which should be accomplished by a single stroke of the scalpel. The deeper layer of the superficial fascia forms a thin but dense membrane, which closely blends in the middle line with the ante- rior layer of the deep cervical fascia. Between it and the deep fascia lie the venous trunks that form the an- terior jugular plexus. The size, the number, and the position of these veins are subject to great variations. In cases of dyspnoea they become swollen and engorged with blood. They are often laid bare by the first in- cision, and their division may be unavoidable. Hae- morrhage from them when cut is profuse, but may be readily controlled, so that it does not become a matter of critical moment in the early stage of the operation. A transverse venous trunk is common at the root of the neck, a little above the sternum, and is liable to be wounded when the incision is prolonged downward. This vessel is not so superficial as those higher up, and is therefore not so easy to secure; when it is wounded during the last steps of the operation, it forms a serious complication to the final procedures for incising the trachea. Mindful of this fact, it behooves the operator to prolong his incision down to the sternum at the out- set, so that whatever difficulty this transverse vein is to cause may be met and overcome before the more critical conditions attending the later steps of the operation can cause a wound of it to be unnecessarily dangerous. There is nothing in the anatomical conditions of the superficial layers of the anterior median region of the neck to cause the surgeon to hesitate in making the free incision so desirable for facilitating the later steps re- quired for exposing the trachea. The arrangement of the deep fascia, the cervical apo- neurosis proper, is of great interest and importance in this region. Stretched from the hyoid bone above, over the prominent thyroid cartilage to the upper border of the sternum below, and supported on either side by the thick sterno-cleido-mastoid muscles, it forms a dense re- sisting roof for the space under it. This aponeurosis, at a point about midway between the cricoid cartilage and the sternal notch, divides into two well-marked dense, fibrous layers, the more superficial of which is inserted into the anterior border of the sternum, and the deeper into its posterior border, the interval between them be- ing filled by connective tissue and fat. If in operating, after the exposure of this aponeurosis, it be seized by forceps or tenaculum just above the sternum, and, hav- ing been nicked by the knife, the attempt be made to pass a director upward beneath it, the passage of the di- rector will be stopped at the point where the deeper layer is blended with the superficial, nor can it be thrust be- yond this point except by using an improper degree of force. The separate incision of this leaflet of the apo- neurosis thus is necessitated, after which, the deeper layer having been in the same manner raised and nicked, a director can be passed with facility underneath the aponeurosis as far upward as to the thyroid cartilage. Whenever by the first incisions large turgid veins are uncovered, either in or approaching closely to the me- dian line, this method of lifting up the deep fascia upon a director, and so steadying it, will enable the surgeon Fig. 3962.-Gerster's Tracheal Tampon-cannula. geon ; the rubber is perishable, and is likely to be found damaged when it is wanted for use ; if overdistended it is likely to burst or to swell over the lower end of the cannula so as to occlude it; or, lastly, the pressure may irritate the trachea and cause violent cough, and if the distention be reduced enough to be tolerated, blood may insinuate itself between the plug and tracheal wall. In a large proportion of cases in which preliminary tracheotomy is indicated, it will be better to tampon the pharynx rather than the trachea. This may be done by crowding a large sponge, its deeper side covered with thin rubber to prevent the passage of blood through it, as suggested by McBurney,48 back into the pharynx after the cannula has been inserted in the trachea. In opera- tions upon the larynx, and especially in complete or par- tial extirpations of the larynx, the sponge-tent cannula of Hahn49 commends itself as preferable to the inflatable device of Trendelenberg. Hahn's device differs from the usual double tracheal cannula chiefly in that the inner tube is longer, being made to project outward from the shield and curve downward so as to facilitate the remov- al of the manipulations necessary for the administration of the anaesthetic away from the field of operation. The outer cannula is provided with a projection at the distal end-the tube being simply made thicker here-to pre- vent the sponge from slipping off. The entire length of the outer tube, down to the projection, is covered with purified sponge which has been saturated with iodoform by means of an ether solution, and then compressed. This prepared sponge is sewed and tied on with silk. After introduction of the cannula the sponge expands and securely occludes the trachea without causing any ill effects. Anatomical Considerations.-In the performance of the operation of tracheotomy it is highly important that the surgeon keep in mind the anatomical details of the region in which he operates, both as a guide to the successive steps of the operation and as a monitor to cause him to be prepared beforehand for the exigencies likely to arise during its course. The laryngo-trachea passes from above downward through a region which I have termed the anterior me- dian region of the neck. It is a lozenge-shaped space 167 Tracheotomy. Tracheotomy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. to incise it with delicacy and accuracy, and often with- out wounding the vessels he desires to avoid. Immediately beneath the deep fascia appear the ante- rior ribbon muscles of the neck, the depressors of the larynx and hyoid bone. In the median line, the adjacent margins of these muscles, which in some cases are nearly in apposition, and in others are separated by a more or less consider- able interval, are connected by a layer of fibrous tissue, often resistant and membraniform, sometimes lax and easily torn. This muscular plane, with its median lam- ina of connective tissue, forms a third distinct layer to be recognized and dealt with in the course of a tracheotomy. The white line between the muscles can usually be recognized without difficulty, but it has been my own experience to meet with cases while operating in which I could not distinguish it. A reference to other landmarks by which to be assured that the middle line of the neck is not being departed from becomes neces- sary in such a case. The division of this layer may be accomplished with safety and facility by seizing the in- termuscular connective tissue between two pair of ana- tomical forceps, and tearing the tissue between them by causing them to pull against each other. With the divis- ion of this layer and the retraction of the muscles to either side, the pretracheal space proper, with its important structures embedded in much loose connective tissue, is exposed. The tissues of this space form the fourth layer to be dealt with in the effort to expose the trachea. The pretracheal space is divided into two very nearly equal parts by the isthmus of the thyroid gland, which parts differ greatly as to their accessibility, and as to the possible complications which operations upon them may be accompanied with. The intermuscular connective- tissue layer at the level of the isthmus of the thyroid is closely applied upon its anterior surface, and furnishes a sheath for it which is reflected outward upon the lateral lobes, and affords a distinct fibrous envelope for the whole gland. At those points where the gland is in contact with the trachea, this fibrous envelope is blended inti- mately with the thin layer of condensed areolar tissue which, sheath-like, surrounds the trachea, so that the gland and the air-tube share alike in the movements of either. Above the isthmus, by tearing through the in- termuscular connective-tissue layer, the cartilages of the larynx are at once exposed. Between the isthmus of.the thyroid gland and the cricoid cartilage-the cricoid being the most prominent structure of the larynx in children- there is a layer of connective tissue which covers the first ring of the trachea. By tearing or cutting through this transversely until the first ring of the trachea is exposed, it is quite easy to get under the thyro-tracheal connective- tissue layer (fascia thyro-trachealis), and separate the isthmus from the trachea sufficiently to permit its de- pression so far as to expose the two rings next below. Room may be thus afforded for an incision into the trachea above the isthmus, in many cases without incis- ing the cricoid cartilage. The comparative elasticity of the cricoid in children makes the dilatation of an incision through it nearly as easy as that of one through a tracheal ring, so that where room enough for the required in- cision is not easily obtained by efforts to depress the isth- mus, it may be unhesitatingly included in the incision. The opening of the air-tube at this point constitutes the high operation for tracheotomy or laryngo-tracheotomy. The isthmus of the thyroid may vary greatly in volume. I have found it entirely absent, and again have found it so broad as to cover nearly the whole of the suprasternal portion of the trachea. The vascularity of the isthmus is also subject to great variations. In addition to the vascular net-work in its interior, which varies according to the degree of development of the isthmus as a whole, there is usually a small arterial loop which runs along its upper border, connecting the superior thyroid arteries on either side. I have found this to be of considerable size, as in the case from which the accompanying illustration was drawn (Fig. 3963). A transverse vein, the companion of the transverse ar- tery, is regularly present at the superior border of the isthmus, inosculating on either side with the superior thyroid veins. Occasionally a large venous trunk, a deep anterior jugular vein, will be found running per- pendicularly in the median line from the subhyoid region above, deeply seated, grooving the anterior surface of the isthmus, receiving the superior and inferior thyroid veins, running in front of the trachea, and finally emptying into the great transverse vein below. Such a condition I have met with both in the dissecting-room and in the course of operating upon the living subject. Whenever this deep median anterior jugular vein is present, any method of reaching the trachea, other than that of layer by layer, would inevitably wound it and occasion dangerous haem- orrhage. The transverse vessels of the isthmus are en- closed within the fibrous capsule of the gland, and when the fascia laryngo-thyroidea is divided transversely at the lower border of the cricoid cartilage, they are drawn down with the isthmus and thus are secure from injury Fig. 3963.-The Vessels of the Pretracheal Space : natural size. From child three years of age. A, great transverse vein ; B B, internal jugular veins; C CC, inferior thyroid venous plexus ; D, lateral thyroid vein; E, left common carotid artery : F, isthmus of the thyroid gland ; G, crico-thyroid space, with artery ; H, superior thyroid artery, with accompanying vein. when this method of operating is adopted. Incision of the isthmus itself, it is apparent, may be attended with a varying degree of haemorrhage and peril. Experience has shown that, though in most cases the bleeding from an incised isthmus stops spontaneously after the intro- duction of a tube and the restoration of respiration, yet repeatedly has impending suffocation been made com- plete by the flow of blood into the trachea with the first inspiration after it had been opened ; many cases also are on record in which fatal secondary haemorrhage has oc- curred from an incised isthmus. Its division, therefore, when it is at all developed, is always a serious proceed ing, and may precipitate a crisis at a time when, especially, deliberation and caution are needed. The possible presence of a large crico-thyroid branch, or of the superior thyroid running abnormally across the crico-thyroid space, is to be borne in mind if an incision is to be made in it. 168 Tracheotomy, Tracheotomy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The inferior pretracheal space, the space extending from the lower margin of the isthmus of the thyroid to the sternum, is much deeper than the superior space in which, as has been seen, the superficial coverings are closely applied to the anterior face of the larynx and trachea. By the recession of the trachea, which follows the backward trend of the lower cervical and upper dorsal vertebrae, a continually increasing distance is pro- duced between its anterior surface and the superficial coverings which roof it over. On either side this space is walled in by tlie sheaths of the great vessels of the neck, above it is closed by the blending of the superficial layers with the envelope of the thyroid gland, its floor is the anterior face of the vertebral column, and below it is continuous with the anterior mediastinum. It is filled with loose connective and adipose tissue, contain- ing some small lymphatic glands, and affording a bed in which ramify the vessels of the region. The thymus gland may still extend up into it from the mediastinum, and occasionally may be of sufficient size to embarrass attempts to uncover the trachea in this space. In the course of an operation for tracheotomy in croup, as soon as this space is opened by the tearing of the intermuscular fascia and the retraction of the muscles, the alternate sinking in and thrusting up of the loose tissue of this space, as the labored efforts at inspiration cause them to be sucked down behind the sternum and then projected again up into the wound at each expiration, constitutes a serious embarrassment to deliberate and certain incision of the trachea ; a special retractor to depress toward the sternum this loose tissue greatly facilitates manoeuvres in this space. The vessels which are normally present in this space are the branches of the inferior thyroid venous plexus. The number, arrangement, and size of the trunks of this plexus are subject to great variations. Fig. 3963 shows the typical arrangement in which the radicles from the various parts of the thyroid gland converge to a common trunk, which passes downward vertically in the median line in front of the trachea, and empties into the great transverse innominate vein at its centre. In some cases the inferior thyroid veins form lateral trunks which pass downward on either side of the tra- chea, and leave the middle line free from vessels. Just below the lower boundary of this space, crossing from left to right, is the great transverse or left innom- inate vein. Normally its upper margin is on a level with the sternal notch, its lower crossing the origins of the arteries which rise from the arch of the aorta. Its possible elevation above the level of the sternal notch, particularly when the head is extended, should be borne in mind. The innominate artery so frequently rises up into the lower part of the pretracheal space that its pres- ence there can hardly be considered an abnormality. My own dissections have shown this to be of greater relative frequency in young children than in adults. Burns's ob- servation was that in early infancy the innominate artery seldom turns to the side of the trachea lower than a fourth to a half inch above the chest. He has seen it mounting so high in front of the trachea as to reach the lower border of the thyroid gland. The close proximity of this artery has been often recognized by many operators during the operation of tracheotomy, being seen or felt pulsating at the lower angle of the wound. It has repeatedly been opened by ulceration from the pressure of the cannula upon it, causing fatal haemorrhage. Delay on the part of the innominate in crossing the trachea may bring the right carotid artery also in relation to its anterior surface. Burns records that in a boy, twelve years of age, he found the right carotid ascending in front of the trachea for two and a half inches above the top of the sternum before it passed to the side. Many variations in the branches which arise from the arch of the aorta have been met with, some of which cause the front of the trachea above the sternum to be crossed by large arterial trunks. A middle thyroid artery, arteria thyroidea ima, ascend- ing vertically in front of the trachea up to the thyroid gland, is found, according to Neubauer, in one out of every ten cases. It is derived from the arch of the aorta, or the innominate usually. Irregular origins from other of the great vessels at the root of the neck have been noted. Blandin states that he has seen a middle thyroid vessel as large as the radial artery. Burns records four cases in which the innominate artery, when on a level with the sternum, just before bifurcating, gave off from its left side a branch about the size of a crow-quill, which soon divided into two main branches and then broke up into a number of twigs which ascended along the front of the trachea to the thyroid gland in such a manner that there was hardly a single point of the trachea into which an incision could be made without dividing some of the pretty large twigs of the vessel. The inferior thyroid arteries occasionally take an abnormal course, in which one of them crosses in front of the trachea. From this presentation of the varying vascular con- ditions in the pretracheal space, it is evident that the greatest caution should be used in attempting to ap- proach the trachea through it. There is no line of safety to be preserved. Whatever freedom from other compli- cations may be present, the presence at least of an im- portant venous plexus, covering the trachea in the mid- dle line, will demand special precautions for its avoidance, except in occasional instances. In addition to the dangers and difficulties which the haemorrhage from a wound of this plexus occasions, the additional peril of entrance of air into the heart through them has been found to be no chimera. A case of this kind has been reported by Parise.60 While doing tracheotomy for diphtheritic croup in a girl, five years old, after having made the usual incisions, wishing to uncover more fully the trachea, which was covered by an unusually large thyroid isthmus, this surgeon wounded the left branch of the middle thy- roid vein near its junction with that from the right side ; copious haemorrhage resulted. In the effort to seize the trunk of the vein to tie it, the superficial wall only was seized and raised up, which rendered the vein patent for the moment, during which a strong inspiration took place, a sharp hiss was heard, and instant death followed without a cry or struggle. Upon autopsy air was found in the right cavities of the heart. The loose character of the connective tissue which fills the pretracheal space permits great mobility to the trachea both vertically and from side to side. To this mobility is due the mischance, which has happened to some op- erators, to miss the trachea altogether, by reason of its having been pulled to one side from the line of incision, and to continue their dissection until arrested by the ver- tebral column. This lax connective-tissue envelope also permits the burrowing of the tube in front or at the side of the trachea when unskilful or hasty attempts at its in- troduction are made while the lips of the tracheal incision are not properly retracted, and the field of operation is covered with blood. This tissue also favors the burrow- ing of pus downward into the anterior mediastinum in certain cases. On account of this looseness of the peritracheal tissue the trachea can be lifted up from its bed and brought near to the surface when once it has been exposed. If a pair of catch-forceps, like the pinces hwmostatiques of Pean, be fastened on either side into the layer of fascia that has been torn away from the front of the trachea, and then be permitted to fall outward to the side of the neck, by their own weight they will both lift up the trachea and depress the side walls of the pretracheal space so that the tube is rendered quite superficial, its in- cision and exploration being thus greatly facilitated. All the tissues in front of the laryngo-tracheal tube in the neck have now been passed in review. Some points as to the tube itself remain for consideration. In the child the thyroid cartilage is relatively little developed, and its upper border rises up behind the body of the hyoid bone, which obscures it except when the head is extended. The outlines of the thyroid cartilage cannot be clearly made out through the overlying tissues. The resistant outline of the cricoid cartilage, however, can always be recognized through the skin in children. The distance between the hyoid bone and the cricoid cartilage 169 Tracheotomy. Tracheotomy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. in a child three or four years of age is about one centi- metre ; this space may be more than doubled by bending the head strongly backward. The relatively small size of the larynx in children persists until the time of pu- berty, so that the difference in size between the larynx of a child of three years and one of twelve is small, and cannot be estimated by the difference in stature. The result of this is that the cricoid cartilage is always placed relatively high in the neck of a child, and, as its position determines the position of the isthmus of the thyroid, the space between the lower border of the gland and the sternum is relatively large. As the larynx, however, begins to evolve at puberty, the cricoid cartilage is de- pressed, the thyroid gland descends along with it, and the comparative distance between the gland and the sternum is lessened in the adult. These points are especially noted by Burns in his work on " The Surgical Anatomy of the Neck," who drew from them inferences in favor of incising the trachea in children below the isthmus. Tillaux gives a table of the distances between the cricoid cartilage and the sternum in thirty-one chil- dren between the ages of two and a half and ten years. The average for those between two and three years is three and a half centimetres (1$ in.); for those between three and six years, four centimetres (1-^ in.); and for those between six and ten years, about five centimetres (2 in.) ; while the average distance in twenty-four adults was but six and a half centimetres (2^ in.), the shortest being four and a half, and the longest eight and a half. I have myself often felt surprised to find in very young children upon whom I have had occasion to operate, quite as much room in the pretracheal space as in children much older, while I have experienced great difficulty in exposing the trachea below the isthmus in adults with short necks. As far as the trachea itself is concerned, an incision below the isthmus is certainly favored in chil- dren, for the younger the subject the less room there is above the thyroid isthmus, and the more room, relatively, there is below it for gaining access to the air-tube. The greater depth, and the varying vascular net-works that are found in front of it in the pretracheal space, however, increase materially the dangers of attempts to reach it here. If, however, these difficulties can be met by skil- ful and deliberate manipulation, the question of what particular point should be chosen for the incision ought to be decided less on the score of operative difficulties than on that of therapeutic value. As a rule, the anatomical difficulties which the low operation involves may be so controlled as to make it safe and facile. If, however, on exposure of the con- tents of the pretracheal space, it is apparent that great peril would be incurred by persevering in the attempt to reach the trachea through it, prolongation of the incision upward, so as to expose the space above the isthmus, is always possible. The cricoid cartilage, being the most easily and cer- tainly identifiable point along the laryngo-tracheal tube from the outside in children, becomes the most important landmark in the anterior median region of the neck by which to determine the first incisions for tracheotomy. If laryngo-tracheotomy, or tracheotomy through the upper rings by depressing the isthmus, is chosen, the cricoid prominence should fall midway in the incisions ; if the low operation is to be done, the incision, beginning above over the cricoid, should extend downward from it to the sternum. The tracheal rings form by their association an irregu- larly rounded canal whose volume varies little through- out its cervical portion. They can always be easily cut, and their longitudinal section makes a wound which can be dilated without difficulty, but which returns to itself as soon as the dilatation ceases, facilitating thus the heal- ing of the incisions of tracheotomy. The elastic and compressible nature of the tracheal rings in young chil- dren may be the occasion of a serious complication, em- barrassing the last steps of an operation for tracheotomy. In conditions of laryngeal stenosis the force of the atmos- pheric pressure upon the parts at the outlet of the thorax is extreme, and is supported by the musculo-aponeurotic covering which is stretched over the trachea from cricoid to sternum, secured, as it is, along the sides to the sterno- cleido-mastoid muscles. After this protective covering has been incised the tissues beneath are exposed to the force of the atmospheric pressure. The sucking down- ward behind the sternum of the loose pretracheal con- nective tissue has already been noted ; the trachea is affected by the same pressure, and in children, in whom the walls of the tube are much less resistant than in adults, it may be so flattened by the retraction or insuck- ing of its anterior wall that the already scanty supply of air to the lungs is materially diminished and the symp- toms of impending asphyxia become alarmingly aggra- vated. The more intense are the obstructive symptoms previous to the operation, the greater is the liability to peril from this cause, and the more likely is a crisis to occur in which instantaneous opening of the trachea at any hazard is demanded. The mucous membrane of the trachea receives from the inferior thyroid arteries vessels which may acquire in the adult some development, and even in children afford a vascular supply to this membrane that requires notice in a surgical point of view, in consequence of the haemorrhage which they occasion in tracheotomy when the trachea is incised. However perfectly bleeding may have been arrested before the trachea is opened, some haemorrhage will take place at this time, the blood flow- ing into the tube and occasioning the violent spasm of coughing which occurs when the trachea is opened. The impression has been usual that this paroxysm of cough is caused by the stimulating effect of the sudden free ac- cess of the air to the interior of the trachea. The idea that it is in fact caused by the entrance of blood into the tube is advanced by Tillaux, who supports it by an ob- servation, communicated to the Surgical Society of Paris, in 1874, of a case in which, the trachea having been opened in an adult by the use of the thermo-cautery, there was not a drop of blood shed ; when the trachea was opened no cough followed, and those present, not hearing the char- acteristic sound, could not believe the operation finished. Burns quotes a case in point from Sabatier, in which a soldier, having suffered tracheotomy for the relief of wsuffocative laryngitis, was so tormented by a convulsive cough produced by blood falling into the trachea that it was impossible to keep the cannula in place. Relief was finally obtained by turning him upon his face until the blood ceased to flow. The patient ultimately recovered. Haemorrhage from this source is usually insignificant in its amount, and is speedily arrested by the pressure of the cannula when inserted. The diameter of the interior of the tube is to be con- sidered with reference to the size of the cannula to be used after tracheotomy. The special conditions which chil- dren present after tracheotomy for croup, by the con- tinual accumulation in the tube of tenacious mucus, makes it desirable that, in such cases, tubes of as large a calibre as possible be used. The measurements of Til- laux,61 Marsh,62 and Weinberg63 show that, though there is a gradually increasing average diameter of the trachea with increasing age in children, there are yet many va- riations among those of the same age, and that a smaller diameter among older ones than that of some of the younger ones is not uncommon. The average diameter of thirty-eight different tracheae, taken from children whose ages ranged from four months to five years, was about six and a half millimetres (J in.), the least having been four millimetres, in a child of two years, and the greatest nine, in a child of five years. The average diameter of the adult trachea is sixteen millime- tres (fin.) in the male, and thirteen millimetres (f in.) in the female. In practice I have found that the trachea in small children will admit tubes larger than the measure- ments above given would indicate. Among my first cases of tracheotomy was an infant of thirteen months, whose trachea received readily a tube seven and a half milli- metres (-^ in.) in diameter, and in no case since that time have I found it necessary to employ a smaller tube. The Different Laryngo-tracheal Incisions.-Ac- cording to the indications which a special case may pre- 170 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tracheotomy. Tracheotomy. sent, the air-tube should be opened at a higher or lower point of its course. Operations which involve incision through some part or all of the larynx come under the general class of laryngotomy ; those involving the trachea alone, tracheotomy ; those involving both, laryngo-trache- otomy. Laryngotomy.-Incision of the larynx may be partial or total. If it involve only the thyroid cartilage it is des- ignated as thyrotomy ; if the cricoid cartilage, cricotomy; if the cricothyroid membrane, intercrico-thyrotomy. Laryngotomy is indicated whenever it is necessary to gain access to the cav- ity of the larynx for the relief of conditions that resist operative attacks through the mouth. These conditions include impacted foreign bodies, certain wounds of the larynx, strictures, some cases of acute perichondritis for removal of ne- crosed cartilages, and, lastly, tumors of the larynx. Intercrico-thyrotomy and cricotomy may be resorted to for the relief of urgent and sudden suffo- cative symptoms that demand haste. The extent and the superficial position of the crico-thyroid membrane in adults, and the ease with which its position may be recognized just above the rigid and prominent cricoid ring, render its opening by a quick plunge of a knife, in cases of emergency, easy and comparatively safe, even in in- experienced hands. In many cases, laryngotomy will have already been preceded by tracheotomy, done for the immediate re- lief of suffocative symptoms caused by the laryngeal con- ditions ; when it is expected that the work within the larynx will be accompa- nied with consider- able haemorrhage, as in the removal of multiple or ses- sile growths, pre- liminary tracheot- omy is desirable. In general, it may be said that section of the thy- roid cartilage is to be avoided if the necessary end can be gained by a sec- tion restricted to the lower struct- ures of the larynx, because of the sub- sequent impair- ment of the voice which must fol- low the cicatricial agglutination o f the anterior part of the vocal bands, which is inevita- ble to some extent after thyrotomy. The conditions of each case must, of course, determine the decision of the operator at the time as to the ex- tent of the divis- ion of the laryn- geal structures which he must make. Division of the crico thyroid ligament and of the cricoid cartilage will be found sufficient for the removal of many laryngeal polypi and subglottic growths ; dislocated fragments, in cases of fractures of the cartilages of the larynx, may be readied and manipulated into position through such an indsion ; necrosed cartilaginous fragments ami impacted foreign bodies may likewise be removed thereby. If more room is desired than the partial laryngotomy affords, the prolongation downward of the incision through as many of the upper rings of the trachea as is necesssary may suffice, and is to be preferred to total splitting of the thyroid. When, as the result of the condition for which the operation is to be performed, the vocal apparatus has already been irretrievably dam- aged, the surgeon may split the thy- roid cartilage throughout its whole extent with- out hesitation, if it may seem desirable in order to render his work more fa- cile and radical. T RACHEOTOMY. -Incisions of the trachea are classi- fied according to their relation to the isthmus of the thyroid gland. If above the isthmus, the incision is tra- cheotomia superi- or, or the high op- eration ; if below, it is tracheotomia inferior, or the low operation; if be- hind the isthmus, it is tracheotomia media, or the middle opera- tion. Superior Tracheotomy.- The first ring of the trachea being the only one usually exposed above the isthmus, it is evident that sufficient room for a satisfactory open- ing into the air-tube can be gained only by drawing the isthmus down so as to ex- pose the rings behind it, or by extending the cut up- ward through the cricoid cartilage. The extent to which the isthmus must be depressed so as to permit the introduction of a cannula is shown in the accompanying- life-size plate, displaying a vertical mesial section of the neck of a child twro years of age. It is reproduced from a plate by Symington.64 The dotted outlines of the can- nula in place have been add- ed for the purpose of bring- ingoutclearly thcirrelations to the various parts when in in situ. It is quite easy to depress the isthmus to the extent required by separat- ing its capsule above, as already pointed out in the preceding section on Ana- tomical Considerations. When this is done, however, the incision has practically been made behind the isth- mus, and falls into the category of the middle operation. Sufficient room is more frequently obtained by ex Fig. 3964.-Vertical Mesial Section of Neck of Child Two Years of Age; life-size, a, Isthmus of thyroid; b, innominate artery; c, left innominate vein ; dotted lines show position of tracheal cannula in high and low operations respectively. (Modi- fied from Symington.) 171 Tracheotomy. Tracheotom y. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tending the incision upward through the cricoid carti- lage. In young children the softness and elasticity of the cricoid make easy its incision and the separation of the parts so as to admit of the introduction of a cannula. The high operation, therefore, is to be considered as a crico-tracheotomy. Such an operation has a very con- siderable field for its employment. In general, wdien- ever the air-tube must be opened in haste, or by an inex- perienced operator, the high operation is to be chosen. The operative difficulties are less, the parts are more superficial, there is less likelihood of the field being occu- pied by blood-vessels which would embarrass the opera- tion by being wounded. In young children the cricoid cartilage is the most prominent and easily identified struct- ure of the air-tube, and presents a landmark which can be recognized quickly, and as quickly and certainly ex- posed by the knife of the surgeon. When the imminence of suffocation is such as to demand haste in opening the trachea, every other consideration must for the time be held in abeyance; the dangers of haemorrhage and the relative advantage in the after-history of the case of this or that point of incision into the trachea have to be dis- regarded. Crico-tracheotomy is the operation to be done under such circumstances, on account of the reasons just given. The objections against the general selection of the high incision, when opportunity for choice is present, are as follows: 1. The nearness of the vocal apparatus and the dangers of the extension to it from the wound of inflammatory or necrotic processes, so as to perma- nently impair it in case of recovery. 2. The impairment of the intercrico-thyroidean movements, resulting from the contraction and stiffness of the cicatrix of the opera- tion-wround, and the modification of the voice resulting therefrom. 3. The inelasticity of the cricoid cartilage as compared with the tracheal cartilages, owing to the thick, expanded, cartilaginous mass wdiich forms its posterior portion, instead of the simple membrane of the latter. On this account a tube is less easily borne, and necrosis from pressure is more likely to occur. 4. The greater liability to the development of intralaryngeal granula- tion-vegetations, and the greater peril from such vegeta- tions at a point so near the glottic" orifice. (See subse- quent section on this point.) 5. The greater narrowness of the lumen of the cricoid ring, as compared with the trachea below, necessitates a greater separation of its halves, after division, to admit of a sufficiently large cannula, and a consequent aggravation of the objections already mentioned in No. 3. 6. The shield of the cannula, after it has been introduced, lies so high in the neck, in children, that it is often pressed upon by the chin in flexion of the head and in deglutition, so that an unde- sirable complication is introduced into the after-treatment of the case. 7. As already noted in the sections devoted to the indications for tracheotomy, in the great majority of instances in which the operation is called for it is de- sirable to open the trachea at as low a point as can safely be done. The high operation, therefore, is contraindi- cated in these cases, except under stress of haste or inex- perience. The force of the first four of the objections enumerated is not great enough to deter from the operation where good reasons exist for its adoption. In one instance in wdiich I performed crico-tracheotomy-a child of thirteen months, and in which the tube remained in use for six months before it could be dispensed with-the cry re- mained hoarse, and any cough would be croupy for a long time thereafter. Now, at the end of twelve years, the child has become a well-grown boy with a voice which, though husky, would not attract special attention from any peculiarity about it. In another case, in wdiich I was compelled to operate twice within a few weeks, and after the second operation to retain a tube in the trachea for sixteen days, no permanent damage to the voice re- sulted. In another case necrosis of a portion of the cricoid and thyroid cartilages did take place, but death from asthenia, on the eighteenth day, made the occurrence of no special moment in the case. This case wdll again be referred to in the section devoted to after-treatment. De Saint-Germain,66 Surgeon to the Hospital for Sick Children of Paris, is a warm partisan of crico-tracheotomy in diphtheritic croup-out of 309 operations reported by him in 1882, 69 recoveries were secured, and all but one of the patients speak admirably. In one the cannula has never been dispensed with. Fleiner,6' from an exami- nation of sixty-five cases of stenosis of the trachea fol- lowing tracheotomy, compiled from literature, and of six more cases which came under his personal observation in the Heidelberg Clinic, states that the greater number of these stenoses developed in the region of the cricoid cartilage, and therefore contribute a reason against in- cising the cricoid. Mneukomm61 reports that out of 81 recoveries after tracheotomy for diphtheria in the Zurich Surgical Clinic, from 1881 to 1885, the total number of operations having been 203, one end of the cricoid carti- lage stood out over the other in four cases, and in eight there was some vocal disturbance-long-continued hoarse- ness or cough, or loss of power in the otherwise clear voice ; a few showed insuflicience of the vocal cords, and three became short of breath on overexertion. Two had died from later laryngeal stenosis. The force of the fifth objection, as given above, may be lessened by altering the shield. The ordinary tracheal cannula is widened at its centre by quite a projection up- ward of its upper border so as to accommodate the key by which the inner cannula is locked in place (see Fig. 3971). By placing the key at the side, as in the German model (Fig. 3972), this upward projection of the upper border of the shield can be dispensed with, and a form given to it which will be more easily borne by a patient in whom a high operation has been done. Median Tracheotomy.-An incision into that part of the trachea usually covered by the isthmus of the thyroid gland constitutes median tracheotomy. The trachea rftay be exposed at this point either by pulling it down from above, after loosening its attachments, or by cutting directly through the overlying isthmus. In occasional instances the isthmus is wanting altogether, in which cases the median incision becomes a very simple matter. In cases where, from the shortness of the neck, the exist- ence of large blood-vessels overlying the trachea imme- diately below the isthmus, the unusual development of the isthmus, or from the persistence of the thymus gland, the exposure of the trachea below the isthmus is difficult or extra-hazardous, the median incision is to be chosen. The method of gaining access to the trachea by de- pressing the isthmus is to be preferred and should be tried ; if it is found impracticable or insufficient, the isthmus must be severed. Haemorrhage is the one com- plication to be guarded against when the isthmus is in- cised. It may be sufficient of itself to compromise life. The varying vascular conditions which may exist have been described in a previous section. A more common source of embarrassment is the manner in which the flow of blood obscures the final incision into the trachea, and causes this important step to be taken blindly and hastily, and to be followed by the immediate introduction of a cannula instead of it being done with a clear field and deliberately, and followed by careful inspection of the conditions within the trachea, and by the toilet of the trachea before the tube is inserted. The section of the isthmus by the thermo cautery knife has been practised for the purpose of avoiding haemorrhage, and is greatly praised by those who have used it (Krishaber,68 Boeckel,59 Poinsot,60 Fowler61). For the same purpose a double ligature may be passed beneath the isthmus by means of an aneurism-needle and the isthmus thus be ligatured en masse, one ligature on each side of the median line, fol- lowed by a cut between the two. Inferior Tracheotomy.-In most of the conditions for which tracheotomy is required the low incision is prefer- able. In stenosis from diphtheritic laryngitis, in cases of foreign bodies in the air-passages (unless there is good evidence that the body is fixed in the larynx or high up in the trachea), in many cases of chronic laryngeal dis- ease, in cases of stenosis of the trachea, and in cases of preliminary opening of the trachea to facilitate operations upon the larynx, it is desirable to make the opening into the trachea at some distance below the larynx. The re- 172 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tracheotomy. Tracheotomy. cession of the trachea from the surface, and the plexus of blood-vessels in the deep pretracheal space overlying the trachea, make the operation more deli- cate, and one requiring more delibera- tion and experience for its proper and safe performance than the higher opera- tions, but with care and attention to the special operative details which the par- ticular conditions of the region demand, the trachea below the isthmus may gen- erally be easily, expeditiously, and safe- ly exposed. Operative Technique ; Instru- ments.-The list of instruments which experience has shown me to be desir- able to have at hand to facilitate the various steps of a tracheotomy com- prises a small scalpel; a small, probe- pointed, curved bistoury ; a director ; a half-dozen pairs of haemostatic forceps ; two pairs of anatomical forceps ; suita- ble retractors for depressing the supra- sternal tissues and for elevating the isthmus ; an aneurism-needle for possi- ble use in ligating the isthmus ; a small, sharp, double hook for fixing and steadying the trachea when it is about to be incised; a pair of blunt double- hook retractors for dilating the tracheal wound; a pair of curved forceps for in- troduction into the trachea, and, finally, a tracheal cannula. Equipped with these instruments, the surgeon will find himself prepared to cope with any emergency likely to arise in the course of the operation, and by their proper use he can make himself to a great degree independent of assist- ants. I attach great importance to the help to be obtained from the haemostatic forceps, after the model of P6an, Koeberle, or Wells. By these it is possible, not only to control all haemorrhage with facility and without loss of time, but also to automatically retract the di- vided tissues, as the dissection progresses, by fixing them in the deeper parts exposed and causing them to fall outward over the edges of the incision upon the sides of the neck. Finally, when the trachea is reached, they may be fixed in the fascia that envelopes it, and as they fall outward by their own weight they will so elevate it from its bed and press back the wound surfaces on either side that the trachea will be made quite superficial. The suprasternal retractor (Fig. 3965) is an- other simple device which has given me very great help whenever operating without assist- ance. It is for use in retracting the tissues at the lower angle of the wound, and may be em- ployed to obviate the difficulty arising from the mobility of the mediastinal connective tis- sue, which in labored respiration is alternately sucked down behind the sternum and then thrust up again in front of the trachea to an embarrassing degree when the deeper pretra- cheal space has been exposed. As shown in the illustration, it is a retractor with a shield- like curved portion at one end, broad enough to confine and protect the tumultuously mov- ing tissues at the lower angle of the wound, having a shaft well arched, so as to clear the projecting upper border of the sternum, and terminating in a sharp double hook, which is to be fixed in the integument over the ster- num. When used, the broad retractor is first to be adjusted in place ; then as the hooks fall over upon the skin over the sternum below, this skin should be pushed upward so that when the hooks are fixed in it and the skin is relaxed the tension of the skin glid- ing back to its place will securely hold the retractor in situ. The retractor for elevating the isthmus is shown in Fig. 3966. By it the lower border of the isthmus may be drawn up from the field of operatiort and a more extended exposure of the trachea effected, while it also protects the isthmus from acci- dental wound from the knife when the trachea is incised. It may be used also for pulling down the isth- mus in the higher sections. The trachea fixation hook (Fig. 3967) may be the ordinary fixation hook of the oculists, but a little greater strength of shank and of hooks will be found desirable. It is to be used after the trachea has been exposed, when the anterior wall of the trachea should be hooked up by it and steadied, while the puncture with the scalpel is made. If sec- tions of the cartilages are to be cut out, this hook may be fixed in the portion to be removed, which is held by it while being cut away by the knife or scissors. The tracheal wound retractors, the model of which is shown in Fig. 3968, greatly assist the final steps of the operation, after the trachea has been incised. Two of the retractors are needed, one for each side. Their blunt, hooked extremities are in- serted into the incision, and by trac- tion upon them the tracheal wound is held open for the inspection and cleansing of the interior of the tra- chea, and, finally, they permit the cannula to be readily passed in be- tween them, and may be removed when the latter is fairly settled in its place. It is especially to be noted that the prongs of this retractor should be blunt, and that they should not be too much curved ; they are intended to act simply upon the cut edges of the tracheal wound to retract them; if their points are sharp they will wound the mucous membrane within the trachea, and if they are too much curved their points will press unduly upon the lateral walls of the trachea within when traction is at- tempted. The figure, which is two-thirds the size of the actual instrument, shows the proper curve. Of the many automatic retractors which have been devised for keeping the tracheal wound open by the action of springs and screws, there is none whose merits seem to me to be worthy of description. The two-bladed dilating forceps of Trousseau, and the three-bladed instrument of Delaborde, are well known, Fig. 3965.-Automa- t i c Suprasternal Retractor ; full size. Fig. 3967.- Tra chea Fixation Hook. Fig. 3968.- T r a cheal W o u n d Retractor. and have been much used, but have no place in the methods of operating advocated here. The latter instru- ment sometimes finds a field for use in the later history of a tracheotomy, when, after an attempt at dispensing with the cannula, it is found necessary to replace it. In such a case the collapsed sinus for the cannula may often be conveniently dilated again by the insertion of the three-bladed dilator so as to permit the ready reintroduc- tion of the tube. Fig. 39(59.-Tracheal Exploring Forceps. (Model of Collin.) Fig. 3966. -Isthmus Retractor. 173 Tracheotomy. Tracheotomy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Exploring Forceps.-A slender, curved forceps (Fig. 3969), which may be introduced into the trachea through the incision directly, or through the cannula if it has been put in place (see Fig. 3970), should be at hand for the purpose of seizing and withdrawing portions of exfoli- ating membrane or other foreign material that may be obstructing the trachea. Armed with a bit of sponge, it which is made of a nai'row silver band spirally wound so as to form a flexible tube. This flexibility renders it easy of introduction, and of accommodation to the often some- what tortuous course of the trachea in such cases. As regards the ordinary cannula for general use, some further observations should be made, in the way of es- tablishing standards for the guidance of the instrument- maker in manufacturing, as well as for the surgeon in selecting an instrument. The Material for the Tube.-Silver or aluminum is pref- erable as the material to use in making the tubes. Hard rubber is objectionable because of the necessarily greater thickness of the walls, which is secured at the expense of the lumen of the tube. Time and use also render the rubber brittle, so that the danger of the tube breaking away from the shield and slipping down into the trachea is created. The calibre of the tube relatively to the size of the trachea is not the same in all cases. In adults the trachea is so capacious that a tube con- siderably narrower than the lu- men of the trachea will suffice in most cases. The average diameter of the male adult tra- chea is 16 mm., and of the fe- male 13 mm., but 10 mm. will^^^^^ be found abundantly large enough for the largest-sized cannula that will be required in any case. Indeed, in most cases 8 mm. will suffice. For children the tube should be as wide as possible, without stretching the tra- chea ; not that a tube of less calibre would not suffice if it remained unobstructed, but because the accumulation of mucus along its interior is so likely to take place that the full capacity of the tube for the transmission of air is never to be depended upon. The membranous pos- terior wall of the trachea admits of some stretching, so that a tube of larger calibre than the measurements of the infantile trachea would indicate can usually be introduced with- out difficulty. A silver tube whose outside diameter is 6.5 mm. will give a diameter of 5 mm. to the interior of its inner tube. This will answer every requirement of children from three to ten years of age, and will be easily admitted into the trachea of many chil- dren as young as eighteen months. For very young infants, and for exceptionally narrow tracheae in other cases, a tube whose outside diameter is 5 mm. is desirable. Only four different diameters, therefore, are needed to answer the varying requirements of all ages-viz., 10, 8, 6.5, and 5 millimetres re- spectively. The length of the tube should also be consid- ered. The tube should penetrate the trachea sufficiently to insure against its slipping out- side of it in efforts at coughing, or in the move- ments of the neck, or in consequence of any swelling of the outside tissues that may super- vene, while at the same time it should not penetrate too deeply, lest the greater excursions of the point in move- ments of the tube produce undesirable pressure-effects. Passavant64 recommends a penetration into the trachea of from 10 to 12 mm. in children, and of 15 mm. in adults, measuring from the lower angle of the tracheal cut. My experience convinces me that a little greater penetration is preferable, and I would advise as a standard, 12 mm. for children and 16 mm. for adults. Inasmuch as the dis- tance from the skin-surface against which the shield of the tube should rest will vary according to the point of the larynx or trachea that has been cut, upon the leanness or plumpness of the neck, and upon the greater or less amount of wound-infiltration present, it is obvious that the length required for the extratracheal portion of the tube will vary in different cases, and at different times in the same case. When the high operation has been done, a shorter tube is needed than in cases of the low operation. Fig. 3970.-Collin's Forceps introduced through the Tracheal Cannula. may serve as a swab to more thoroughly clean out the trachea from mucus and debris. The Cannula.-In most instances in which tracheotomy has been done, some kind of a cannula will be indispen- sable in the after-treatment of the case, to prevent the premature closure of the new respiratory orifice. The model which in general gives best satisfaction is a curved double tube, approximating the quadrant of a circle, which is loosely attached at its outer end to an expanded shield-like plate, to which tapes may be fastened to secure it in place. When this plate is fixed, the tube in the trachea is allowed to move to a considerable extent, to ac- commodate itself to the movements of the parts. Fig. 3971 shows the cannula as usually found in the instrument- shops. It is, however, open to some objections which will appear in the course of this discussion. Dr. Fuller,62 of London, has recommended making the outer tube of two blades, like a bivalve speculum, which may be ap- proximated by the finger and thumb during the introduc- tion of the instrument, and are afterward kept apart by the insertion of the usual complete inner tube. This bivalve feature is, however, entirely superfluous as far as the in- troduction of the instrument is concerned, and is attended Fig. 3971. Fig. 3972. Fig. 3971.-Tracheal Cannula. Ordinary model. Fig. 3972.-Tracheal Cannula. Passavant's model; actual size. Fig. 3973. -Konig'a Cannula. with serious objections in other respects, and is not to be recommended. Mr. Durham,62 of London, has advocated a form of cannula in which that portion of the tube which is outside of the trachea is elongated, and a sliding ad- justable collar is adapted to it. The distal portion of the inner tube is made of several small pieces jointed together in the " lobster-tail" fashion, so that it may pass into its place. The contrivance is a complicated one, is impossi- ble to keep clean, and is inconvenient for prolonged use on account of the way in which it projects upon the surface of the neck. It is mentioned here, together with the tube of Fuller, only because they have both been prominently brought before the profession as desirable models-an opinion from which I strongly dissent. In cases of ob- struction from the pressure of a goitrous tumor, if the trachea has to be opened above the affected portion, it is necessary to use a cannula whose tracheal portion is elongated so as to pass beyond the place of stenosis. The cannula of Konig63 (Fig. 3973) is adapted to such cases. As shown in the illustration, it is lengthened by a portion 174 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tracheotomy. Tracheotomy. Frequently tlie inflammatory swelling which takes place in the borders of the operation-wound will greatly increase the depth between the trachea and the skin-surface. It is impossible to use mathematical exactness in prescribing just so many millimetres of length to each case with its varying phases; we have to be content with a general ap- proximation. It is desirable that two different lengths of each of the sizes recommended for the tubes be acces- sible to the surgeon. The measurements are to be made upon the concave under-surface of the tube, and for chil- dren should be 18 mm. for the short tube and 24 mm. for the long one, while for adults 24 mm. for the short and 34 mm. for the long should be allowed. The Curve of the Tube.-The careful measurementsand calculations of Passavant have established definite stand- ards for the curve of the tube, which, I think, deserve to be generally accepted in the manufacture of tracheal cannulae. They are as follows : For infants the tube should be the segment of a circle whose radius, calcu- lated from the concave side of the tube, is 19 mm.; the radius of the next larger size should be 21 mm., of the next, 24 mm., and of the largest adult size, 29 mm. For general use, therefore, four sizes of tubes are desirable, differing in their calibre and curve; and of each size, two different lengths. Let these sizes be de- noted respectively by the letters A, B, C, and D, and their dimensions may be presented in tabular form as follows: Measurements for Tracheal Cannulas. jecting from the lower aperture of the inner tube, is desirable for use during the after-treatment of a case of tracheotomy. Its use facilitates the reintroduction of a tube, and diminishes to a minimum the dangers of ex- coriations and lacerations which are often produced by attempts to introduce without such aid a tube through a partially collapsed channel. The fenestrum, which is commonly put at about the centre of the convexity of the outer tube is usually un- desirable, and should not be present in the ordinary tube. Where it is commonly placed it lies partly outside of the lumen of the trachea, and permits the soft tissues lining the cannula-sinus to press into it whenever the inner tube is removed, so that often, when the inner tube is replaced, it shaves off a slice of the protruding granulations. Its supposed value in facilitating the early appreciation of ability to breath through the glottis is fanciful. The ' ' iodoform tampon cannula " is a modification of the ordinary cannula recommended by Roser,65 of Marburg, for the purpose of preventing the descent of irritating or infectious materials from the interior of the trachea above the cannula, and to render aseptic the portion of the trachea with which it is in contact. The device con- sists simply in wrapping round the cannula a strip of gauze moistened in a sublimate solution, about two-thirds of an inch wide and three inches long, and rubbing pow- dered iodoform into it while yet moist. When it dries, the gauze forms a smooth, hard envelope, surrounding the cannula and extending from near its extremity to the guard. When the tube, thus covered with iodoform gauze, is inserted into the trachea, it absorbs moisture, becomes soft, and completely fills the lumen. The custom at Marburg is to leave the first cannula in place for at least two days, and then to substitute for it another, prepared in a like manner. After five days it is believed that there is no longer danger of secondary infection of the trachea, and no specially prepared cannula is needed ; in fact, no cannula at all is needed if the larynx is clear. Roser believes that this method of mod- ifying the ordinary tracheotomy tube is of service even when the trachea is already implicated in a diphtheritic process. Out of forty-seven operations for the relief of diphtheritic laryngitis thus treated at Marburg, the mor- tality was only forty-seven per cent. Anesthetics.-Except in cases where more or less complete insensibility is already developed from asphyxia, an anaesthetic should be given. Anaesthesia not only robs the operation of much of its terror to the patient and to the friends, but it greatly assists the surgeon in en- abling him to exercise the desired care and thoroughness in all the steps of the operation. If laryngeal spasm is complicating the case and increasing the dyspnoea, the anaesthetic will allay it, and will improve the breathing; if, on the other hand, the respiration has been carried on largely by the help of the voluntary muscular efforts of the patient, which is the case in ad- vanced stenosis from any cause, the anaes- thetic, by the suspension of the voluntary ef- forts which it determines, will immediately aggravate the asphyxiative symptoms, and precipitate the necessity for immediate open- ing of the trachea. An anaesthetic should therefore be given with caution ;• but little will usually be required, and it need not be pushed to the full degree considered desirable for most surgical op- erations. Chloroform is to be preferred, as less irritat- ing to the air-passages, and especially because its dosage and its effects can be more readily and exactly regulated. Preparations for the Operation. The Table.-A suitable surface on which to place the patient is the first requisite. It should be high enough to make the sur- geon's work convenient, and hard enough to keep the patient's shoulders from sinking down into it. Under no circumstances should the operation be undertaken with the patient lying in bed or in a crib. An ordinary dining or kitchen table answers well. The top of a bureau, if it is not too high, I have repeatedly made use of. A piano is another article that I have utilized, and in many No. of size. Outside diameter of the outer tube. Length of the tube meas- ured upon its concave side from posterior sur- face of shield to lower end. Radius of the concave side of the tube. Short. Long. A mm. 5.0 6.5 8.0 10.0 mm. 30 30 40 40 mm. 36 36 50 50 mm. 19 21 24 29 B C D The shield of the tube should be as narrow as possible, that it may neither embarrass flexion and extension of the head, nor cover too much the wound. The form shown in Fig. 3971 is not so desirable as the one shown in Fig. 3972, in which the lock for securing the inner tube is set at the side instead of at the top, as in the ordi- nary model. The lower end of the tube should have both its anterior Fig. 3974.-Showing the relation of the Inner Tube and of the Obtunder to the Tracheal Cannula. and posterior wall slightly cut away, as shown in Figs. 3972 and 3974 ; and this lower end of the inner tube should project slightly beyond the outer tube when fully down into its place. A suitable obtunder, slightly pro- 175 Tracheotomy. Tracheotomy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. instances I have laid children on the top of the stationary wash-tubs found in the kitchens of city houses. Light.-The more light, the better; but usually the surgeon has no choice, and he must make use of what he can get. If the operation is by daylight the table should be brought close to a window, so that it shall be between the latter and the operator. If the operation is in the night the lamps and candles must be arranged and held so as to especially illuminate the field of operation. A single candle properly held will give light enough, and is preferable to several lamps placed at a distance. More than one light should, if possible, be provided, lest some mischance to the sole light should cause sudden embar- rassment in the course of the operation. Assistants.-Two assistants are desirable, but if the patient is already insensible none is absolutely necessary. If an anaesthetic is. to be given, one assistant is needed to administer it. He will stand at the head of the patient, and will also be able to render all the assistance needed to hold a retractor or ligate a vessel as the operation pro- ceeds. He may possibly also assist with a sponge, but, as a rule, the operator himself can better do his own sponging. The second assistant is needed only at the feet of the patient to hold the legs quiet and prevent un- desirable struggling in case the patient should recover sensibility and should resist be- fore the opera- tion is complet- ed. Any nurse, parent, orfriend is quite compe- tent to act as this second as- sistant. Sponges.- Small squares of old, soft, and absorbent, cot- ton or linen ma- terial, which is always at hand in every house- hold, suffice for sponges. A number of these pieces should be torn and wrung out in hot water, and made ready for use before the beginning of the operation. As fast as one becomes saturated with blood, it is to be thrown away and a fresh one taken. Miscellanea.-Hot water should be at hand for use in arresting persistent oozing of blood which sometimes is met with ; thread for ligating vessels, iodoform for appli- cation to the wound-surfaces, tape for securing the can- nula in position, and a soft catheter or piece of rubber tubing for purposes of insufflation, if it should be neces- sary. A small piece of oiled silk and an ordinary sewing needle, armed with thread, will be needed to complete the final dressing. The Position of the Patient.-Everything being ready, the patient is to be placed in position for the operation. The most important feature of this position is that it shall be one in which the neck of the patient is strongly extended. Upon this point the facility with which the after-steps of the operation may be done will greatly depend. A firm cushion should be placed under the shoulders-not under the neck-so as to lift them up and cause the head to fall back and thus extend the neck as the patient lies on the back (see Fig. 3975). The desired cushion will usually have to be extempo- rized from articles to be found in the sick-room. A small pillow made into a firm roll; a bundle of clothing ; a bottle with a towel wrapped around it; some books ; a floor-mat rolled up, or other like materials may serve for the purposes of this cushion. The front of the chest as well as the neck should be made bare, and the field of operation and the adjacent skin should be cleansed with soap and water, if time permits. The Operation.-I shall first describe in detail the method pursued by myself in opening the trachea below the isthmus in children suffering from diphtheritic croup, since these constitute the vast majority of the cases for which the operation is demanded, and since the low opera- tion is the one to be chosen, if possible, for reasons already given. Other operative methods will be described after- ward. Inferior Tracheotomy.-The patient being in position and anaesthetized, and the instruments and sponges ar- ranged on a table or chair within easy reach of the oper- ator, he places himself on the right of the patient. The position of the cricoid cartilage is first identified, by the left index-finger, as the first landmark for the operation. The skin is then made somewhat taut, and the larynx steadied by the thumb placed on one side of.it and the fingers on the other, as shown in the illustration (Fig. 3975), and at once with a scalpel in the other hand a free incision is made through the skin and superficial layer of the superficial fascia from the cricoid to the upper bor- der of the sternum. Nothing will be gained but embar- rassment in the further steps of the operation by making a less free external in- cision. If any superficial veins have been di- vided by this first incision, as is often the case, they are secured b y haemostatic forceps. The deeper layer of fascia is n o w exposed, and not infrequent- ly upon its sur- face appear large and swol- len branches of the anterior jug- ular plexus of veins, which so closely approxi- mate each other in the middle line as to make it difficult to avoid them in pursuing the dissection further. The operator will be helped to avoid them by seizing the fascia at the lower end of the incision, just above the sternum, with a pair of forceps and nicking through it, and then, having passed a director underneath the fascia upward to the upper angle of the incision, lift- ing the fascia upon it. By this manoeuvre he puts upon the stretch the tissue in the mid line between the vein- trunks, and can slit it up with much less danger of wound- ing the vessels than if he continued his incision free-hand. If, however, no vessels appear demanding this use of the director, the deeper layer of fascia may be divided with- out delay by a stroke of the scalpel to an extent corre- sponding with the cutaneous incision. A pair of haemo- static forceps is now fixed in the free border of the in- cised fascia on either side and permitted to fall outward upon the side of the neck ; this retracts the wound-edges and freely exposes the connective tissue which joins the inner margins of the anterior ribbon-muscles of the neck. The operator now seizes this connective tissue between two pairs of anatomical forceps, and, by causing them to pull against each other again and again, tears his way down to the trachea and freely opens up the pretracheal space. As the dissection deepens, the forceps which have been used as retractors are fixed in the deeper lay- ers of tissue which have been opened up, until they are Fig. 3975.-Patient in Position ready for Tracheotomy. 176 Tracheotomy. Tracheotomy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. finally fixed in the tissue that insheathes the trachea on either side, at the same time securing any bleeding veins that may be torn, while they continue to act as efficient retractors. The inferior thyroid plexus of veins will be identified, as its branches are exposed, and may usually be easily drawn aside and secured out of the field of the dissection by the retracting forceps. At this stage of the operation the most embarrassment will be likely to spring from the tumultuous rising and falling of the loose me- diastinal tissues at the lower angle of the incision, in- cluding, occasionally, a persistent thymus gland. These are to be depressed and kept out of the way by the supra- sternal retractor (Fig. 3965). The broad shield of the retractor is placed in the lower angle of the wound and crowded downward toward the sternum, pulling out of the way and protecting from possible injury the vessels at the root of the neck, while its sharp hooks are fixed in the skin over the sternum below. This retractor holds itself in position. At the upper angle of the wound the lower border of the isthmus may encroach upon the field, especially if the isthmus is unusually broad. The clear- ing away of the pretracheal space should always be thorough enough to uncover and clearly define the lower border of the isthmus. If the breadth or low position of the isthmus is such as to hinder the ready and sufficient exposure of the trachea, it should be pulled up by a proper hooked retractor (Fig. 3968) and held out of the way by an assistant. If, now, all these precautions have been taken, the trachea will be found to be quite superficial and accessible, on account of the way in which the retracting forceps on either side lift it up from its bed and press back the wound-borders. The anterior surface of the trachea should now be cleanly exposed by tearing through any connective tissue that may still cover it; any large vessels that may have been unavoidably wounded and temporarily secured by for- ceps, should be tied; if possible all capillary oozing should also be staunched, although if the method de- scribed is adopted it will be rare that any troublesome haemorrhage will be met with. The anterior wall of the trachea is now to be hooked up in the middle line by the fixation hook (Fig. 3967), or in default of such a hook by a tenaculum, and held steadily by the operator with one hand, while, with the scalpel in the other hand, he pushes the point of the knife through the opening wall of the trachea into its cavity. The hiss of escaping air an- nounces that the cavity of the trachea has been penetrated. The sharp-pointed scalpel is now laid aside, and the probe-pointed, curved bistouri is taken and, its point having been introduced through the opening into the trachea, the incision is carefully enlarged, either upward or downward, as may seem most judicious in the particu- lar case, until the length of the incision is at least one and a half times as great as the diameter of the tube which is to be inserted. The incision should be made deliberately, with a full and exact knowledge of just where and to what extent tissue is being cut. Except in the most ur- gent cases, where respiration has already actually ceased, there will be ample time to make the careful and sys- tematic approach to the trachea which has been de- scribed. The doing of it takes by no means as much time as the description of it; for one who is at all ex- perienced in the work, five minutes will not be required from the time the first incision is made till the cut in the trachea is accomplished and the new respiratory orifice is provided. As soon as the cut into the trachea has been made, the operator takes the tracheal retracting hooks (Fig. 3968), and placing the hooks in the incision, from either side retracts the edges and dilates widely the new opening. One or both of these hooks may now be entrusted to an assistant, while the hands of the operator are set at liberty for the further cares which the case may demand. A tube should not at once be thrust into the opening, but it should be kept patent by the retractors, while a careful inspection of the interior of the trachea is made. In many cases in which the operation has been done on account of pseudo-membranous disease, immedi- ately upon the incision being dilated, there will occur a copious ejection through it of membranous debris and of muco-pus, and not infrequently of large membranous flakes, and even complete casts of the trachea. If the respiration has apparently ceased and artificial respiration is resorted to for resuscitation, firm compression of the thorax may cause the liquid contents of the trachea and the bronchi to well up out of the opening. Every care by immediate sponging should, of course, be taken to prevent the sucking back into the trachea of these mat- ters. In the cases in which tracheotomy has been done on account of a foreign body in the air-passages, the exploration of the trachea for its detection and removal will follow as the next step after the trachea has been opened into. When the healthy trachea has been opened for the relief of laryngeal obstruction, or for preventive reasons, the immediate insertion of a cannula is to be made ; in the cases, however, in which the trachea, when opened, is found to contain an exudate that is in process of exfoliation, every effort should be made to secure its removal before the cannula is introduced. For this pur- pose a chicken's feather may be passed down into the trachea and twisted about. This will often be efficient in detaching membranous bits and in provoking a spasm of coughing sufficient to expel them. The tracheal ex- ploring forceps (Fig. 3969) may be carried down into the trachea to directly seize and withdraw portions of exfoli- ating membrane. Their introduction will cause a strong expulsive cough, which will tend to loosen and drive be- tween their open jaws any exudate not too firmly at- tached. I often fasten a small piece of sponge or soft rag in the jaws of the forceps, and introduce the for- ceps thus armed into the trachea, like a swab, to more thoroughly cleanse its interior. If, by any mischance, considerable blood should have entered the trachea from the operation wound, the same measures to secure its re- moval, as far as possible, should also be resorted to. Attempts at removal by aspiration of intra-tracheal ac- cumulations, including blood, mucus, and membrane, by which the trachea is found to be blocked when it has been incised, have often been made, either by applying the mouth directly to the tracheal opening and sucking out its contents, or by the insertion of tubes through which suction is made. The operator who performs the aspiration in diphthe- ritic cases incurs the gravest risk of infection to himself. I cannot think that, under any circumstances, a surgeon could be justified in subjecting himself to such a risk. The most efficient aspiration of the trachea can be made by an ordinary hard-rubber syringe, to the nozzle of which a short piece of flexible rubber tubing has been attached. This tubing may be inserted into the trachea, even as far down as the primary bronchi, and through it any loosened masses or fluid accumulations may be sucked out. The tube must not be so large but that sufficient room may remain for the air to freely pass down by its side as it lies in the trachea, or otherwise efforts at aspiration will be futile. Gay has called attention to the satisfactory manner in which the ejection of offending matters from the air-passages may be effected, by forcibly blowing air into the lungs through a large catheter introduced through the tracheal opening-an effect more readily obtained by this means than by suction. This is in imi- tation of the method which nature pursues to fully inflate the lungs as a preliminary step to forcible expiration or cough. In a case which has been conducted in the method de- scribed, the insertion of a cannula becomes a minor inci- dent in its course, easily and safely accomplished after the toilet of the trachea has been completed. The cir- cumstances will be such as to preclude the occurrence of any of the traditional accidents that have been connected with this part of the operation. Before the cannula is put in place, while the tracheal opening is still kept patent by the hooks, the toilet of the external wound should be made. All haemostatic forceps still in use should be removed, and final haemo- stasis effected. The wound surfaces should be lightly dusted with iodoform or bismuth, after which the cannula, armed with its retaining tape, should be gently put in 177 Tracheotomy. Tracheotomy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. place, its tracheal portion being slipped into the trachea, while the edges of the tracheal wound are sufficiently separated by the dilating hooks to permit its entrance. If the cannula is so large as to somewhat distend the trachea, and it is necessary, or is deemed best, to use so large a one, it should not be crowded down the trachea ; but if its end is once fairly engaged within the trachea, it will soon gradually work its own way down as far as it can get. The immediate effect of the introduction of the cannula is to excite a spasm of coughing, which, however, usually soon ceases. The cannula should be gently held in place by the fingers of the operator until this storm of coughing has subsided. The tapes should then be passed around the neck and tied so as to hold the cannula securely in place. Care should be taken in tying the tapes, not to draw them too tight at first, but, while they are tight enough to prevent the end of the tube from slipping out of the trachea, still to have sufficient slack to provide for the swelling of the neck from infiltration of the bor- ders of the wound, which always occurs within the first twenty-four hours after an operation. Otherwise the tapes will soon become too tight, and will cause much suffering to the patient if delay in frequent examination of them should occur. The final dressings may now be applied. If the ex- ternal wound has been made so freely upward as to extend considerably above the upper edge of the shield of the cannula, a single suture may be applied so as to diminish the extent of the gaping here ; but this will rarely be required. No attempt at suturing the lower portion of the wound should ever be made, lest retention of secretions and their burrowing downward behind the sternum be occasioned. A small compress should be made out of any thin, soft material, as an old pocket- handkerchief, or prepared gauze. It should be large enough to cover the wound and extend out on either side to the outer border of the flanges of the shield of the cannula. This compress should be slit down to its centre on one side so as to facilitate its application around the tube ; it should then be smeared with an ointment of oxide of zinc and salicylic acid (oxide of zinc, gr. x. ; salicylic acid, gr. iij.; vaseline, 5 ss.), and, finally, should be applied around the tube and under the shield, so as to cover and protect the whole wound. Next, a bib made of oiled silk should be applied to the front of the neck and half-way down the front of the chest. It should be se- cured around the neck, having been cut away at the top so that its upper edge may easily be slipped under the lower edge of the shield, between it and the compress. The object of this is to protect the necessarily exposed parts of the chest from the air and from the secretions continually being expelled through the tube. Finally, a small veil made of two thicknesses of gauze or similar material, or a thin, flat sponge wrung out in hot water, should be adjusted over the external opening of the cannula to keep out dust and to moisten somewhat the in- haled air ; the dressing is now complete, and the patient may be removed to his bed. Superior Tracheotomy.-If the trachea is to be entered above the thyroid isthmus, the cricoid cartilage is again the landmark which is first to be identified. The skin and superficial fascia are to be divided by an incision at least one and a half inch long, the centre of which should fall upon the cricoid. The deep fascia may next be divided by free dissection, or upon a director. The thin connective-tissue layer which lies underneath is then to be divided carefully, or torn with forceps, so as to expose the surface of the cricoid. A careful trans- verse incision or tear of the fascia which is attached to the lower border of the cricoid, is then to be made. This will loosen the isthmus from its attachment to the trachea, and now, with a suitable hooked retractor (Fig. 3966), the isthmus is to be pulled downward as far as pos- sible. The upper two or three rings of the trachea are now exposed ; the sides of the wound should be kept apart by the catch-forceps, as in the low operation, the fixation-hooks should be inserted into the cricoid, and a longitudinal incision, cutting from below upward, made through the exposed rings of the trachea after the man- ner already described. If the incision made into the trachea does not give room enough for the easy introduc- tion of the cannula, the cricoid also is to be divided. The toilet of the trachea and of the wound, and the placing of the cannula, are to be done in the same way as already described for the low operation. Tracheotomy with the Thermo-cautery.-For avoiding the inconveniences and the perils which may possibly arise from haemorrhage during the division of the deeper structures that overlie the trachea, and especially when it is deemed best to divide the isthmus of the thyroid, the thermo-cautery of Paquelin is substituted for the knife by some operators, who praise the method very highly. Personally I have never resorted to it, nor felt the need of doing so ; for the methods which I have described for preventing and controlling haemorrhage have been so uniformly easy of execution and certain in their results, that the cautery would have presented no advantage. According to the-directions given by Boeckel69 and by Poinsot,60 all the preliminary arrangements for the opera tion with the cautery are the same as in any other case, except that to manage the cautery apparatus an additional assistant is required, who must be skilled in its manage- ment. The skin and superficial fascia are first divided freely by the scalpel, as usual, by an incision the centre of which should fall over the isthmus of the thyroid. The scalpel is then laid down and the thermo-cautery taken in hand. The blade of the cautery-knife should be only at a dull-red heat, at the most its point should appear reddish to the extent of a few millimetres only. By light and repeated strokes with the hot knife the connective tissue covering the isthmus is then divided. A certain spontaneous retraction of the wound borders takes place as the division proceeds, so that the use of special retractors is usually not required (Poinsot), though Boeckel states that he finds it better to use retractors. When the body of the isthmus is well exposed it is divided, by continued light strokes with the cautery, until the section is completed. The rings of the trachea then come into view ; as soon as they are thoroughly exposed the cautery is laid aside, the scalpel is used to open the trachea, and the remaining steps of the operation are the same as in the ordinary cutting operation. Boeckel states that he has had neither primary nor secondary haemorrhage in a series of sixty-one cases thus operated upon. Poinsot states that, though secondary haemor- rhage may occur more frequently after the use of the cautery than with the cold steel, it has always been in- significant. He claims also that the eschars protect the wound from diphtheritic invasion, and that phlegmonous complications are at least as rare as when the scalpel has been used. Tracheotomy at a Single Stroke (Method of Saint-Ger- main).-In cases that have reached that degree of urgency from suffocation that no time can be taken for the systematic exposure and incision of the trachea, but instantaneous relief must be given, the procedure which is most to be commended is the one perfected and practised, in cases of pseudo-membranous laryngitis in children, by Saint-Germain,66 of the Hospital for Sick Children of Paris. That surgeon prefers to wait until the last possible moment before operating, so that his operations necessarily are operations of urgency. He never uses an anaesthetic, but simply places the child upon a table, a cushion under its shoulders, the head firmly held by one assistant, while the hands and legs are held by another. The operator then fixes the larynx be- tween the thumb and middle-finger of the left hand, pressing the tips of these fingers in behind the larynx, as if trying to enucleate it. The two other fingers of this hand rest upon the vertebral column and serve to steady the hand. The larynx is thus made prominent, and the skin over it is made taut. A transverse depression is then recognizable between the cricoid and the thyroid cartilages, which marks exactly the location of the crico- thyroid membrane. This is the critical point to be iden- tified, for it is here that the bistoury is to be plunged in. The bistouri, narrow-bladed and sharp-pointed, is then taken in the other hand, as a pen is held for waiting, so 178 Tracheotomy. Tracheotomy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. that the blade shall project beyond the fingers not more than a centimetre and a quarter (half an inch). Such a limitation is important to prevent too deep a penetration and possible transfixion of the posterior wall of the trachea. Saint-Germain reports such an accident as hav- ing befallen himself in a case in which he neglected this precaution to limit the extent of his blade, and held the knife by the handle only, as if he was opening an abscess. With a blade only half an inch long he says that it is absolutely impossible to reach the posterior wall of the trachea. The bistoury, thus guarded, is then plunged perpendicularly through the skin and crico-thyroid mem- brane ; then, without inquiring whether the trachea has been penetrated or not, the operator prolongs his incision downward a little less than an inch in length, cutting the tissues from without inward, until two or three of the tracheal rings have been divided. As soon as the trachea is opened, the index-finger of the left hand, hitherto free, is thrust into the wound and stops up the tracheal cut, for the double purpose of making sure that the trachea has been opened, and to prevent the entrance of blood into it. Upon tins finger, as a guide, a dilator is then easily introduced into the trachea, the wound is dilated, and a cannula is quickly inserted. Beginners are apt to open the dilator too widely and thus convert the tracheal opening into a transverse slit, which hinders the intro- duction of the tube. Only a moderate dilatation is re- quired. By the use of a cannula to which is fitted an inner tube, with a blunt conical fenestrated extremity that projects below beyond the outer tube, the dilator may be dispensed with, the conical extremity of the cannula pressing apart the tissues before it, wedge-like, so that it readily finds its own way into its place in the trachea. Danger from haemorrhage is that which naturally suggests itself in connection with such a mode of operating, but Saint-Germain says that, out of three hundred and nine tracheotomies done in this way upon children, only three times has he been disturbed by the haemorrhage. The danger from haemorrhage, he states, is greater when this method is adopted with adults. Having had three deaths on the operating-table in adults, he has abandoned the practice with such, and recommends the deliberate dissec- tion for them. The supreme act of the process is in the speedy intro- duction of the cannula, for the sure and ready accomplish- ment of which coolness, adroitness, and experience are required on the part of the operator. In this method the placing of the cannula is elevated to a position of impor- tance which it ought not to have ; inspection and cleaning of the trachea are impracticable, and the high point at which the opening is made is defensible only on the plea of urgent haste. The method cannot, therefore, be rec- ommended for general adoption, but should be reserved only for those cases in which immediate suffocation is plainly imminent. The dangers of a free and open wound, and the difficulty with which any complications connected with it may be controlled, are always incom- parably less than those of a deep and restricted wound. Realizing this, I have always in my own work, in those urgent cases where at every hazard an immediate opening must be made into the windpipe, chosen the following method: It is the work of but a moment to get the child upon a table, get a book or cushion under its shoulders, and tear away the clothing from in front of its neck. The larynx then being steadied and made prominent by the thumb and fingers of the left hand, with one free stroke of the scalpel in the other hand, all the superficial tissues are divided down to the cricoid and the isthmus ; possibly the latter is also divided by this single cut. Does free bleeding follow the cut, the tissue from which the bleed- ing comes is seized en masse in the grasp of an haemostat- ic forceps, with another stroke of the scalpel the trachea is opened, then the hook retractors are inserted, and the opening is dilated. There is always some one by to whom the dilating hooks can now be entrusted, while I insti- tute artificial respiration, if needed, or seize any vessels that may be bleeding,- or remove any masses of exudate that may be blocking up the trachea. Free respiration having been re-established, haste is over, and all that is further required, including the introduction of the can- nula, may be done with deliberation. Complications of the Operation.-The varying anatomical conditions which may embarrass the ready performance of any of the different methods of tracheot- omy, have been sufficiently dwelt upon in the section devoted to anatomical considerations. It is by ignoring these conditions, by using too much haste in operating, by the lack of needed instruments, or by other imperfec- tions in operative technique, perhaps unavoidable on ac- count of emergency, that most of the serious accidental complications of tracheotomy are caused. The follow- ing list of complications is to be considered : Haemor- rhage, entrance of air into veins, asphyxia, displacement of the trachea, faulty incisions into the trachea, failure to introduce the cannula into the trachea, emphysema, and fatal syncope. Hemorrhage.-The occurrence of haemorrhage is the most frequent of the accidents that complicate tracheot- omy, and the one which brings in its train most of the other accidents enumerated. Cases in which children have died on the operating-table from suffocation caused by the entrance of blood into the trachea are not rare. The imminent danger of death, which is apparently es- caped only by a hair-bread th in many cases, has caused the operation in cases of pseudo-membranous laryngitis to be discountenanced by many surgeons, and always to be undertaken with dread. There is far less danger of serious embarrassment from this cause in the high opera- tion than in the low' one, and for this reason I have advised that in cases of supreme urgency the high operation should be chosen. An operator will always obtain in- estimable assistance in quickly and easily controlling the haemorrhage arising in the course of a tracheotomy from a sufficient number of haemostatic forceps. None of the precautions for the avoidance of haemorrhage which I have described in the section devoted to operative technique is unimportant. It is important that, if possible,, bleed- ing should be arrested before the trachea is opened, but it may happen that delay for such a purpose may itself be fatal from the unrelieved asphyxia. Where suffoca- tion is imminent, therefore, the surgeon must, regardless of haemorrhage, boldly and rapidly proceed with his ef- forts to open the trachea. When the trachea has thus been opened through a pool of blood, the immediate in- troduction of the cannula is required, for the special pur- pose of preventing the flooding of the trachea with blood as well as for furnishing a conduit for the air. As soon as free respiration is again established, the bleeding will usually cease spontaneously, or may easily be controlled by pressure. Haemorrhage from the vessels of the tracheal mucous membrane may also be a source of trouble. However perfectly bleeding may have been arrested before the tra- chea is opened, some haemorrhage from the divided ves- sels of the tracheal mucous membrane will follow the in- cision of the trachea. The blood flows into the trachea, but its flow usually ceases spontaneously, and the small quantity that has been effused is readily coughed out. Two instances have occurred in my experience in which continued internal haemorrhage from these vessels de- manded special care for its arrest. The first case wms a girl ten years of age, in whom the signs of general diph- theritic blood-poisoning at the time of the operation were well marked. Nevertheless, as the dyspnoea was urgent, I operated. The operation was almost bloodless, and the child rallied well, but about two hours after the opera- tion a general oozing from the raw surfaces, both inter- nal and external, began. The application of persulphate of iron, of hot water, and of pressure, were the means used to control it. It was not until persistent and in- telligent efforts had been continued for six hours that the bleeding finally ceased. The second case was in a boy twelve years of age. After the incision of the tra- chea had been accomplished, persistent oozing of blood from the surfaces of the wound defied all the usual modes of arresting it. Finally, by uniting together the edges of the tracheal incision and the skin incision, on either side, by sutures, I controlled the most of it; but oozing still 179 Tracheotomy, Tracheotomy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. continued from the incision in the tracheal mucous mem- brane at the lower angle of the wound. By inserting a large-sized cannula and applying a compress, this was at last controlled. These cases of persistent internal htemorrhage from the tracheal vessels proper are fortunately rare. In both these instances there was profound blood-poisoning an- tecedent to the operation. The method of operating, and of dealing with the trachea, which has already been advocated in the previous pages of this paper, will be the one best adapted for early discovering and successfully overcoming this complication. In addition to the means of treatment which have been illustrated in the cases de- tailed, Sanne, in his " Trait e de la Diphtherie," advocates the employment of alcohol in large doses, as an agent possessed of rapid and general haemostatic power. His language is, " Large doses are the surest; no fear need be entertained of going too far." In his first work, " £tude sur le Croup, apres la Tracheotomie," p. 191, he details a case in which a child had become nearly destroyed by repeatedly recurring internal haemorrhages, which finally were definitely arrested when she had taken at one dose between forty and fifty grammes ( 3 x. to 3 xij.) of rum. Entrance of Air into Veins.-This accident is very rare, but yet cases of it are recorded. One reported by Parise has been referred to in the section on anatomical con- siderations. A second one is reported by Sands.66 He was tracheotomizing a man who was nearly asphyxiated from an enormous malignant tumor, involving both the interior and exterior of the larynx, and extending down- ward so as to cover a considerable portion of the trachea. The wound being very deep, he was obliged to trust to the sense of touch rather than to that of sight, and while endeavoring with the point of a scalpel to scratch through the areolar tissue in front of the trachea, a sharp hissing noise was heard ; presently it was repeated, and though the trachea was instantly opened by a free incision, it was too late. The patient almost immediately expired. The autopsy revealed a slit-like wound in an enlarged inferior thyroid vein which was imbedded in indurated connective tissue, and therefore had not collapsed when cut into, but readily admitted air, which was found in abundance in the pulmonary artery and right cavities of the heart. Treves91 reports yet another case of entrance of air into veins during tracheotomy. Asphyxia.-The manner in which the asphyxiative symptoms may be aggravated in some cases by an anaes- thetic has already been pointed out. Another source of aggravation, incident especially to the low operation, is liable to be present in very young children whose tracheal rings are not very resistant. When the deep fascia is incised and the deep pretracheal space is opened up, an important protection to the trachea from external press- ure is lost, so that the soft tube is exposed to the full effects of atmospheric pressure at every attempt at respi- ration. A certain amount of collapse of the trachea may thus be caused, with speedy asphyxia unless the tube is quickly opened. This will occur, of course, only when the laryngeal obstruction is already very great, and there- fore is more likely to complicate those operations that are deferred until the suffocative symptoms have already be- come extreme. This is the cause of the marked increase in the asphyxiative symptoms which so often develop during an operation, and alarm the surgeon lest the pa- tient die before the trachea is opened. It is just at this crisis that, in his haste and solicitude, the operator is most likely to wound a vessel and add to the existing perils the dangers and difficulties of a sudden flooding of the wound with blood. To delay to stanch the bleeding would be fatal, to find the trachea through the deep, nar- row wound filled with blood is difficult, and to incise it thus obscured is hazardous ; but nevertheless, in such an emergency, it must be done as the only resource. The surgeon may properly protest against the delay in operat- ing which should expose his patient to such perils, but in many cases the time of operating is not a matter of choice, for he may not arrive at the bedside of the patient until extreme symptoms have already developed. As soon as the trachea is opened, if done under such cir- cumstances of haemorrhage, the patient should be turned over on his face to prevent the flow of blood into the trachea ; if breathing has already ceased artificial respira- tion must be instituted ; if the trachea has been flooded with blood it must be forced out by compression of the thorax, and by blowing air into the bronchi through a tube, as a catheter, so as to excite expulsive cough. It should be noted, however, that in any case the amount of time required for such a careful and systematic ex- posure of the trachea as would suffice to guard against operative mischance is so short that the surgeon need rarely feel himself compelled to depart from the cool, safe, and regular prosecution of his work. The preserva- tion of a dry wound, and the obtaining of a clear, unob- structed opening into the trachea are the very best safe- guards against the occurrence of uncontrollable asphyxia, and to secure these he may well disregard for the mo- ment threatening asphyxia, relying on his ability to re- excite respiration by artificial means if it should actu- ally cease before the opening in the trachea is made. Fatal asphyxia may be caused by a plug of false mem- brane crowded down into the trachea before a hastily introduced tube. Boeckel records a death from this cause, and mentions two other cases in which the acci- dent occurred, but in which death was averted by rec- ognizing the cause of the asphyxiative symptoms at once, removing the tube, and seeking for and dislodging the membranous mass. Trousseau, Hueter, Jacobi, and others report similar accidents. A thick and loosely adherent lining of membrane may be pushed before the point of the knife which cuts the more resistant tracheal wall, and a hastily introduced tube, pushing its way be- tween the membrane and the wall of the trachea, may find itself within the trachea but still shut off from its cavity by this membranous layer. Death from asphyxia may occur before the cause is recognized and remedied. In general, as to these dangers, it may be said that pre- vention is better than cure. If care is taken to have the trachea clear of loose exudate before the cannula is in- serted, such accidents cannot happen. If, however, as the result of circumstances beyond his control, the surgeon finds himself confronted by this accident, as indicated by increased embarrassment to the breathing or its total ces- sation upon the introduction of the cannula, the latter must be at once withdrawn, the tracheal opening dilated, perhaps enlarged, and, by the use of forceps, swabs, sy- ringes, inflating tubes, or feathers, the cavity of the tra- chea must be quickly cleared, and artificial respiration resorted to. Displacement of the Trachea.-The trachea may have been dragged or pushed away from its proper position in the median line by tumors. In a recent case of tra- cheotomy required to relieve dyspnoea caused by paraly- sis of the glottic dilators from pressure of an aortic aneu- rism, in which I was called to assist a colleague, the great development of the intra-thoracic tumor had pushed the thoracic portion of the trachea so far to one side that the cervical portion had likewise been dragged away from the mid line. In the generally swollen condition of the neck this was not recognized until the usual dissection in the median line had failed to expose the trachea. By making a transverse incision to the right from the upper angle of the mesial wound, and turning down a flap, the trachea was finally exposed. A more frequent cause of displacement of the trachea is unequal retraction of the borders of the wound in the course of the dissection to expose it, or unintentional departure from the mid line of the neck by the surgeon. The result is that the oper- ator strikes the trachea laterally, or misses it altogether. Cases have been related to me in which the operator, hav- ing thus missed the trachea, has continued his dissection until the vertebral column was reached. Thornton68 says that he has seen, at the post-mortem examination of a child at one of the London hospitals, three cuts on the vertebral column, which had been made by a house- surgeon in fruitless attempts to open the trachea. Such mischances are most likely to occur when the field of operation is obscured by blood, and an inexperienced operator is under the pressure of symptoms demanding 180 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tracheotomy. Tracheotomy. haste. The history of the case of lateral incision shown in Fig. 3976 is a type of these cases. The illustration is taken from a photograph which I had made from a specimen presented by the late Dr. Giberson before the Brooklyn Pathological Society. In the course of the operation so much trouble was experienced from haemor- rhage, and the child's extremity appeared so great, that a hasty in- cision and an immediate insertion of a cannula was deemed necessary. Much embarrassment to the respi- ration continued after the cannula was in place, confined chiefly to expiration. This continued unre- lieved, and was a prominent factor in determining the fatal result, which took place in about twenty- four hours. The specimen showed that the incision had been made through the first two rings, and upon the lateral aspect of the tra- chea. The cannula, when inserted, passed down by the side of a poly- pus-like roll of exudate, whose lower free end extended below the end of the tube. By every expira- tory effort the loose portion of the exudate was carried up against the inner opening of the cannula, par- tially occluding it, while it was floated away again at each inspi- ration. To guard against such accidents it is important that the landmarks for the operation which have been described in earlier sections be identified at the outset of the operation, and that, when haste in operating is im- perative, the larynx should be steadied and the tissues evenly retracted by the fingers of one hand, while the incisions are made with the other. Faulty Incisions into the Trachea.-These include lateral incisions, multiple incisions, too short incisions, too long incisions, and complete transfixion of the trachea with penetration into the oesophagus. They are generally the result of haste and haemorrhage. A lateral incision will make the cannula stand awry upon the surface of the neck, and increase the dangers of irritation to the tra- cheal mucous membrane from its extremity; an inciden- tal disadvantage, as regards the cleansing of the trachea, is illustrated in the case from which Fig. 3976 was taken. Multiple incisions are the result of repeated inef- fectual stabs at the trachea when the first incision is lost beneath shifting tissues or in a pool of blood. Holmes69 relates having witnessed a case in which a small incision was made in the trachea before the superjacent tissues had been sufficiently cleared away from it ; the disturb- ance of the tissues from the coughing and struggling which followed caused the operator to lose the opening, and before he could find it again the patient died. He says that several times he has seen children almost as- phyxiated from efforts of the operator to insert a tube into an insufficiently exposed opening, the cannula being pushed down into the cellular tissue in front of the windpipe instead of into its cavity. One fatal result he ascribes to this accident. The same author relates a case in which he had to complete an operation in which the first operator had already made two incisions into the windpipe, each too small and away from the middle line. Mr. Holmes made a third incision in the median line and succeeded in finally introducing a tube. The patient survived several days, and no inconvenience resulted from the superfluous punctures. When a puncture has been made and lost, so that it cannot quickly be found again, time should not be wasted in searching for it, but a new incision should be made. Too short an incision interferes with the ready introduction of a tube ; too long an incision leads to dif- ficulty in retaining a tube in the trachea. The length of the incision should not exceed one and a half times the diameter of the tube that is to be inserted, and when the tracheal cartilages are too rigid to permit ready separa- tion of the edges of the incision to a sufficient extent, ex- section of a portion of them should be done. Complete transfixion of the trachea may easily be done in young children in whom the tracheal walls are quite soft, and possibly already somewhat collapsed. Mr. Marsh 62 says that he has several times seen two, in some cases three, cuts made at the trachea before a sufficient opening was secured; and in one instance the scalpel was driven through both the anterior and the posterior walls of the trachea, and through the oesophagus, till it struck the spine. I have already quoted Saint-Germain's ac- count of the case of transfixion which occurred under his knife. Trousseau, in the course of one of his contro- versies on the subject of tracheotomy, describes the work of an antagonist as having " with one stroke of his knife divided the oesophagus as well as the trachea." SanneT0 reports three such cases, all fatal. Cohen11 cites from literature further cases of the kind. At a post-mortem examination which I made upon the body of an infant, in which the trachea had been hastily opened by a col- league under stress of emergency, I found the posterior wall of the trachea pierced into the oesophagus. It is to prevent this accident that the recommendation is made to hold up and steady the anterior wall of the trachea by a fixation hook or tenaculum before it is carefully pierced by the point of the knife. Attempts to open the trachea by quick thrusts of the knife should never be made. Failure to Introduce the Cannula into the Trachea.-Mr. Marsh62 says that he knows of three cases in which the cannula was not placedin the windpipe at all. In one it lay in a cul-de-sac in the cellular tissue in front of the trachea ; in another it was thrust also in front of the trachea, and toward the mediastinum ; and in the third it lay by the side of the trachea. Death before the can- nula is introduced, on account of delay from some of the accidents already mentioned, has occurred many times. There can be no excuse for leaving a cannula thrust down by the side or in front of the trachea. Such an accident can happen only when the incision in the trachea is imperfectly exposed and retracted, perhaps hidden by blood, or when the trachea has been missed altogether. The rush of air through the tube when it enters the windpipe is unmistakable, and the operator should never be satisfied until the free current of air in and out of the tube clearly demonstrates that it is properly in place. Emphysema.-Sanne 10 reports that this accident oc- curred twenty-two times in 766 cases. I have never seen it. When it does occur it must be produced by some operative mischance whereby the peritracheal connective tissue is opened up deeply without corresponding external wound, or lateral or multiple incisions into the trachea have been made, or an incision into which the cannula either has not been introduced at all, or has slipped out of, so that the expired air is forced into the connective tissue. Though the cannula may have been properly in- troduced at first, it may slip out of its place later, either because too loosely tied in, or because the tracheal incis- ion is too long, or because the cannula is too short from the first, or the subsequent tumefaction of the tissues lengthens the track so that it becomes too short later. The appearance of the emphysema may be first noted during the operation, or it may not be noted until some hours have passed, depending upon the time when the causes of it become active. It may be limited to the re- gion of the wound, or may in extreme cases, become generalized. As soon as its cause is removed, it will rapidly subside. Syncope.-A transient syncope occurs in some cases immediately upon the incision into the trachea being made, caused by the sudden free in-rushing of an abun- dant stream of air. For a moment further inspiratory efforts cease, and the child appears as if it would never breathe again. There is no cause for anxiety, however, since the momentary shock is quickly rallied from and regular respiration begins again. Compression of the Fig. 3976.-Lateral Incis- ion into the Trachea. (From a photograph.) 181 Tracheotomy. Tracheotomy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. thorax and dashing cold water into the face of the patient may be resorted to, if the syncope is prolonged. Fatal syncope may occur at any stage of the operation in children who are the subjects of diphtheria, from heart-failure determined by agitation, haemorrhage, or possibly the anaesthetic. The only death upon the table which I have ever had occurred from this cause. It was in the case of a child aged three and a half years, suf- fering from diphtheritic croup. While the indications for operation were pronounced, his condition was not extreme. Chloroform had been administered, and the trachea had been exposed ; while a moment's delay was caused in stilling the bleeding, he recovered conscious- ness sufficiently to struggle somewhat and utter an ex- clamation, and then suddenly expired at the moment when the cricoid was fixed by the tenaculum for incising the trachea. Though the trachea was instantly opened and abundant and unobstructed entrance to air was afforded, and artificial respiration was carried on, no re- suscitation occurred. After-treatment.-The details of the after-treat- ment are of the greatest importance, especially in the cases where tracheotonjy has been done for pseudo-mem- branous laryngitis, to which class of cases the following remarks are more especially applicable ; the more simple cares required in other cases will naturally be included in the more extended discussion. The general treatment of the patient should be very carefully conducted. Usually the shock of the opera- tion is not great, and, except in cases attended with pro- fuse haemorrhage, will not require especial attention. Exhaustion from the previous dyspnoea is the rule, but in children is quickly recovered from after free respira- tion is once more established. It is common for the child to sink into a restful sleep soon after the subsid- ence of the first tumult of coughing caused by the inser- tion of the tube. The general comfort and quiet appar- ently enjoyed by the patient after the operation are marked when contrasted with the previous distress and agitation. According to the judgment of the physician, such medi- cation and stimulation will be resorted to as the particular case may seem to demand, the fact being kept in mind that the obstruction of the windpipe, for the relief of which the operation has been done, is merely an incident in a general disease. Much difficulty is often experienced in inducing children to take the needed amount of food, not necessarily because it hurts them to swallow, but because of their general state. Not infrequently, also, such paralytic weakness of the pharyngeal and laryngeal muscles develops, that at every attempt to swallow more or less food will enter the larynx and provoke vio- lent coughing. Rectal enemata, or feeding through an oesophageal tube, must be resorted to in such cases. The general principles of dietetics which are recognized in other cases attended with exhaustion, will find their application in the after-treatment of tracheotomized pa- tients. The air should be pure and abundant, as well as warm and moist. I can see no advantage to be gained from shutting up the patient in a close tent, or in maintaining the temperature of the sick-room at a very high point and having it filled with steam, which cannot be equally well obtained from simple and less depressing measures. A temperature of from 72° to 75° F. is high enough. The floating dust of the air should be strained out, and additional moisture given to the in-going current of air by keeping the orifice of the tube covered with a moist veil or sponge. The fact must not be lost sight of, that the pre-existing condition of congestion of the pulmo- nary and bronchial capillaries induced by prolonged dyspnoea, predisposes to the development of pneumonia and bronchitis-of which the entrance of blood into the air-passages, the aspiration of portions of food and of necrotic bits of exudate, or unhealthy secretions from the larynx and trachea, may frequently be the final determin- ing cause. It is important, therefore, to keep from the respiratory tract as far as possible every depressing influ- ence; hence the importance of the injunction that the air supplied should not only be warm and moist, but also abundant and pure. In no class of cases is the value of intelligent and careful nursing more marked, and it would be greatly to the advantage of the little unfortu- nates in large cities, where diphtheritic croup prevails, if all such cases could be kept after tracheotomy in special wards of hospitals, equipped with every facility for their proper care. Traumatic fever, to some extent, is unavoidable from the character of the wound. If no complication in the course of the wound-healing takes place, the fever will demand no special treatment; if it is excessive and prolonged, the cause for it is to be sought in some complication to which appropriate treatment must be directed. In addition to the general cares above outlined, special care will be required for the management of the wound, of the trachea, and of the cannula. The Wound.-In general, the cares which the wound will demand are very simple ; being open, its secretions, together with any tracheal secretions that are ejected upon it, readily flow away. No dressing should ever be applied which could favor the retention of secretions in the wound. Twice daily, the wound should be lightly dusted with iodoform or bismuth to prevent septic changes, while the wound, as a whole, should be kept protected from external irritation by a small square of linen or similar material laid over it, smeared w'ith an emollient, like the salicylated zinc ointment, already men- tioned. The removal of dried crusts, and the general cleanliness of the adjacent parts must be looked after on general principles. After the cannula has been dispensed with, the wound rapidly contracts, the cannula-fistula collapses, its walls quickly adhere, and a simple super- ficial granulating surface is left, the treatment of which is conducted on general principles. The rapidity with which these reparative changes take place will depend on the amount of the previous disturbance of the wound and on the general vigor of the patient. When much loss of substance has taken place, or the cannula has been worn for a long time, so that its sinus has become lined by a well-organized membrane, a permanent fistula may remain, the obliteration of which may require a plastic operation. Phlegmon of the Wound.-Some phlegmonous inflam- mation of the borders of the wound is common. They become tumefied and indurated, and a zone of redness extends to a variable extent outward upon the skin of the neck, and downward upon the thorax. Little tendency seems to exist to the formation of abscesses-at least I have never observed it; the necrotic changes which it de- termines in its more intense forms take place on the sur- face, and may range from slight ulceration to extensive sloughing. If erysipelas or diphtheria is engrafted upon it, these necrotic changes will be aggravated. This wound-inflammation is septic in character, and aggra- vated by the irritation of the cannula. It begins to manifest itself more especially during the third day ; if life is prolonged and the case does well in other respects, it will begin to subside after three or four days, especi- ally if the cannula can be dispensed with. An efficient antiseptic treatment of the wound from the first, as al- ready advised, is the best preventive of this phlegmonous invasion, and the best curative, if the invasion has al- ready taken place. The inflamed integument should be kept anointed with carbolated oil (carbolic acid, three per cent.), or an ointment of ichthyol (ichthyol or ichthyolate of ammonia, ten per cent.). The cannula should be kept out of the wound as much as possible. Even though the condition of the larynx may not permit of the permanent removal of the cannula, still the stiffness of the wound- borders will suffice to keep the track of the cannula pa- tent enough for respiration for quite a while after the tube has been taken out, so that the patient may be able to get along without the latter for fifteen to sixty min- utes or more at a time, before it becomes necessary to re- place it. After the tube has been in place for an hour, it may be removed again, and so on as long as the per- sistent wound-inflammation may require such help. In such cases as this the use of a suitable obturator to facili- tate the reintroduction of the tube (see Fig. 3974) is espe- cially needed. With the help of such an obturator any 182 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tracheotomy. Tracheotomy. intelligent nurse can carry out this procedure. Erysipe- las of the wound is characterized by a more extreme spreading of the skin inflammation, is simply a more severe form of septic disturbance of the wound, and is to be antagonized by the same kind of treatment. Diphtheria of the wound demands no special treatment different from that given to the phlegmonous inflamma- tion which attends it. If the case does well in other respects, the exudate exfoliates spontaneously in due time, and cicatrization proceeds. Gangrene of the Wound.-This may manifest itself either in a progressive ulcerative process that converts the wound into an ill-conditioned spreading ulcer, or in the formation of distinct sloughs of necrosed tissue. Its causes are the same as those of the less severe forms of septic infection already noted, and indicate a more in- tense form of infection, and less local and general resist- ing power on the part of the patient. A black discolora- tion of the cannula, caused by the disengagement of sulphuretted hydrogen, indicates the beginning of the gangrenous process. The treatment consists in the use of local stimulants and antiseptics, and general tonics, and the suppression of the cannula as much as possible. If the gangrene is superficial, the sloughs soon become cast off, the wound assumes a healthy appearance, and its cicatrization proceeds without any permanent damage having been occasioned. Every degree of disorganization may, however, occur, even to the invasion of the larynx and trachea, as in the case illustrated in Fig. 3978, which is described in the section devoted to the care of the tra- chea. Such extreme loss of substance, if ultimate cicatri- zation should be accomplished, would entail stenosis of the windpipe requiring permanent wearing of the can- nula. Abscess of the mediastinum is rarely recognized, except at the autopsy. Sanne10 collected eleven cases which oc- curred in the service of Barthez, and refers to other ob- servations. He well observes that inflammation of the mediastinum is the result of operative accidents-nu- merous and incautious attempts at introducing the can- nula, false passages, contusion and dissecting up of the peritracheal connective tissue, associated with vicious incisions of the trachea, which provoke a cellulitis that rapidly reaches to the connective tissue of the mediasti- num. Such mediastinal inflammation would usually be associated with other inflammatory and septic conditions that w'ould mask it, and render it of little relative im- portance ; if, however, the patient was doing well in other respects, and after three or four days high fever and dyspnoea should develop, no pulmonary complica- tions sufficient to account for the symptoms being dis- cernible, mediastinal abscess might be suspected. It is almost impossible, however, in any given case to elimi- nate with positiveness pulmonary complications, so that some uncertainty must always attend the diagnosis. If the surgeon were satisfied that a strong probability ex- isted of mediastinal suppuration having occurred, it would be proper for him to trephine the sternum, and explore; if pus was found, the cavity should be freely opened up and cleansed, and drained through the sternal opening. Secondary Haemorrhage.-Bleeding may take place at any time during the after-history of a case until all ulcer- ative tendencies have been arrested. It may be due to the reopening of a vessel wounded during the operation, to the erosion of the coats of a vessel through the press- ure of the cannula, or to the falling of a slough. The expectoration becomes not infrequently tinged with blood from time to time. This is due in most instances to slight erosions of the tracheal mucous membrane by the cannu- la, most frequently at its point, and calls either for greater gentleness in the manipulations about the cannula, or for a change in the tube itself, so that, by having one of a dif- ferent length or different curve, the ulcerating point may be relieved from pressure. Many cases of profuse and fatal bleeding have been reported. Zimmerlin,72 in 1882, reported twenty cases of profuse secondary haemorrhage, five of which terminated in speedy death, among one hun- dred and forty-one tracheotomies for diphtheritic croup done in the Children's Hospital at Basel. The cause of these haemorrhages was to be found either in diphtheritic sloughing of the wound, pressure ulcerations of the tra- chea, or incisions into the thyroid isthmus during the operation. The bleedings occurred from eroded tracheal vessels, from those of the thyroid gland, or from a com- municating branch between the anterior jugular veins. Sanne10 collected accounts of twenty-two cases of copious secondary haemorrhage, twelve of which resulted fatally. Marsh6'2 had serious secondary haemorrhage occur in two out of thirteen operations, once from eroded tracheal ves- sels, with spontaneous arrest but subsequent death, and once from some vessel in the external wound ; the bleed- ing in the latter case was stayed by the actual cautery, and ultimate recovery was secured. Three other cases of fatal haemorrhage, in addition to his own, are mentioned by this writer. The bulletins of the Anatomical Society of Paris (1880, p. 306, and 1884, p. 385) contain accounts of four cases in which the innominate artery was opened by ulceration from pressure of the cannula, causing fatal haemorrhage. Mr. Bell, in The Lancet, March 1, 1879, re- ports a case of fatal secondary arterial haemorrhage, which he supposes to have come from ap ulcerated innominate artery, and refers to a similar case which had been under the care of Mr. John Wood. Another similar case is re- ported by M. Bouju, of Rouen, in La Normandie Medicale and quoted in the New York Medical Journal, 1887. Partial incisions of the isthmus of the thyroid with subsequent ulcerative opening of its vessels previously undivided, are reported by Fidele,13 of Turin, as having led to fatal secondary haemorrhage in. two cases. Many other in- stances of fatal or serious secondary haemorrhage after tracheotomy might be collated from the literature. Its possibility should always be borne in mind, and every care should be taken to prevent or limit the ulcerative processes upon which it depends. When a large vessel is the source of the bleeding, the immediate inundation of the air-passages with blood will cause speedy death. If the bleeding is less overwhelming in its onset, the bleed- ing point must be sought for, and the flow stanched by the use of the ordinary means available for haemos- tasis. The Trachea.-Pseudo-membranous Exudate.-The extent and character of intra-tracheal exudations is one of the most important conditions upon which the success of tracheotomy depends, especially in cases where the opera- tion is performed in the course of diphtheria. The amount of the tracheal mucous surface that may become involved in the pseudo-membranous exudate varies much, and it is generally impossible to determine, previous to the opening of the trachea, whether the exudate extends below the larynx or not; in a large proportion of cases it remains limited to the larynx throughout; in others, if life is prolonged by tracheotomy, it afterward extends to the trachea and to the bronchi; in many the trachea is in- volved from the first; of these, in some, after the exfolia- tion of the exudate already formed, no further deposit occurs; in others its progressive formation leads irresist- bily to death. When the trachea already contains an exudate at the time of operation, more or less extensive particles of it, accompanied by much muco-pus, will often be ejected through the incision when made. In other cases, in which the exudate is still adherent, it may be possible to secure the detachment and expulsion of por- tions of it by the introduction through the wound into the trachea of suitable instruments, as already advised in a previous section. The readiness with which exfoliation of the membra- nous exudate takes place, depends upon the degree to which its elements adhere to and penetrate the mucous membrane beneath, which again is a very fair index of the intensity of the local inflammation. The cases marked by a ready exfoliation are those in which the depth and intensity of the local disease is slight, and which give a ready hope for recovery, provided that the special dangers incident to the location of the deposit be overcome. In many of the cases in which the loosened exudate is ejected upon the first opening into the trachea, or is easily removed at once, unimpeded and speedy recovery will 183 Tracheotomy, Tracheotomy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ensue if only the simplest precautions be taken to protect from hurtful extraneous influences. Much more frequently, however, the detachment of the membrane isdelayed, and it takes place in smaller masses, of varying size, that appear from time to time in the ex- pectoration during the after-progress of the case. These loosened pieces of membrane, usually mingled with viscid mucus or muco-pus, are often expelled with difficulty ; they provoke suffocative crises that for a time seem to threaten the utmost peril; and in not a few instances, when skilled and instant assistance is not rendered, they produce death by blocking up the lumen of the trachea, or of the cannula that may be in use. In any case where there has taken place a membranous exudate within the trachea below the point of incision, such a suffocative crisis is likely to suddenly arise at any time during the period of its exfoliation. These are the cases in which the ultimate result depends directly upon the completeness with which the indications presented by the presence of this loosening membrane are appreciated, and the faithful- ness and thoroughness with which they are carried out. Catarrhal Inflammation.- Some catarrhal inflamma- tion of the tracheal mucous membrane always accom- panies a membranous exudate, and frequently causes conditions that complicate greatly the after-treatment. It is liable to be excited de novo, in cases not associated with membranous exudate, by the inhalation of unmodi- fied air-cold, dry, and dust-laden-through the new respiratory aperture. It may extend to the smaller bronchi ; it is the immediate cause of death in a consid- erable proportion of cases after tracheotomy. Even in cases in which the catarrhal inflammation does not extend beyond the trachea or the primary bronchi, the secretion may be so copious and so viscid that the air- passage can be kept clear with difficulty ; where there is membrane also present, it is by the catarrhal secretion that the membrane is lifted up and disintegrated ; this secretion mingles with the membranous shreds that are expectorated, and may cement them together in masses too large to be expelled without assistance ; it clings to the interior of the cannula, where it readily dries in the air current and forms incrustations that rapidly diminish its lumen. The greatest trouble from this catarrhal se- cretion is usually experienced within the first three or four days after tracheotomy. It then either diminishes greatly in quantity, or becomes muco-purulent and difflu- ent. In many cases the character of the secretion has already become muco-purulent before the incision into the trachea is made, in which case its copious and ready expulsion through the opening then takes place. The indications for treatment of catarrhal inflammation of the trachea are to limit its extent, to modify its inten- sity, and to obviate dangerous accumulation of its secre- tions. The first two indications may be fulfilled by the same measures. Whatever remedial measures have been recog- nized as of value in the treatment of inflammations in general of the respiratory mucous membrane, will be of equal value in these cases, and will be applied according to the experience of the individual practitioner. Calo- mel, antimony, and muriate of ammonia each possess a positive influence in promoting free secretion and render- ing it less viscid, but in the majority of cases dependence will be mostly placed on local applications. The air inspired must be warm, moist, and pure. The use of the moist sponge or gauze veil over the mouth of the cannula, advised in a previous section, should be kept up. If necessary they may be held in place by tapes fastened at either side, and tied over the head or around the neck. In addition to this precaution, whenever diffi- culty is being experienced by the patient in fully cough- ing out the tracheal secretions, inhalations of vapor, in- stillations, and injections of liquids may be practised. Inhalations of steam, of steam charged with vaporized Peruvian balsam, with atomized lime-water, or with solu- tion of muriate of ammonia, may be used with benefit. Instillations and injections are also of great advantage. When the symptoms are not urgent, three or four drops of warm water and chloride of sodium, of lime-water, or of dilute lactic acid, may be made to run down through the tube into the trachea as often as seems to be necessary to keep the secretions diffluent and the expectoration free. Whenever this is not sufficient to prevent the continued marked accumulation of secretions, whether of tenacious and inspissated mucus, or of muco-pus and membranous debris, injections of the solvent liquid, to the amount of a drachm or more, are to be made by means of a syringe deep into the cavity of the trachea. For this purpose a small syringe, as a hypodermic syringe, having a tube attached to it of suitable size and curve to pass through the cannula, terminating in a perforated bulb, as shown in the illustration (Fig. 3977), is desirable. The use of such intra-tracheal injections is the suggestion of the late Dr. H. A. Martin,14 of Boston. In making the injec- tions, the bulb is quickly passed down through the can- nula, or through the wound after the cannula has been withdrawn, for an inch or more into the trachea, and the liquid is injected with some force. A violent expiratory paroxysm follows, the diluted and loos- ened mucus is dislodged and expelled ; after a minute or two the injection may be repeated, and will be followed by still greater relief. These injections may be repeated from time to time, as often as the reaccumulation of viscid mucus in the air-passages is evident. Pressure Sores.-The possible erosion and ulceration of the tracheal walls from the pressure and friction of the cannula is always to be borne in mind. The mere pressure exerted by the can- nula does not seem to be the only thing at fault in the development of ulcera- tions of the trachea, as the prolonged wearing of a cannula after tracheotomy for conditions other than diphtheritic croup, and even in many of these cases, without unpleasant pressure-effects ever being experienced, is sufficient to prove. The vitality of a tissue which has been the seat of a diphtheritic exudation is diminished ; it naturally tends to necro- sis ; the more intense the diphtheritic process, the greater the necrotic ten- dency. In such cases the slight addi- tional irritation afforded by the pressure of the cannula suffices to determine a slough. Bloch,76 of Copenhagen, out of tliirty autopsies upon patients who had died after tracheotomy, in sixteen found that the trachea had suffered from the pressure exerted by the cannula, the seat of injury being the anterior or the posterior wall, or, most commonly, both simultane- ously, and including every degree of effect, from simple anaemia and superficial erosion, to destruction and per- foration of its entire thickness. These ulcerations had been previously studied by Roger,36 who published a monograph upon them in which he analyzed twenty-one cases, and by Sanne,10 who devotes a chapter to their consideration in his work on croup after tracheotomy, based on seventeen cases observed by himself. By far the most frequent seat of these ulcers is upon the ante- rior wall of the trachea, below the inferior angle of the tracheal wound, at a point corresponding to the lower end of the cannula. According to Bloch, nine cases of death, from haemorrhage resulting from these ulcers, are on record, in most of which cases the innominate artery had been perforated. Fig. 3978 illustrates an extreme degree of these press- ure-effects. The trachea is represented as laid open from behind. The original incision was made through the cricoid cartilage and the first ring of the trachea. Sloughing of the borders of the incision has destroyed Flo. 3977.-Syringe for Intra-tracheal Injections. 184 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tracheotomy. Tracheotomy. the anterior half of the thyroid cartilage, one lateral half of the cricoid, and the anterior portion of the three upper tracheal rings ; about one-third of the way down to the bifurcation is an ulcer on the anterior wall of the trachea which has destroyed portions of four tracheal rings. The case was a patient of my own, a boy of two and a half years ; the local diphtheritic pro- cess was intense and involved the whole of the trachea ; death took place on the eighteenth day after the operation by asthenia. The cannula was retained in the trachea for fourteen days. It was one of the bivalve tubes of Fuller. Much of the damage sustained by the trachea I believed at the time to have been due to the par- ticular form of tube used. That in the movements of the neck, and in the manipulations of the tube, frequent antero- posterior tilting of the cannula should be done is unavoidable; and it would be expected that the striking of the ante- rior edge of the inner end of the cannula against the anterior wall of the tra- chea in these frequent til tings would cause that point to be the one at which ulceration should most frequently take place. Many cases of mere erosion, or of slight ulcer- ation, undoubtedly pass unnoticed. The most important symptoms which indicate the exist- ence of ulceration are two - namely, the appear- ance of bloody streaks in the expectoration some days after the operation, and a black discoloration of the lower end of the tube. It is on account of the danger of these pressure- effects that so much stress has been laid in a previ- ous section on the use of such form of tube as shall in its construction provide as perfectly as possible against friction and pressure while it is worn. For the same rea- son efforts to dispense with the cannula should be begun very early, and whenever evidences of pressure-effects are detected, its removal, if but for a short time at any one trial, should be frequently practised. In cases of the high operation the cannula may possibly sometimes be dispensed with altogether. A hundred years ago, Sabatier16 suggested that there might be a doubt whether the cannula, of which nearly every practitioner spoke, was indispensable. Again, in the same chapter, he said : " Perhaps it would be much better to do without the cannula, and nothing appears more easy if laryngotomy is practised. . . . The wound, superficial, and of the slight extent that such an operation would involve, could remain without being dressed, without the least inconvenience resulting there- from." Martin,74 in 1878, reported that he had carried to a successful termination several cases of tracheotomy without tubes, and earnestly advocated it as generally feasible. This suggestion I put into practice in the case of a boy six years of age, the son of a physician, upon whom I operated in 1882. The trachea was opened below the isth- mus, a semilunar bit was excised from either border of the tracheal incision, and two stitches were put in on either side of the wound, uniting the pretracheal connective tissue and the edge of the sterno-thyroid muscle to the lip of the skin incision. The free ends of the threads used for these stitches were then tied together, forming a loop, through which a bit of tape was passed which was carried behind the neck and around through the like loop on the other side. This was drawn tight enough to gently retract the edges of the wound and keep the chan- nel to the tracheal opening patent. The child died at the end of nineteen hours from the general diphtheritic tox- aemia, but no difficulty was experienced in keeping the tracheal opening free during this period. In my very next case, a boy of nine years, I found the procedure im- practicable. The operation was the same, the low one ; the same method for keeping the tracheal opening patent was adopted, but within half an hour the tendency of the skin and soft tissues to fall together was too great to be overcome by such measures, and a cannula had to be in- serted. This was due to the greater depth of the wound and tonicity of the tissues than existed in the previous case. Less trouble would doubtless have been met with if the operation had been a high one. Since this time I have continued to use a cannula from the first, and, by care in the choice of a model and gentleness in its after- use, I have not for years met with any serious pressure- effects. In-turned Cartilages.-An hitherto undescribed source of injury to the trachea from the cannula was demon- strated by Dr. Louis Carrie,77 in a thesis for the doctor- ate, before the Faculty of Medicine, Paris, 1879. A young child, in wrhom for some cause difficulty was ex- perienced in finally taking away the cannula after tra- cheotomy, died in a fit of suffocation induced by cauter- ization of a reddish prominence, seen in the interior of the trachea. Upon autopsy it was found that, upon the posterior wall of the trachea, at a point directly opposite to that where the section of the cartilaginous rings had been made, where the cannula had been introduced, there existed a reddish prominence which, projecting into the interior of the air-tube, diminished notably its calibre, without, however, completely obliterating it. This pro- jection, which had been perceived during life at the bot- tom of the wound, was not formed by a mass of exu- berant granulations, as had been thought, but by the posterior wall of the trachea itself, which had been thrown into a longitudinal fold involving its whole thickness; a folding which was owing to the pushing toward each other of the posterior extremities of the rings that had been separated in front to admit the can- nula. The same folding and in-pushing of the posterior wall was repeatedly reproduced experimentally on the cadavers of children by Carrie, and the final conclusion announced in the thesis, based on this case and upon the experiments, was that very often the introduction of a cannula into the trachea of an infant produces a diminu- tion in the transverse diameter of the posterior wall ; that this posterior wall is made to project more or less markedly into the interior of the trachea, and that if this projection persists after the removal of the cannula and the cicatrization of the wound, a permanent constriction of the trachea will be produced. It should be noted that in subjects under two and one-half years of age, in whom the tracheal cartilages have little resistance, this folding of the posterior wall wTas not observed. While the descriptions of this observer as to the changes in the posterior wall of the trachea may be ac- cepted as correct, it is evident that the simple separation of the tracheal rings in front, whether to admit the can- nula, or to maintain a patent aperture without the can- nula, would cause this change in the structures behind. I have observed this protrusion forward of the poste- rior wall of the trachea when the lips of the tracheal wound were widely drawn apart, and in one instance re- member to have mistaken it for a mass of exudate, having grasped it with forceps in my efforts to remove it. By Fig. 3978.-Sloughing of a Portion of the Larynx, and Ulceration of the Trachea through Pressure of the Can- nula. 185 Tracheotomy, Tracheotomy, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. whatever means the tracheal wound may be kept dilated, this forward projection of the posterior wall may be ex- pected to occur ; but as soon as the margins of the cut rings are permitted to come together in front, the pos- terior wall may be expected to unfold, and the protru- sion to be effaced, unless, as the result of some irritation, inflammatory exudation shall have so complicated it as to render it persistent. The irritation of the cannula, particularly if it be long retained in situ, would be a fruitful cause of the conditions needed to make this source of obstruction persistent. The unnecessary presence of a fenes- trum on the convexity of the outer tube, which is so common, is likely to be a source of irritation to a protruding posterior wall, and for this reason, if for no other, is undesirable. If the careful methods of operating which 1 have advised be followed, the operator will readily discern, when he separates the lips of the tracheal incision, whether the posterior wall is thrown up into such a ridge as to be a serious matter. If such is the case, a semilunar portion should be cut out from the edge of the tracheal cut on either side, so as to di- minish the amount of outward drawing that the cut ring would be subjected to in order to accommodate the cannula. Granulation-vegetations. - Exuberant granulations, forming polypoid excres- cences projecting into the trachea, have been noted by many observers; they may be sessile or pedunculated, single or multiple ; they most frequently occupy the superior or inferior angle of the wound, at which points a small space exists not occu- pied by the cannula, which is early filled by granulation- tissue and is constantly subject to the irritation of the tube thereafter. Fig. 3979, from Hueter's " Grundriss dcr Chirurgie," shows the location and the most usual form of these granulation-vegetations, and illustrates the man- ner in which obstructive symptoms are caused by them. In most reported cases they have attained their full de- velopment by the time the first efforts at final removal of the cannula are made, and at once cause such obstructive symptoms that the tube has to be indefinitely retained or the masses destroyed. I n more rare in- stances they do not give rise to any serious symptoms when the cannula is re- moved, but by a subsequent growth produce later em- barrassment after complete cicatriza- tion. Fig. 3980 illus- trates such a growth, reported by Wansch- er,18 of Copenhagen. These polypi are very vascular, and this vascu- larity may be increased by strong respiratory ef- forts, which may gives rise to such rapid swelling from congestion and oedema as to cause speedy death. Ross19 analyzes fourteen cases of these late-appearing polypi collected by him from the literature. Gill10 gives an additional case, which is peculiar in that no tube was employed to keep the open- ing patent, but a heavy silk thread was passed through the ends of the divided cricoid on either side, upon which the traction necessary to keep the passage free was made. In most of these cases high tracheotomy had been per- formed, and in none of them was the cannula retained longer than a week or ten days. The most characteristic symptoms of the development of such a polyp are a noc- turnal respiratory bruit, snoring in character, and respira- tory embarrassment during the day after any excitement, bodily or mental, after taking cold, or under similar con- ditions. These symptoms are the precursors of attacks of dyspnoea, which may end fatally unless the trachea is reopened. According to Ross, of the recorded cases four died before operation could be performed. The case re- ported by Gill also died suddenly, apparently from spasm of the glottis. In seven, a second tracheotomy saved the patients' lives. Five of these made a good recovery, no recurrence of the polyp taking place ; but in the other two a third tracheotomy had to be performed, with per- manent use of the cannula thereafter. In one case the polyp was expelled through the glottis by cough, and the patient subsequently did well. In two the tumors were found by accident at the autopsies, death having occurred from other causes. Whenever vegetations are discovered protruding into the trachea from the angles of the tra- cheal wound, they are to be treated as exuberant granu- lations would be in any other locality. They are to be destroyed by the application of caustics, or if they can be torn away their bases should be cauterized. What- ever operative procedure may be necessary to make them accessible to the required applications must be done, as their presence is always a source of danger. Whenever a prolonged use of the cannula is necessary a watch should be kept for any signs of their development, and their growth repressed from the first. Care of the Cannula.-A constant watch over the cannula should be had from the moment of its introduc- tion until either it is possible to remove it altogether, or the trachea has become accustomed to its presence and the tracheal secretions are normal. The surgeon must see that the nurse is thoroughly familiar with the mech- anism of the double tube and knows how to remove and replace the inner tube with the least possible dis- turbance to the patient. It is especially desirable that the care of the cannula be entrusted to a judicious person who will not neglect it on the one hand, nor needlessly torment the patient on the other by useless fussiness over it. The inner tube should be removed only when there is a manifest occasion for it, as shown by some interfer- ence with the free passage of air. If the toilet of the trachea has been carefully made before the tube is intro- duced, the amount of expectoration will often not be very great during the first twenty-four hours, but if a rapid breaking down of membrane, or a copious tracheal or bronchial catarrh coincides with the introduction of the cannula and occasions profuse expectoration, the ten- dency to clogging of the tube will be so frequently mani- fest that the removal of the inner tube and its cleaning will be required at comparatively short intervals. Even in cases which are not giving much trouble, obstructive crises are likely to develop suddenly at any time, caused by clumps of inspissated mucus, or pieces of exfoliated membrane, being driven into the tube by cough, or being brought up against its lower end so as to occlude more or less completely its opening. The extreme dyspnoea caused by such an accident, if not quickly relieved, will soon end in death. If the removal of the inner tube does not relieve the symptoms, the whole tube should be re- moved, and the needed measures to clear out the trachea be carried on through the unobstructed wound. When the inner tube is to be removed, the shield of the outer tube should be steadied by the thumb and forefinger of one hand, while the inner tube is disengaged and with- drawn with the other hand. The withdrawn tube should then be dropped into a cup of warm water, in which it should be left for a short time, in order to soften the more or less inspissated mucus within it. Then a small mass of cotton-wTool or a piece of sponge should be pushed through it, so as to clear it out. A splint from a broom will always be available for the purpose of push- ing the cotton or sponge through, and is to be chosen rather than a wire or hairpin ; for the latter, if not very Fig. 3979.-Typical Granulation - poly- pus. (Natural size. Hueter.) g, Posi- tion during inspi- ration ; g', position during expiration; o, opening in the trachea from tra- cheotomy. Fig. 3980.-Cicatricial Polypiform Vegetation, growing from the Tracheal Cicatrix. (Wanscher.) 186 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tracheotomy. Tracheotomy. carefully used, may scratch and mar the soft metal of which the tube is made. The tube having been cleaned out, it should then be rinsed in the water and replaced. The inner tube ought not to be left out any longer than is necessary to clean it, lest, when it is replaced, it push before it a possible mass of inspissated mucus, gathered on the inside of the outer tube while the inner one has been out, which by the time the tube is down in place may become a plug sufficient to entirely occlude it. The outer tube may usually be left in place, with- out being disturbed, for the first two days. At the end of this time, that is at the close of the second or the be- ginning of the third day, it will be desirable to remove the whole apparatus for the purpose of cleaning up. By this time the wound-borders will have become somewhat firm, so that the opening down to the trachea will remain patent for a while without the tube, and sufficient time can be had to clean up the wound and the parts about, as well as to cleanse the tubes and arm them with fresh tapes. When the cannula is ready to be replaced, it will generally easily slip back into the trachea along the track which it has already made for itself, the walls of which are firm enough to guide the advancing end of the tube, if it is gently pushed along with proper regard to the di- rection which it should take. A hitch may occur when the end of the cannula reaches the entrance into the trachea, owing to the resilient cartilages having sprung back and partly closed the opening. If the tube has been kept out some time this obstacle is more likely to arise. Usually a little gentle pressure will overcome it, and the tube will slide into the trachea. No violent efforts should be made to pass the tube, lest a false passage be made and the tube be thrust down in front or at the side of the trachea instead of into it. The use of a conical- pointed pilot obturator (Fig. 3974) will always prevent any difficulty of this kind, and the surgeon would do well to be provided with one. The three-bladed dilator of Laborde is also very serviceable in overcoming such a difficulty. If the cannula track has not become quite well defined and firm, the hook retractors may be used to advantage for dilating anew the tracheal wound suffi- ciently to permit the cannula to pass. If the walls of the wound are still so soft at this period that they fall together at once after removing the cannula, the wound must be kept open by a dilator while the nec- essary cares are given to it and a fresh tube is made ready for insertion. When this first change of the cannula is to be made the patient should be placed upon a table with the same arrangements as in the original operation, other- wise the surgeon may find himself at a very great disad- vantage in his efforts to give the needed attention to his patient. The further care of the cannula will differ according to the nature of the case for which tracheotomy has been done. If the tube is to be worn permanently, or until some cause of obstruction has been removed by subse- quent operation, it will be left in place, with but rare changes. If the tube is one whose size and shape is adapted to the case, the trachea soon becomes accustomed to it so that it is borne without discomfort; the super- ficial wound heals rapidly, and the track of the cannula becomes a fistula with well-organized walls. If the op- eration has been done for the relief of temporary obstruc- tion from inflammatory or diphtheritic disease of the larynx, it will be desirable to dispense with the cannula as soon as the obstruction shall have cleared away suffi- ciently to permit air again to pass through the larynx. To determine this the tube should be removed at the end of thirty-six or forty-eight hours, with great gentle- ness, so as to alarm the patient as little as possible, and the wound-opening should be occluded with two or three folds of moist muslin placed over it, so as to test the ability of the patient to respire through the larynx. Fre- quently, even as early as this, it will be found that the obstruction has cleared away and that the cannula can be permanently dispensed with. If, however, respiration through the natural channels be found still impossible, the cannula must be replaced. Each day the permeability of the larynx may be again tested for a time. If by the eighth day it shall appear that easy respiration through I the larynx is not yet possible, it will rarely be due to the persistence of obstructive exudate or oedematous swelling, but will be caused in the most cases either by temporary paralysis of the glottic dilators, diphtheritic in origin, or by glottic spasm of emotional origin ; less frequently it will be due to persistent submucous inflammatory sw el- ling or to inflammatory infiltration of the laryngeal mus- cles. More rarely yet, the inability to do without the tube will be due to the tracheal conditions already de- scribed, viz., in-turned cartilages, collapse of the trachea, or polypoid granulation excrescences. Cicatricial con- tractions causing stenosis of the trachea, following upon extensive destruction of its walls by ulceration or gan- grene, may also oblige the patient to permanently retain the cannula. Whatever the cause, it will be well now to suspend for a time the efforts to do without the tube. A week may be allowed to pass during which the larynx is left at rest, and efforts are made to improve the gen- eral condition of the patient by iron and strychnine, and the local paresis by faradization. At the end of this time the efforts to dispense with the cannula should be renewed. All the manipulations should be made with gentleness, accompanied by manner and voice tending to reassure the patient, who has learned to rely on the cannula for breath, and who regards its removal with ap- prehension. As soon as any marked distress is caused by the absence of the tube it should be replaced, and further attempts deferred until another day. If after three or four trials suffocative crises continue to follow quickly after every attempt to remove the tube, these efforts should be desisted from again for some time, a week or more. In the vast majority of cases a time will finally come when the tube may permanently be dispensed w'ith. The periods at which the cannula has been dispensed w'ith in cases of tracheotomy for diphtheritic croup, under my own treatment, have been as follows : Tracheotomy for Diphtheritic Croup.-Total number of cases 60 ; recoveries, 18. Day of Anal removal of cannula. Number of eases. Fourth day 6 Fifth day 4 Sixth day 2 Seventh day .... 1 Eighth day 2 Thirteenth day 1 Twenty-sixth day 1 Twenty-eighth day 1 Total 18 With this table may be compared the following from SanmV0 comprising 134 cases of recovery after trache- otomy for croup : Day of final removal of cannula. Number of cases. At end of first day 1 At end of third day .. 3 At end of fourth day 8 At end of fifth day 14 At end of sixth day 18 At end of seventh day 16 At end of eighth day 18 At end of ninth day 7 At end of tenth day ... 8 At end of eleventh day 4 At end of twelfth day 5 At end of thirteenth day 6 At end of fourteenth day 1 Between fifteenth and twenty-first day 14 Between twenty-third and forty-fifth day 8 At end of 126th day 1 Total 132 Out of 95 recoveries after tracheotomy for croup at the Boston City Hospital (Lovett and Munro28), in 65 the tube was finally removed by the eighth day. Of the others, in four it was impossible to remove the tube definitely until after the expiration of from three months to three years. Emotional laryngeal spasm is a condition which has frequently to be encountered in the effort to remove the cannula in nervous, excitable children. It may co-exist w'ith and thus aggravate the difficulties caused by other conditions, or may be the sole trouble. In the latter case 187 T rac ii e o< o«> y. Trades. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. -to use the description of Sanne-the patient has reached a condition of health which is satisfactory in every re- spect ; the voice is clear, the air passes freely through the larynx; there is no paralysis, and yet the child cannot remain without the cannula. It seems to him that respi- ration is impossible without its assistance, and he refuses to try his powers. As soon as the cannula is removed he becomes agitated and terrified; respiration, which may for the first few moments have been free, becomes embarrassed, and suffocation becomes quickly so immi- nent that immediate replacing of the tube is imperative. In yet other cases, breathing has been good enough as long as the child knew that the cannula was at hand, as, for example, hanging from the neck or by the side of the bed; but whenever it was removed to a distance, suffoca- tive crises would be precipitated. In a case reported by Saint-Germain,56 the cannula had been removed for some hours, and all was going well, when the child took a notion to look at herself in a mirror. As she looked, she imag- ined that she could see the wound-opening closing up, and at once had an hysterical attack with such suffoca- tion that the cannula had to be replaced, and was indefi- nitely retained thereafter. The final removal of the cannula may almost always be accomplished in these cases. In one case reported by Saint-Germain-not the one referred to in the previous paragraph-the cannula was finally dispensed with at the end of four years. In the two cases of my own, in which the cannula could not be withdrawn until in the fourth week, emotional spasm, whenever the effort to withdraw it was made, was the cause of the delay for the last half of the time. In the case of an infant of thirteen months, upon whom I did tracheotomy on account of a bit of bone that remained impacted in the larynx for eighteen days, paresis of the laryngeal muscles and glottic tumefaction delayed the re- moval of the cannula for over two months. During the third month both inspiration and expiration had become free, as demonstrated by blocking up the external orifice of the tube while the child slept, a fenestrum in the tube permitting the air-current to pass through the larynx ; but whenever the tube was removed while the child was awake, a suffocative paroxysm necessitated its immediate replacement. This condition persisted for a number of months, during which the infant grew and developed well. Efforts to remove the tube were made at frequent intervals, and finally, on the 172d day aftei' the operation, when the tube was removed, after a momentary agitation on the part of the child its breathing became tranquil, no further embarrassment ever again arose, and the can- nula was permanently discarded. This emotional condition is to be overcome by tact, patience, and time. Many artifices have been resorted to for conquering the nervous fear upon which the spasm depends. Gradual shortening of the cannula, even down to the point of a mere button resting upon the closed ex- ternal wound, and gradual narrowing of the cannula un- til it is no longer a pervious tube, have each been resorted to successfully. The confidence of the patient in its abil- ity to breathe without the tube must be awakened ; how to do this must be left largely to the ingenuity of the at- tendants and the inspiration of the occasion. Lewis 8. Pilcher. 1 Sprengel, K.: Versuch einer pragmatischen Geschichte der Aerzney- kunde. Trad, par Jourdan, T. vii., Sec. 18, Chap. 6. 2 Paulus -Egineta: Translation and Commentary ; Adams, vol. ii., p. 3C2. 3 Benivieni, Antonio: De abditis morborum causis, Cap. 88, p. 40. Basel, 1529. 4 Brassavola, Ant. Musa : Comment, in Hippocr. de Viet. Acut., iv., p. 120. Lugd. Batav., 1543. 8 Fabricius ab Acquapendente: Opera chirurgica, Cap. 44. Padua, 1617. 8 Casserius, Julius: De vocis auditusque organis historia anatomica, Libr. I.. Cap. xx. Ferrara, 1600. 7 Habicot, Nicolas : Question chimrgicale par laquelle il est demontre que le chirurgien doit assurement pratiquer 1'operation de la broncho- tomie, etc. Paris, 1620. 8 Severinus, Marcus Aurelius: De efficace medicina, Pars, ii.. Cap. 40. De laryngotomia in suffocante angina, p. 102. Francofurti, 1646. 9 Fonteyn, Nicolas : Observat. rarior. analect®. Amstelodami, 1641. 10 Moreau, Rene: Epistola de laryngotomia. Paris, 1646. 11 Purmann, Matthias Gottfried : Chirurgia curiosa. Frankfurti, 1694. >2 Dionis, Pierre : Cours d'Operations de Chirurgie. Paris, 1707. 13 Verduc, Jean Baptiste : Traite des Operations de Chirurgie. Paris, 1693. 14 Juncker, Johannes : Conspectus Chirurgi®. Halle, 1721. 16 Martin, George: Philosophical Transactions, vol, xxxvi., No. 416, pp. 448-55. 1730. 16 Louis, Antoine: Memoiresde 1'Academic royale de Chirurgie, t. iv„ pp. 455-512. Paris, 1768. 17 Richter, Auguste Gottlob : Observat. chirurg., Fascicul. II., Cap. iii. De Bronchotomia. Gottingen, 1776. Anfangsgriinde der Wundar- zneykunst. 1782-1804. 18 Detharding, George : De methodo subveniendi submersis per laryn- gotomiam. Rostock, 1714. 19 Heister, Lorenz : Institutiones chirurgie®, Pars IL, Sec. ii., Cap. 2. Amstelodami, 1739. 30 Home, Francis : Inquiry into the Nature, Cause, and Core ofCroup. 1765. 21 Borsieri, Giambattista : Institutiones medicin® practic®, t. iv., Art. Angina trachealis. 22 Andre, John : Letter to Louis Valentin, Paris Journal general de Medecine, January, 1816. 23 Valentin, Louis: Recherches historiques et pratiques sur le Croup. Paris, 1812. 24 Caron : Traite du Croup aigu. Paris, 1808. 26 Royer-Collard: Rapport adresse aS. Ex. le Ministre de I'Interieur sur les Ouvrages envoyes au Concours sur le Croup. Paris, 1808. 26 Bretonneau : De la Diphtherite, etc. Paris, 1826. 27 Trousseau: Dictionnaire de Medecine, 2me edition, t. x., Article Diphtherite. Paris, 1835. Clinique de 1'Hotel-Dieu, 1865, t. i., Trache- otomie. 28 Lovett and Munro: Results of Tracheotomy at the Boston City Hos- pital, 1864-1887, Amer. Jour, of the Med. Sciences, July, 1887. 29 Gross, S. D.: Foreign Bodies in the Air-passages. 1854. 30 Dekkers, Frederik: Exercitationes practic®, etc. Leid®, 1694, p. 241. 31 Vicq d'Azyr : Memoires de la Socicte royale de Medecine. Hist., p. 311. 1776. 32 Fourcroy: De novo laryngotomi® methodo. These de Paris, 1779. 33 Desault-Bichat: CEuvres chirurgicales, on Expose de la doctrine et de la pratique de Desault, t. ii., p. 236. Publiets par Xav. Bichat., 3 vols. Paris, 1798-1803. 34 Boyer: Traite des Maladies chirurgicales. Paris, 1814-1827. Art. Bronchotomie. 38 Bliss: The Medical Repository, New York. 1813, vol. ii.. No. 4. 38 Chevalier, Thomas: Medico-chirurgical Transactions, 1815, vol. vi. pp. 151-155. 381 Roger: Bulletin de l'Acad. de Med., 1859, t. xxiv., p. 668. 37 Carmichael, Richard: Transactions College of Physicians in Ireland, 1820, vol. iii., pp. 170-193. 37» Bonnet, Charles : Essai sur 1'Histoire de la Tracheotomie. These de Paris, 1884. Schuchardt, Bernhard: Zur Geschichte der Tracheotomie bei Croup und Diphtheric. Archiv fur Klinische Chirurgie, Bd. 36, Hit. iii., 1887. 38 Hume, P.: London Med. Repository, July, 1824. 38a O'Dwyer, Joseph : Intubation in Chronic Stenosis of the Larynx, New York Med. Jour., March 10, 1888. 39 Wrist, J. R. : Foreign Bodies in the Air-passages. Trans. Amer. Surg. Assoc., vol. i., 1883. 49 Durham, Arthur E.: Diseases of the Larynx. Holmes's System of Surgery, vol. iv., p. 541. 41 Van Arsdale, W. W.: Diphtheria and Tracheotomy in Leipsic. An- nals of Surgery, 1885, vol. i., p. 97. 42 Hugonnai, Vilma : Das erste Hundert Croup-operationen in Zurich. Inaug.-Dissert. Zurich, 1878. 43 Monti, Alois : Ueber Croup und Diphtheritis in Kindesalter., p. 311. Wien, 1884. 44 Mastin, William M.: Tracheotomy for Croup in the United States, Gaillard's Med. Jour., January, 1880. 48 Astier, C.: Les Indications de la Tracheotomie, p. 95. These de Paris, 1880. 46 Hall, Marshall: Comptes-rendus de l'Acad. des Sciences, 1851. 47 Michael: Verhandlungen der deutschen Gesellschaft fiir Chirurgie, XII. Kongress, 1883. Beilage zum Centralbl. f. Chir., 1883, No. 23. 48 McBurney, Charles : Tracheotomy as a Preliminary to Certain Op- erations. Annals of Anatomy and Surgery, vol. vii., p. 201, 1883. 49 Hahn, Eugene: Ueber Kehlkopfsextirpation. Volkmann's Sammi, klin. Vortrage, No. 260. 60 Parise : Archives Gen. de M6d., 1880, p. 571. 61 Tillaux, P.: Anatomie topographique, p. 403. 82 Marsh, F. H.: On Tracheotomy in Children, St. Bart.'s Hosp. Rep., vol. iii., p. 331,1867. 83 Weinberg: Untersuchungen uber die Gestalt des Kehlkopfes in ver- schiedenen Lebensaltern. Archiv fur Klin. Chir., Bd. 21, S. 412. 54 Symington, J.: On the Anatomical Relations of the Trachea in the Child, Edinburgh Med. Jour., April, 1881. 66 De Saint-Germain : Lemons cliniques sur la Chirurgie des Enfants. 89 Fleiner, W.: Ueber Stenosen der Trachea nach Tracheotomie bei Croup und Diphtheritis. Deutsche Med. Wochenschrift, XI., 721, 737, 751, 782. Berlin, 1885. 87 Neukomm : Centralblatt fiir Chirurgie, 1885, No. 38. 88 Krishaber : M6moires de la Society de Chirurgie, t. vii., 1875, p. 796. 89 Boeckel, Jules : Note sur 85 Cas de Tracheotomie, pratiquees a l'Aide du Thermo-cautere de Paquelin. Gaz. Med. de Strasbourg, 1884, July 1st, p. 73. 80 Poinsot, G.: De la Tracheotomie par le Thermo-cautere. Paris, 1878. 81 Fowler, George R.: The Cautery in Tracheotomy. Annals of Anat- omy and Surgery, 1881, vol. iii., p. 206. 82 Durham, Arthur E.: Holmes's System of Surgery, vol. ii., Art. Tracheotomy, pp. 509 and 511. 83 Konig, Fr.: Lehrbuch der speciellen Chirurgie, 2 Aufl., Bd. 1., S. 567. Berlin, 1878. 84 Passavant, Gustav : Der Luftrohrenschnitt bei diphtherischen Croup. Deutsche Zeitschrift fiir Chirurgie, Bd. xix., Hft. 6 ; and Bd. xx., Hft. 1. 88 Roser: Deutsche Med. Wochenschrift, February 16, 1888. 188 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tracheotomy. Trades. 88 Sands, H. B.: Tracheotomy, American Clinical Lectures, New York, vol. ii., No. 7. 67 Treves, F.: On the Entrance of Air into Veins during Operations, British Med. Journ., 1883, i., 1278. 88 Thornton, Pugin : On Tracheotomy, p. 33. 1876. 68 Holmes, T.; The Surgical Treatment of the Diseases of Infancy and Childhood, p. 322. 1869. . 7" Sanne, A.: Treatise on Diphtheria, Trans, by Gill, p. 546. 1887. 71 Cohen, Solis : Croup in its Relation to Tracheotomy, p. 45. 72 Zimmerlin, F.: Ueber Bhitungen nach Tracheotomie wegen Croup und Diphtheritis. Inaugural Dissert. Basel, 1882. 73 Fidele, M.: Deux Cas de Mort par Hemorrhagie secondaire apres la Tracheotomie. Ann. des Mal. de 1'Oreille, du Larynx, etc. Mars 1879. 74 Martin, H. A.: Tracheotomy without Tubes. Transact. Amer. Med. Assoc., 1878. 75 Bloch, Oscar: Om Dekubitus af Trakea's Slimhinde, frembragte ved Trakeotomikanylen, og om Valget af Trakeotomikanyler. Hospitals Tidende, 1881, viii., 61, 82, 101, 121, 141,161. 78 Sabatier : De la Medecine ope^atoire, t. iii., p. 45. 77 Carrie, Louis : Contribution a l'6tude des causes empechant 1'abla- tion definitive de la canule aprds la tracheotomie chez les enfants. These de Paris, 1879, No. 13. 7BWanscher: Om Diphtheritis og Croup saerligt med Hensyn til Tracheotomien ved samme. Kjobenhaven, 1877. 78 Ross. J. M.: Sequel® of Tracheotomy, Edinburgh Med. Journ., March, 1883, p. 786. TRADES, OFFENSIVE. There are existent certain products, the handling and treatment of which can scarce- ly be conducted without offence. One of the chief results of civilization is the attempt to make use of the so-called waste products of manufacturing without their becoming a nuisance to the neighboring inhabitants. The reports of the various sanitary bodies throughout the world are tilled with accounts of the endeavors of the manufacturer to utilize all he can, and of the attempts made by those who suffer from his works to control him. The history of these contests is the history of sanitary science, if not of civilization itself. Any antagonism between the health-officer and the manufacturer is needless. Indeed, it is only due " either to want of confidence in the skill or technical knowledge of the professional adviser, or to an unjust or exaggerated view of the necessity of pro- viding for the public health and comfort at any cost."1 Originally the term "noxious and offensive trades," as described in various sanitary acts, was limited to the business of slaughtering animals, with the treatment of the resultant products therefrom ; but, owing to the in- crease of manufacturing industries, the term " offensive trades " now includes any business by which may be created a nuisance to the inhabitants of the neighborhood. Most of the so-called offensive trades are absolutely necessary, and it is impossible to carry on the requisite manufacturing operations without some offence ; for, no matter how carefully a business may be conducted, it is not always practicable to control the workmen or the machinery. This raises an important question. What is the maximum of offence to be allowed ? Here comes the contest between the manufacturer creating the nui- sance and the people suffering from it, and here the sanitary officer acts as umpire, and strives to decide the point at issue. Fortunately, however, in most cases the interest of the general public and that of the manufact- urer go hand in hand, for what is injurious to the former is generally a wasteful loss to the latter. This fact is not always apparent to either party, but it soon becomes so, for suggestions of improvements, not at first readily ac- cepted, are afterward gratefully acknowledged. The only general system of classifying manufacturing industries is that adopted by the French Government, who in 1810 promulgated a decree dividing them into three classes. Since that period various alterations in the list have been made, until at present it is as fol- lows : First Class. Business, Character of Nuisance. Acid. Oxalic, manufacture of, by nitric acid, without destruction of noxious gases. Acid, Picric, when the noxious gases are not burned. Acid, Stearic, manufacture of, by distillation. Acid, Sulphuric, manufacture of, by the combustion of sulphur and pyrites. Nordhausen process, by the decomposition of sul- phate of iron. Aldehyde, manufacture of. Archil, manufacture of, in covered kettles. Arsenite of Potash, manufacture of, by means of salt- petre, when the fumes are not absorbed. Axle-grease, manufacture of. Blood, storehouse of, for the manufacture of Prussian blue and other industries. Blood, manufacture of powder from, for the clarifica- tion of wines. Blood, works for separating the fibrin, albumen, etc. Bone-fat, manufacture of. Bones, drying of, for manure, when the gases are not burned. Bones, fresh, storehouse of, on a large scale. Brown Grease, manufacture of. Burning of Sea-weed, in permanent establishments. Carbonization of animal matters. Chrysalids, shops for the extraction of the silky por- tions of. Coke, manufacture of, in open air, or in furnaces without smoke-consumers. Crude Soda, from sea-weed, manufacture of, in per- manent establishments. Cyanide of Potassium and Prussian Blue, manufact- ure of, by direct calcination of animal matters with potash. Dirt and Rubbish, storehouse of, and Dumps. Dogs, hospitals for. Earths containing pyrites, roasting of. Ether, manufacture and storehouse of. Fat-rendering, establishments for, over open fire. Felt and Glazed Visors, manufacture of. Fertilizers, storehouse of (matters coming from night- soil or offal, unmanufactured, or in an uncovered storehouse). Fertilizers, manufacture of, from animal matters. Fireworks, manufacture of. Fish-oil, manufacture of. Flesh, Scraps, and Offal from the slaughtering of ani- mals, storehouse of. Fulminate of Mercury, manufacture of. Fuse, manufacture of, with explosive materials. Glue, manufacture of. Gold and Silver Refining, by acids. Grease or Thick Oil, for the use of the makers of chamois leather, or curriers, manufacture of. Guano, storehouse of, when amount exceeds 25,000 kilogrammes. Gut-cleaning establishments, handling of fresh intes- tines. Ilogs' Bristles, preparation of, by fermentation. Ivory Black and Animal Black (distillation of bones or manufacture of), when the gases are not burned. Knackeries. Lignite, incineration of. Matches, manufacture of, with explosive materials. Menageries. Neat's-foot Oil, manufacture of, by using matters al- ready putrescent. Nitrate of Iron, manufacture of, when the injurious fumes are not absorbed or decomposed. Oils and other fatty matters, extraction of, from the debris of animal matters. Oils, mixing by heat or boiling of, in open kettles. Oils of petroleum, schist, and tar, essences, and other hydrocarbons employed in lighting, warming, man- ufacture of colors and varnishes, scouring of cloth, arid other uses, manufacture, distillation, and hand- ling of, on a large scale. Olive-cakes, treatment of, by sulphide of carbon. Patent Leather, manufacture of. Pearlash, with discharge of smoke externally. Peat, carbonization of, in open vessels. Percussion Caps, manufacture of. Petroleum, etc., storehouse of. 1. Substances very inflammable, that is, with a flashing-point below 35° C., if the quantity stored is even temporarily 1,050 litres or more. 2. Substances less inflammable, that is, with a flashing-point of 35° C., or over, if the quantity stored is even temporarily 10,500 litres or more. Phosphorus, manufacture of. Piggeries. Fumes. Injurious fumes. Odors, fire. Injurious fumes. Injurious fumes. Fire. Odors. Injurious fumes. Odors, fire. Odors. Odors. Odors. Odors, pollution of water, fire. Odors, fire. Odors. Odors, fire. Odors, smoke. Odors. Odors. Smoke, dust. Odors, smoke. Odors. Odors. Odors, noise. Smoke, injurious fumes. Fire, explosion. Odors, fire. Odors, fire. Odors. Odors. Fire, explosion. Odors, fire. Odors. Explosion, fire. Explosion, fire. Odors, pollution of water. Injurious fumes. Odors, fire. Odors. Odors. Odors. Odors. Odors, injurious fumes. Smoke, injurious fumes. Fire, explosion. Danger from ani- mals. Odors. Injurious fumes. Odors, fire. Odors, fire. Odors, fire. Fire. Odors, fire. Smoke, odors. Odors, smoke. Explosion. Odors, fire. Odors, fire. Fire. Odors, noise. First Class.-Continued. Business. Character of Nuisance. Abattoirs, public. Odors, pollution of water. Acid, Arsenic, manufacture of, by means of arsenious and nitric acids, when the nitrous products are not absorbed. Injurious fumes. .dcid. Hydrochloric, production of, by decomposition of the chlorides of magnesium, aluminium, etc., when the acid is not condensed. Injurious fumes. 189 Trades. Trades. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. First Class.-Continued. Second Class.-Continued. Business. Character of Nuisance. Poudrette and other manures, manufacture of. Odors, pollution Powder and fulminating matters, manufacture of. of water. Explosion, fire. Printing ink, manufacture of. Odor, fire. Prussian and English red. Injurious fumes. Red Oils, manufacture of, by extraction from scraps Odor, fire. and fatty residues, at a high temperature. Resin Oils, manufacture of. Odor, fire. Resins, Galipots, and Common Rosin, works on a large scale, for the melting and clarifying of. Retting of hemp and flax, on a large scale. Odor, fire. Pollution of wa- Roasting of minerals containing sulphur. ter, injurious fumes. Smoke, injurious Sabots, shops for smoking, by the burning of horn or fumes. Odor, smoke. other animal matters, in towns. Scalding-houses for the industrial preparation of offal. Odor. Scouring of woollen goods and cleaning by naphtha or Fire. other hydrocarbons. Scraps, manufacture of. Odor, fire. Slops, extraction of the fatty matters contained in, Odor, fire. for the manufacture of soap and other uses, in open kettles. Starch, manufacture of, by fermentation. Odor, injurious Sulphate of Ammonia, manufacture of, by distillation fumes. Odor. of animal matters. Sulphate of Copper, manufacture of, by roasting py- Injurious fumes, rites. smoke. Sulphate of Mercury, manufacture of, when the va- Injurious fumes. pors are not absorbed. Sulphate of Soda, manufacture of, by the decomposi- tion of pea-salt by sulphuric acid, without conden- sation of the hydrochloric acid. Injurious fumes. Sulphide of Carbon, manufacture of. Odor, fire. Sulphide of Carbon, manufactories in which it is used Fire. on a large scale. Taffetas and glazed or waxed cloths, manufacture of. Odor, fire. Tarpaulins, manufacture of, with the boiling of oils. Fire. Tars and vegetable resins of different kinds, elabora- Odor, fire. tion of. Tars of different origins, special works for the elabo- Odor, fire. ration of. Tobacco, burning of the stems. Odor, smoke. Triperies connected with abattoirs. Odor, pollution Varnish, Oily, manufacture of. of water. Odor, fire. Business. Character of Nuisance. Currying establishments. Odor. Cyanide of Potassium and Prussian Blue, manufact- Odor. ure of, by using matters previously carbonized, in close vessels. Dairies, on a large scale, in towns. Odor. Enamelled Ware, manufacture of, with non-smoke- Smoke. consuming furnaces. Engines, and Cars, shops for the construction of. Noise, smoke. Faience, manufacture of, with non-smoke-consuming Smoke. furnaces. Fat-rendering, establishments for, in jacketed steam- Odor. kettles. Felt, tarred, manufacture of. Odor, fire. Fertilizers, storehouse of, matters coming from night- Odor. soil or offal, dried or disinfected, and in a covered storehouse, when the quantity exceeds 25,000 kilo- grammes. Fish, shops for salting and smoking. Forges and Boiler-works, for large pieces, employing trip-hammers. Gas, for illuminating and heating, manufacture of, for public use. Glass (common, flint, and plate), manufacture of. Gold and Silver Laces and tissues, establishments for burning on a large scale, in towns. Green Leather and fresh hides, storehouse of. Illuminating Fluids made of alcohol and essential Odor. Smoke, noise. Odor, fire. Smoke. Odor. Odor. Fire, explosion. oils, storehouse of. India Rubber, application of coats of. Fire. India Rubber, manufacture of, with essential oils or Odor, fire. sulphide of carbon. Ivory Black and animal black (distillation of bones Odor. or manufacture of), when the gases are burned. Lamp-black, manufacture of, by distillation of coal- Smoke, odor. tar, bitumen, etc. Lime-kilns, permanent. Murexide, manufacture of, in closed vessels, by the Smoke, dust. Injurious fumes. reaction of nitric acid with the uric acid of gums. Neat's-foot Oil, manufacture of, when the matters used are not undergoing putrefaction. Odor. Eitro-bemol, Aniline, anil matters derived from ben- Odor, fire, injuri- zine, manufacture of. ous fumes. Oiled textures for packing, tissues, tarred cords, tarred Odor, fire. paper, bitumenized pasteboard and tubes, manufact- ure of. Oils, mixing by heat or boiling of, in closed vessels. Odor, fire. Oils of petroleum, schist, and tar, essences, and other hydrocarbons, used for lighting, heating, manufact- Odor, fire. ure of colors and varnishes, the scouring of cloth, and other uses. 1. Storehouses of substances very inflammable, that is, with flashing-point below 35° C. If the quantity over 150 litres does not reach 1.050 litres. Odor, fire. 2. Substances less inflammable, that is, with a flashing-point of 35° C. or over. If the quantity stored over 1,050 litres does not reach 10,500 litres. Odor, fire. Onions, drying of, in towns. Odor. Parchment factories. Odor. Pearlash, with burning or condensation of the smoke. Smoke, odor. Peat, carbonization of, in close chambers. Odor. Pigs' Hairs and Bristles, preparation of, without fer- Odor, dust. mentation. Plaster-kilns, permanent. Smoke, dust. Porcelain, manufacture of, with non-smoke-consum- Smoke. ing furnaces. Potash, manufacture of, by calcination of the residue Smoke, odor. of molasses. Protochloride of Tin, or salt of tin, manufacture of. Injurious fumes. Refineries and sugar-houses. Smoke, odor. Retting, on a large scale, of hemp and flax, by the ac- Injurious fumes. tion of acids, warm water, and steam. pollution of water. Roe, storehouses of liquid salted stuff known under Odor. the name of. Sal Ammoniac extracted from the ammoniacal liquor Odor. of gas-works. Sal Ammoniac and sulphate of ammonia, manufact- Odor, injurious ure of, by the use of animal matters. fumes. Salted Fish, storehouses of. Odor. Sardines, factories of preserved, in towns. Odor. Sausages, manufacture of, on a large scale. Odor. Silk Hats, or others prepared by means of a finish, Fire. manufacture of. Slaughter-houses. Danger from ani- mals, odor. Slops, extraction of the fats contained in them, for Odor, fire. the manufacture of soap and other uses, in closed vessels. Starch, manufacture of, by separation of gluten, and Pollution of wa- without fermentation. ter. Stripping of hemp, flax, and jute, on a large scale. Dust, noise. Sulphate of Mercury, manufacture of, when the va- Injurious fumes pors are absorbed. in a less de- gree. Sulphate of the Peroxide of Iron, manufacture of, by Injurious fumes. the sulphate of the protoxide of iron and nitric acid, nitro-sulphate of iron. Second Class. Business. Character of Nuisance. Acid, Arsenic, manufacture of, by means of arsenious Injurious fumes. and nitric acids, when the nitrous products are ab- sorbed. Acid, Hydrochloric, production of, by the decomposi- Injurious fumes. tion of the chlorides of magnesium, aluminium, etc., when the acid is condensed. Acid, Oxalic, manufacture of, from sawdust and pot- Fumes. ash. Acid, Pyroligneous, manufacture of, when the gase- ous products are not burned. Smoke, odor. Acid, Pyroligneous, purification of. Odor. Acid, Stearic, manufacture of, by saponification. Odor, fire. Alcohol, rectification of. Fire. Alkaline Chlorides, Eau de Javelle, manufacture of. Odor. Arsenite of Potash, manufacture of. by means of salt- Injurious fumes. petre, when the vapors are absorbed. Artificial Fuel, or bricks of coal, manufacture of, Odor, fire. with fat resins. Asphalt and Bitumen, works, with open fire. Odor, fire. Injurious fumes. Baryta, decoloration of the sulphate of, by means of hydrochloric acid, in open vessels. Black of refineries and sugar-houses, revivification of. Odor, injurious Blast-furnaces. fumes. Smoke, dust. Bleaching of threads, textures, and paper pulp, by Odor, injurious chlorine. fumes. Of threads and textures of wool and silk, by sul- Injurious fumes. phurous acid. Bones, calcining, for manure, when the gases are Odor, fire. burned. Carpet-beating, on a large scale. Noise, dust. Chamois Leather, manufacture of. Odor. Chloride of Lime, manufacture of, on a large scale. Odor. Chlorine, manufacture of. Odor. Cleaning of rabbit and hare skins for felt. Odor. Cocoons, treatment of the envelopes of. Pollution of wa- Codfish, places for drying. ter. Odor. Coke, manufacture of, in smoke-consuming furnaces. Cooperage on a large scale, using casks impregnated with oily and putrescent matters. Dust. Noise, odor, smoke. 190 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Trades. Trades. Third Class.-Continued. Character of Business. Nuisance. - Sulphate of Soda, manufacture of, with complete con- Injurious fumes. densation of the hydrochloric acid. Sulphur, fusion or distillation of. Injurious fumes, fire. Tanneries. Odor. Tarpaulins, manufacture of, without boiling oils. Fire. Tars and fluid, bituminous substances, storehouses of. Odor, fire. Tars, treatment of, in the gas works where they are Odor, fire. produced. Tobacco, manufacture of. Odor, dust. Tobacco-pipes, manufacture of, with non-smoke-con- Smoke. Burning furnaces. Torches, resinous, manufacture of. Odor. fire. Varnish, manufacture of, with spirit of wine. Odor, fire. Wood-charcoal, manufacture of, in the open air, in permanent establishments, elsewhere than in the Odor, smoke. forest. In closed chambers, with the discharge into the air of the gaseous products of distillation. Odor, smoke. Second Class.-Continued. Business. Character of Nuisance. Fertilizers, storehouses of, matters coming from night- soil or offal, dried or disinfected, and in covered storehouses, in quantity less than 25,000 kilo- grammes. Fire-wood, yards, in towns. Flints, furnace for calcination of. Foundries for second melting. Freezing Apparatus, with ammonia. Freezing Apparatus, with ether or other related and combustible liquids. Gas, for lighting and heating, manufacture of, for private use. Gasometers, for private use, not adjoining the manu- factories. Gelatine for food, and gelatine from white skins and fresh skins, untanned, manufacture of. Gilding and silvering of metals. Glass Works (common, flint, and plate), with smoke- consuming furnaces. Gold and Silver Beaters. Goldsmiths' Ashes, treatment of, by lead. Guano, storehouses of, when the quantity exceeds 25,000 kilogrammes. Guano, for sale at retail. Herring, smoking of. Hungary Leather, manufacture of. Japanned Plate and metals. Leather-beating, hammers for. Leather-dressing works. Lime-kilns, running not over a month a year. Litharge, manufacture of. Massicot, manufacture of. Mills for grinding plaster, lime, flints, and puzzolana. Mineral Black, manufacture of, by crushing the resi- due of the distillation of bituminous schists. Morocco Leather works. Nitrate of Iron, manufacture of, when the injurious vapors are absorbed or decomposed. Oiled Textures for packing, tissues, tarred cords, tarred papers, bitumenized pasteboard and tubes, worked with heat. Worked cold. Oils, refining of. Oil Works, or oil mills. Olives, preserving of. Paper, manufacture of. Paper Pulp, preparation of, from straw and other combustible matters. Pasteboard making. Pasteboard Snuff-boxes, manufacture of. Perchloride of Iron, manufacture of, by dissolving peroxide of iron. Plaster-kilns, not running more than one month a year. Porcelain, manufacture of, with smoke-consuming furnaces. Protosulphate of Iron or green vitriol, manufacture of, on a large scale, by the action of sulphuric acid on iron filings. Puzzolana, artificial, furnace for. Bags, storehouses of. Bed Cyanide of Potassium, or red prussiate of potash. Bed Lead, manufacture of. Salt of Soda, manufacture of, with sulphate of soda. Salted Meats, storehouses of, in towns. Salting and preparation of meat. Scalding-houses, for the preparation of parts of ani- mals fit for food. Sealing-wax, manufacture of. Sheep-skins, drying of. Silvering of mirrors. Soap Factories. Spinning of cocoons, shops in which it is done on a large scale, i.e., employing at least six spindles. Sponges, washing and drying of. Steel, manufacture of. Sulphate of Iron, alumina, and alum, manufacture of, by the washing of roasted pyritous and alumi- nous earths. Sulphur, powdering and sifting of. Tan Mills. Thrashing, carding, and cleaning of wool, hair, and bed feathers. Tile Works, with non-smoke-consuming furnaces. Tinned Iron, manufacture of. Tobacco-pipes, manufacture of, with smoke consum- ing furnaces. Wadding, manufacture of. Wash-houses. Waste of thready matters, storehouses of, on a large scale, in towns. Odor. Injurious fumes, fire. Smoke. Smoke. Odor. Explosion, fire. Odor, fire. Odor, fire. Odor. Injurious fumes. Fire. Noise. Metallic fumes. Odor. Odor. Odor. Odor. Odor, fire. Noise, concus- sion. Odor. Smoke, dust. Injurious dust. Injurious fumes. Dust. Odor, dust. Odor. Injurious fumes. Odor, fire. Odor. Odor, fire. Odor, fire. Pollution of wa- ter. Fire. Pollution of wa ter. Odor. Odor, Are. Injurious fumes. Smoke, dust. Accidental smoke. Smoke, injurious fumes. Smoke. Odor. Injurious fumes. Injurious fumes. Smoke, injurious fumes. Odor. Odor. Odor.' Fire. Odor, dust. Injurious fumes. Odor. Odor, pollution of water. Odor, pollution of water. Smoke. Smoke, pollution of water. Dust, fire. Noise, dust. Odor, dust. Smoke. Fumes. Smoke. Dust, fire. Pollution of wa- ter. Fire. Third Class. Business. Character of Nuisance. Acid, Nitric, manufacture of. Acid, Oxalic, manufacture of, by nitric acid, with de- struction of the injurious gases. Acid, Picric, manufacture of, with destruction of in- jurious gases. Acid, Pyroligneous, manufacture of, when the gase- ous products are burned. Albumen, manufacture of, by means of fresh blood- serum. Alcohols, agricultural distillery. Alcohols, other than from wine, without rectifying works. Ammonia, manufacture of, on a grand scale, by de- composition of ammoniacal salts. Ammoniacal Cochineal, manufacture of. Archil, manufacture of, in closed vessels, using am- monia to the exclusion of urine. Artificial Fuel, or bricks of coal, manufacture of, with dry resins. Asphalts, bitumens, resins, and solid bituminous mat- ters, storehouses of. Bacon, shops for smoking. Bark-beating places in towns. Bleaching of threads and tissues of flax, hemp, and cotton, by the alkaline chlorides (hypochlorites). Breweries. Brick Works, with non-smoke-consuming furnaces. Button-makers and other stampers of metals by ma- chinery. Candles, manufacture of. Candles, and other objects in wax and stearic acid. Candles, of paraffin, and others of mineral origin, moulding of. Castings and rolling of lead, zinc, and copper. Cheese, storehouses of, in towns. Chloride of Lime, manufacture of, in shops making at the most 300 kilogrammes a day. Chromate of Potash, manufacture of. Coal-washing places. Coffee, roasting of, on a large scale. Copper, brass, and bronze foundries. Copper, cleaning of, with acids. Cotton and oily cotton, bleach works for the waste of. Cow-yards, in towns of more than 5,000. Distilleries in general, brandy, gin, cherry-brandy, absinthe, and other alcoholic liquors. Drug Mills. Dyeing of Leather, shops for. Dyers. Earthenware, manufacture of, with non-smoke-con- suming furnaces. Enamel, application of, to metals. Enamelled Ware, with smoke-consuming furnaces. Enamels, manufacture of, with non-smoke-consuming furnaces. Faience, manufacture of, with smoke-consuming fur- naces. Farina factories. Fattening of poultry in towns, establishments for. Felt Hats, manufacture of. Injurious fumes. Accidental fumes. Injurious fumes. Smoke, odor. Odor. Pollution of wa- ter. Pollution of wa- ter. Odor. Odor. Odor. Odor. Odor, fire. Odor, smoke. Noise, dust. Odor, pollution of water. Odor. Smoke. Noise. Odor, Are. Fire. Odor, fire. Noise, smoke. Odor. Odor. Odor. Pollution of wa- ter. Odor, smoke. Metallic fumes. Odor, injurious fumes. Pollution of wa- ter. Odor, drainage of urine. Fire. Noise, dust. Odor. Odor, pollution of water. Smoke. Smoke. Accidental smoke. Smoke. Accidental smoke. Odor, pollution of water. Odor. Odor, dust. 191 Trades. Trades. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Business. Character of Nuisance. Whalebone, manufacture of. Odors. White Lead, manufacture of. Injurious fumes. Wire-drawing works. Noise, smoke. Wood Charcoal, storehouses of, in towns. Fire. Wood Charcoal, manufacture of. in closed chambers, Odor, smoke. with combustion of the gaseous products of distilla- tion. Woollen Thread, scraps, and waste of spinnings of Noise, dust. wool and silk, in towns, special works for the beat- ing and washing of. Wool-washing places. Pollution of wa- ter. Zinc-white, manufacture of, by combustion of the metal. Metallic fumes. Thibd Class.-Continued. Ballard 3 recommends a pavement consisting of Port- land cement mixed with ground stone run upon a ba- sis of brickbats. Any of the granolithic, or other arti- ficial pavements, will answer equally well. Even with a wooden floor the drains for urine should be made of cement or artificial stone, so as to be impervious to moist- ure. Asphalt becomes too soft during the hot weather of the American summer for any floor, and cobble-stones are too difficult to clean. The removal of manure is a serious nuisance in popu- lous neighborhoods. Putrefaction does not generally set in within twenty-four hours after the excreta are voided. If, therefore, the manure is removed daily, all nuisance from this cause will be avoided. This is how- ever impracticable, if not impossible, in large cities. The smell of freshly deposited excreta is in itself ex- tremely unpleasant and should be covered by the use of disinfectants. In Germany, according to Layet, per- chloride of iron is used, in France phenol, in England a mixture of carbolate of lime and magnesium hyposul- phite. In New York dead oil, an impure carbolic acid, was formerly used, but at present a system of compress- ing or baling the manure is being enforced by the Board of Health, whenever a cart load or more has been accu- mulated. By the same ordinance no manure vault is al- lowed to be placed under the sidewalk or within three hundred feet of any occupied dwelling, or of any manu- factory where more than five persons are employed. Cows.-Whatever has been said in regard to horses is applicable to cows, with the addition that the effects of the crowding are far more severe on them. The distil- lery grain upon which the city-kept cow is usually fed is an unwholesome and unnatural diet. It produces gas- tric troubles, and if acid, as is generally the case, causes diarrhoea and enteritis, and, according to Fleming, is one of the causes of contagious pleuro-pneumonia. In New York and Brooklyn distillery or swill-fed cows have been found in terrible physical condition, be- ing covered with pustules and ulcers, while in some cases the tails have rotted off, leaving a diseased stump. This, however, is now happily a thing of the past. As milk can now be readily brought from the country in good condition, and as cows kept in the city are always deprived of proper air and exercise, and as they can only be fed on unwholesome food instead of the natural grass, it would be well if the keeping of cows in the city should be entirely forbidden. An exception to this might be made where, under a special permit, a single animal was to be kept, on premises affording good pasture and sufficient space for the animal to obtain proper exercise. In the country, even, the manure should never be al- lowed to remain in the stable, as, during the prevalence of pleuro-pneumonia in England, in 1857, Ballard (op. cit.) found, " while eight out of thirty-one sheds in which the manure was not stored within the shed had had cases of lung disease, as many as eight out of eleven in which the dung was stored within the shed had had cases of it. And as respects the cattle-plague in 1865, I found gener- ally that, while sixty-six per cent, of the sheds in which the manure was not stored within the shed were invaded by the disease, as many as ninety-one per cent, of those in which it was so stored were invaded. " Hogs.-Hog-yards should never be allowed in any crowded neighborhood. Even in the country they should be well paved with cement, or with one of the artificial pavements above mentioned. A pig is not naturally an unclean animal, but has be- come so through the long years of neglect. It is well known that if a pig has been accustomed to good food, nothing but starvation will drive the animal to live on swill. If the yards are well paved and ■well drained, if the feeding-troughs are made of iron or stone, as they should be for all animals fed on material liable to ferment or putrefy ; if the manure and dirt are removed daily, and if the animal is well fed and washed, so as to keep the skin free from scurf, the yield of pork will be so much greater and of so much better quality that it will amply repay the extra trouble and expense incurred. To describe the nuisances produced by these various trades, and the remedies required in each, gives rise to constant repetition ; and yet it is almost impossible to make a system of classification broad enough to embrace all branches of industry, interlaced as they are with each other. For the purpose of this article, therefore, it will be convenient to divide the nuisances produced under the following heads : I. Those produced by the keeping of live animals. II. Those produced by the slaughter of animals and the utilization of the so-called by- or waste-products. III. Those produced by the escape of noxious or of- fensive effluvia, gases, and vapors. IV. Those produced by smoke. V. Those produced by the discharge of noxious or offensive matters into gutters, ditches, or water-courses. VI. Those produced by unnecessary noises, such as boiler shops, blacksmithies, etc. VII. Those which are produced by dust, or other mechanical impurities. This classification is of course unscientific, and can only be admitted on the score of convenience. Many industries might be classified under several of the head- ings. Gas-works, for instance, emit offensive vapors and at the same time permit the escape of offensive liquids. There is, however, no difficulty in laying down general principles upon which the appropriate means of prevent- ing or minimizing the nuisances from business establish- ments must be based. A nuisance may be dependent on : 1. The accumula- tion of filth on or about the premises, or its removal in an offensive condition. 2. The filthy condition of the in- terior of the buildings and of the machinery. 3. An im- proper method of disposing of the refuse. 4. Careless arrangements in the reception of offensive materials, or in the removal of the offensive products. 5. Improper methods of keeping the offensive materials or offensive products within the works. 6. Permitting the escape of offensive gases or vapors from the works during the process of manufacture. I. The Keeping of Living Animals-Horses.-It is difficult to realize how serious a nuisance may be created by the keeping of horses. Like human beings, they are kept in all grades of buildings. Those of the poor are crowded into the closest quarters, while those of the wealthy are far better housed and cared for than are the majority of human beings in the world. Stables should be well built, paved, and properly drained, w'ith suitable vaults for the reception of ma- nure. In the crowded tenement-quarters horses are fre- quently kept in the back yards or even in the cellars ; the manure is allowed to accumulate, and the liquid ma- terial, percolating through the floor, saturates the ground. A horse requires fifteen hundred cubic feet of air,2 and the sole ventilation of a stable should not be furnished by means of cracks in the broken walls. The floors should be made of heavy pine-boards thoroughly calked, so as to be made water-tight. In case a harder floor should be desired, it can be made of rectangular or ob- long blocks of trap-rock set in cement or concrete, or filled in with molten tar and gravel, so as to make the joints perfectly tight. Flag-stones are liable to crack, break, or sink, rendering the floor irregular. 192 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Trades. Trades. Poultry.-A farmer cannot realize the terrible nuisance occasioned by the keeping of poultry in a crowded city, where the incessant noise and odor create a nuisance so bad that it has to be felt to be appreciated. In New York the Board of Health for many years maintained an incessant contest to prevent the keeping of poultry in tenement-houses by Polish and Russian Jews, and it is only after twenty years of hard work that they have succeeded in crushing out the practice. This class of the population, on the plea that their re- whence the feathers, offal, and refuse are removed daily, as they would be in the case of larger animals. II. The Slaughtering of Animals.-The slaugh- tering of animals is generally conducted within a build- ing specially adapted to the purpose, but occasionally the killing may be done in an open yard or stable, or even within a dwelling-house. In many portions oi England and of this country the slaughter-houses are situated in close proximity to the shops or dwellings of butchers, and in the midst of a Fig. 8981.-Plan of Abattoir of La Villette, Paris: A, Logement des Agents-officials; B, Bouveries et Bergeries-cattle and sheep sheds; C, Echaudoirs-slaughter-houses; D, Parc aux Boeufs-slaughter-house yards; E., Magasins-storehouses ; F, Fonderies-melting-houses ; G, Ma- chine-engine-house ; H, Ecuries-stables; I, Voiries-manure pits. ligion required them only to eat fowls killed by a special slaughterer, in accordance with the Talmudic ritual, insisted on keeping the poultry either in their sleeping- rooms or in coops in the basement of their crowded tene- ments. Within the past few years a special slaughter- house has been established at Gouverneur Slip,wdiere the killing of fowls is conducted in a proper manner, and crowded neighborhood. In London the private slaugh- ter-houses are in some cases so situated that the animals have to be driven through the butcher's shop, or even through a dwelling-house ; but it is self-evident that such a system is radically wrong. (Ballard.) The slaughtering of animals should be carried on in buildings as remote as possible from dwellings and in 193 Trades. Trades. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. those specially built and adapted for the purpose, well drained, and fitted with proper appliances for the disposition of the offal and blood. These buildings, known as abattoirs, are founded on the system preva- lent in ancient Rome, under the em- perors, w'hen a guild or corporation of butchers supplied the entire city with meat. The slaughter-houses, first scattered about the city, were eventually confined to one quarter. This market, under Nero, was one of the most imposing and magnifi- cent buildings in the entire city, as we learn from a medal which has transmitted its description to the present day. As the Romans governed Gaul, they probably transferred the sys- tem to Paris, where a company was charged with the business of slaughtering the animals and with the sale of the meat. As early as the reign of Charles IX. the need of a reform was felt, and a decree, dated February 25, 1567, laid the foundation of the modern system of abattoirs. But notwithstanding this and the repeated discussions held in the years 1689 and 1691 by the provost, the aidermen of Paris, and the Sieur Chandore, nothing was actually done until the time of Napoleon I. On February 9,1810, a decree was passed authorizing the building of abattoirs in the outskirts of Paris, under the direction of a specially appointed commission ; and the five general abattoirs now in use, three on the right and two on the left bank of the Seine, were formally opened, September 15,1818. The plan of the one at La Villette shows their general arrangement (Fig. 3981). The history of the New York slaughter-houses is similar. In early days of the Colony the slaughter- houses were connected with the shops and dwellings, as in London at the present day. As the city grew larger they in- creased in number, until in the year 1866 the Council of Hygiene, on whose reports was based the system of the Metropolitan Board of Health, stated that there were two hundred slaughter-houses, mostly surrounded by tenements, scattered throughout New York City, fifty in Brooklyn, and in addition there were sixty fat- renderers. Under the regime of the Metropolitan Board they were all brought together into seven locali- ties.4 The present New York Board of Health have limited the slaughter- houses of New York to three spots: From Thirty-eighth to Forty-first Streets, between Eleventh Avenue and the Hudson River ; from Fifty- eighth to Fifty-ninth Streets, between Eleventh Avenue and the Hudson River; and from Forty-third to Forty-seventh Streets, between First Avenue and the East River. The business of these abattoirs has somewhat diminished since the introduction of a system of bringing Western dressed meat to New York in refrigerator-cars, and the estab- Fig. 3982.-Abattoir, foot of East Forty-fifth Street, New York. 194 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Trades. Trades. lishment of the immense buildings at Harrison's Cove and the other railroad termini in the immediate vicinity of the city. Nevertheless, there are probably killed on New York island about two-thirds of the animals slaugh- tered to supply the New York markets. This may be appreciated by the following comparative table : Table showing Comparative Value of the Slaughtering In- dustry of New York Island. Value of cattle, etc., slaughtered in 1887 * $56,461,596.00 " anthracite coal mined in 1887 2 86,500,000.00 " bituminous coal mined in 1887 2 100,000,000.00 " gold mined in 1887 3 35,000,000.00 " silver mined in 1887 3 51,000,000.00 " coinage in 1887 6 57,703,413.40 '• petroleum crude oil in 1S87 4 30,480,000.00 " petroleum refined, paraffin, etc., in 1887 4 51,480,000.00 1 Journal of Commerce, Market Trade Journal, and other sources. 2 Coal Trade Review. 3 Reports Director of Mint; Wells Fargo's Report. 4 Reports Standard Oil Trust. Fig. 3982 shows a plan of a new abattoir, just com- pleted, occupying the block between Forty-fifth and Forty-sixth Streets, First Avenue to the East River. Plans are now being drawn for a similar building on the adjoining block. A somewhat similar one occupies the Fifty-ninth Street district, and within a short time it is probable that the present inconvenient buildings in the Fortieth Street district will be replaced by a properly constructed abattoir. The slaughtering business may be divided into three parts : The keeping of the animals, the actual slaughter- ing, and the disposition of the offal, blood, and other so- called waste-products. What has been said in relation to the keeping of living animals is applicable to the stock-yards and cattle-pens connected with the slaughter-houses. They should be kept in a thoroughly cleanly condition, paved with nar- row rectangular blocks set in cement, with the interstices filled in with a mixture of melted tar and gravel. As- phalt or any artificial stone pavement is unsuited for this purpose ; the former becoming too soft in summer, and the latter is too slippery in wet weather, the animal being liable to strain himself in slipping, or, by falling, to bruise the meat. The stock-yards, as well as the slaughter-houses proper, should be furnished with a plentiful supply of water, so that every portion of the building can be kept thorough- ly clean and sweet. There are several methods of killing beeves. In France the face is covered by a mask and an iron pin or " hou- blon " is driven into the centre of the crown about two inches in front of the horns. In the opening thus made a long cane is driven into the spinal column, which is technically called " pithing." In England the ox is led by a rope around his neck, which is fastened to a ring in the wall near the floor, the head is drawn down to a level convenient to the reception of a blow, the experi- enced slaughter-man drives a pole-axe, a steel instrument shaped like a large punch, and attached to a strong handle, into the centre of the crown. Through the op- ening thus made the animal is " pithed" as in France. In some parts of America the animals are driven, one by one, under a platform on which stands a man with a lance or rifle. With the weapon he strikes or shoots the ox just behind the horns, severing the spinal cord. In all of these methods the slaughterer then drives a knife deeply into the carcass above the sternum, so as to cut well into the large vessels behind that part, and presses upon the abdomen and sternum so as to drive out all the blood. If this is not done immediately, so as to prevent the co- agulation of the blood in the flesh, the meat is spongy, of a purplish color, and readily decomposes. In New York and some other localities the Jewish method of killing has been generally adopted. A slip- noose is thrown around one of the hind-legs, from which a rope passes over a pulley fastened to a beam overhead. The animal is hauled up, head downward, until the fore- feet are off the ground, the head is turned so that both horns and the nose touch the floor, the butcher passes a sharp knife across the throat, severing the tissues back to the spine. The blood, in all cases, runs through open- ings in the floor, where it is received in iron trucks to be taken to the "dryers," which will be described under the head of Blood-drying. After an incision is made in the skin along the whole length of the carcass it is turned back, the abdomen is opened and the intestines are removed, and the fat is trimmed off, and used for the manufacture of oleomar- garine and tallow. The stomachs are distributed to the manufacturers of tripe, the heads to the head butchers to be used in making canned meats, and the hoofs for the making of glue. The hearts, livers, and lungs are used as food for man or animals, and the hides are salted and sent to the tanners. After the meat has cooled it is trans- ferred to the refrigerating rooms. Pigs.-The arrangement of a hog slaughter-house varies somewhat from that of one used for cattle or sheep. The building is always at least a two-story one, the upper floor being used for killing, the lower for dressing the animal. The animals to be killed, at any one time, are kept in pens holding from fifteen to twenty, each. In one of these pens a " chainer " and his assistant pass a slip-noose over the hind-legs of the pigs in succession. As each one is caught he is raised and hung by a hook on an iron tramway, along which he is shoved until he is brought in front of the " sticker," standing in another pen six or eight feet away. The latter thrusts a narrow double- edged knife into the neck (the pig being head downward), turns it upward, and divides the aorta. The animal, after having the blood drained out, is passed along the tramway to another man, who loosens the chain and al- lows him to drop into a vat of boiling water on the floor below. The animal is then hoisted, by a single motion of a fork-shaped lever, upon a long bench with a down- ward inclination, on both sides of which stand men to remove the bristles on the sides. These bristles are gathered up from the floor and carried away by the brush-makers. The animal then passes up through a machine set with circular knives, which remove most of the bristles left untouched by the men already spoken of. The carcass is then lowered to the bench, where the re- maining bristles behind the ears and legs are " shaved" off. A crotched stick, called a "gambrel," is then placed between the legs, the body is opened, the entrails are removed, the interior washed, and it is then hung up to cool. The blood, offal, and fat are disposed of in the same manner as are those of cattle. A slaughter-house gang of twenty-five men will kill and dress one hundred hogs per hour for ten hours per day. Three hundred and twenty-two hogs have been handled by the same number in fifty-nine minutes. In England the bristles are removed by singeing, and, according to Ballard, it takes twenty-five seconds to singe a pig properly, the smell of the burnt hair being added to the other odors. It is claimed at Caine that the singe- ing process produces a better-flavored pork than the scalding one. The nuisances caused by a hog slaughter-house are more serious than those of a cattle slaughter-house. The odors are more unpleasant and travel to a greater dis-> tance. The noise made by the animals is far worse. The squealing of the pigs before being killed is pierc- ing and incessant. It is, therefore, necessary that a hog slaughter-house should be far more remote from dwell- ings than one used for cattle alone. Sheep and Calves.-In the killing of sheep or calves the animal is laid on its side and a knife run through its throat. It is placed over a drain so that the blood is readily collected and removed. The more thoroughly the calf is bled the 'whiter and firmer becomes the veal. Poultry.-In New York, poultry are usually brought in dead from the country, except, as has been before mentioned, in the case of those killed for use by the Pol- ish and Russian Jews. These are slaughtered in a spe- cial building in Gouverneur Slip. Several floors of this building are filled with coops which are rented out. 195 Trades. Trades. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. When the bird is to be killed, it is held over a large zinc trough and its throat is cut with a sharp knife, of a pe- culiar shape. At one end of the trough is an overflow- pipe connecting with the sewer, and at the other is the water-supply. The premises, like all other slaughter- houses, are kept thoroughly washed and are whitewashed daily. Other Animals.-In Europe the disabled or useless horses are killed in special buildings, called " knacker- ies " in England. In America the animal is shot wherever he may fall, and the dead body is removed to the rendering works, the skin being sent to the tanners, the horns to the button or knife-handle makers, and the hoofs to the glue makers. Stray dogs are gathered in by offi- cial dog catchers and, unless redeem- ed, are drowned in a n iron cage or killed by the intro- duction of carbonic acid gas into a closed compart- ment. The dead There are diverse opinions in regard to the effects of slaughter-houses on the general health of a neighborhood. Ballard, as well as other authorities, lays stress on the fact that butchers are said to possess remarkable freedom from epidemic diseases. Dr. Carpenter {Lancet, 1871, vol. instates that slaughter- houses may be the starting-point of scarlatina. Dr. Spear, of South Shields, believes that the slaughter-houses have been the chief foci of zymotic diseases. It is but just to say that the experiences of both these gentlemen are con- fined to the badly built private slaughter-houses, in imme- diate connection with dwelling-houses, already spoken of. There is no evidence that the inhabitants in the neighborhood of well-constructed and properly drained and sewered abat- toirs are any mor esubject to disease than a similar class of people elsewhere. If the fresh meat is hung up to cool in an atmosphere loaded with septic matter, it will become unfit for human food. The essentials of slaughtering, so as to avoid nui- sances, are. scrupulous cleanliness of the yards, of the slaughter-houses, and of all the utensils, together with the speedy removal of all decomposable matters. The New York Sanitary Code provides "that all fat, blood, and offal be utilized on the premises while fresh." The buildings should be erected of brick or stone, or, as in Paris, of iron and glass ; the floors should be covered with concrete or arti- ficial stone, and, where the heads are chopped off, the floor should be covered with a layer of heavy planks placed on slats which can be taken up and thoroughly washed. The side walls, to the height of five or six feet, should be covered with smooth cement, slabs of slate, zinc sheeting, or other impervious material capable of being washed clean with water. Were it not for the expense, en- amelled bricks Fig. 3983.-Elevation of Fat Rendering Tank (" Wilson's") for Live Steam. bodies are converted into fertilizers, as in the case of horses. The nuisances produced in slaughter houses are usu- ally confined to the immediate neighborhood. The noises and peculiar odors due to the keeping of the live cattle, the generally uncleanly condition of the buildings, if not properly paved and drained, caused by the decom- position of scraps and spattered blood attached to the walls and floor, the storage and accumulation of the hides, skins, blood, fat, offal, and manure, all show the necessity of removing the slaughter-houses as far as pos- sible from dwellings. would be the best. The paving should be so sloped as to allow all liquid matters to run off properly. The slaughter-houses should be furnished with an un- limited supply of water. Tardieu 6 states that ninety thousand litres are used daily in each of the five Paris abattoirs. In New York the supply is practically unlim- ited, being furnished from the rivers ; but, as an illustra- tion, 4,419,480 gallons are used daily in the single abattoir at East Forty-fifth Street, the plan of which we have al- ready given. This would give a total of about 15,000,000 gallons used daily in the New York slaughter-houses. III. The Rendering of Fat.-Under this head are 196 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Trades. Trades. included: 1. The manufacture of oleomargarine. 2. Manufacture of tallow from the refuse of the former process. 3. Manufacture of tallow from shop fat. 4. Manufacture of lard from the rendering of pig fat and similar processes. The most important kinds of fat melting, as far as the production of nuisance is concerned, are classed under headings Nos. 2, 3 and 4. Butcher's fat is produced directly in the slaughter- houses, and may be either beef or mutton fat. The former is sorted in the abattoir, the best portions se- lected for the manufacture of oleomargarine, and the waste and refuse rendered directly into tallow. This fat is rendered in a comparatively fresh and inof- fensive condi- tion. Shop fat includes all the trimmings from the retail butch- er shops and the remnants pro- duced by the household. This is usually rendered after fermenta- tion has set in, and is the cause of most of the complaints against fat rendering. Fat is rendered : 1st, by means of an open tire ; 2d, in a steam jacketed kettle ; 3d, by means of free steam. 1st. When fat is .rendered by means of an open fire, it is cut into small pieces and placed in a large kettle with a furnace underneath. After the fat is melted, it is dipped out with ladles, and the residue, consisting of skin, meat, tendons, etc., is subjected to pressure, the remaining fat squeezed out, and the solid cakes of "scrap" or "greaves" are sold for dog food. 2d. When fat is rendered in a jacketed tank, it is placed in an upright cylindrical double tank. The inside tank, containing the fat, has an opening in the top through which the fat is introduced and the scrap taken out, the melted fat being drawn off by means of a cock. Outside of this is another iron vessel completely surrounding it, called a jacket. Live steam is then introduced into the space between the two. The scrap is treated as in the case of open ket- tles. 3d. Live steam is introduced di- rectly into the fat, disintegrating the particles; the scrap, after be- ing pressed, is used for fertilizing material. Open Kettles.-This process of fat rendering is one which is only carried on on the smallest scale, and should never be allowed in the neighborhood of any inhabited building. It is claimed by the manu- facturers that the tallow thus produced is of superior quality, and that the greaves are of special value. I do not believe that the former is the case. Tallow is now sold by analysis, and a properly made tank tallow will be fully as "strong" as open kettle tallow. With proper care in making, the color will also be as good. Open kettle rendering is, of course, the cheapest possible method, but this is no reason why the manufacturers should be allowed to become a nuisance to the neighbor- hood. A method for controlling the odors from this pro- cess will be described under the head of Lard Rendering. Rendering in Steam-jacketed Kettles.-This process was greatly in vogue a few years ago, in the shape of the so- called Lockwood and Everett tank. Its approval by the Metropolitan Board of Health spread it broadcast through the city of New York. It was supposed to produce as fine a tallow as the open kettle, with the additional ad- vantage of a decrease in labor. When it was properly connected with a suitable condensing apparatus, all the odors were supposed to be controlled. This proved fal- lacious. After the fat was rendered it was necessary for the workman to enter the tank, dig out the scrap, and throw it out of the man-hole. As the water in the jacket continued hot long after the fire was drawn, the tank was, therefore, cooled by taking off the man-hole plate, thus allowing the fumes and odors to escape into the open air. This, of course, could have been remedied by using one tank one day and another the next, but as this tank was calculated to be used in very small factories this was impracti- cable. The greaves also retained a large amount of fat, and had to be resteamed to remove it. The increase of labor in handling the fat by the Lockwood and Everett process, and the loss of fat in the greaves, more than made up the extra cost of an engineer in the di- rect steam process. Rendering by Live Steam.-The fat is rendered in a modification of Papin's digester, which is illus- trated in Fig. 3983. It is often described as a Wilson tank, after one of the early makers. The best form of apparatus consists of a strong iron cylinder set upright, with a truncated conical top and bottom. On the side of the upper cone is a charging hole covered with a plate. A man-hole at the base of the lower cone allows the discharge of the solid refuse. Cocks at different levels are used for drawing off the fat, etc. Pipes at the bottom bring in steam at a pressure of about sixty pounds. A safety-valve on the top serves to regulate the pressure. The apparatus being charged, steam is turned on at full pressure for two hours, the pressure is then reduced to one-tenth for four and one-half hours. The steam is then turned off, and the fat allowed to settle for one hour and a half ; the cover of the charging hole is then removed, and water is pumped in to float the melted fat up to the draw-off cocks. The tallow runs off into the jacketed covered cooler alongside, in which it stands for twelve hours. It is then stirred to make a thoroughly uniform mass, run into the packing tank, and dipped out into casks. The odors escape through a vent-pipe in the top of the condensing apparatus. The safety-valve should also be connected with the condenser. After the tallow has been run off, the water and scraps drop into the covered box below, through the man-hole in the bottom of the tank. This is known as "tankage," and is sold to the manu- facturers of fertilizers. Fat rendering is apt to become a serious nuisance to the neighboring inhabitants. The smell of the partially decomposed fat stored on the premises, and the gases pro- duced by the distillation, are exceedingly offensive. The Fig. 3984.-Vertical Section. 197 Trades. Trades. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. buildings are often old and become readily saturated with these odors. The history of most melting-houses is the same. The nuisance is borne with a long time, until some habitual neglect on the part of the fat melter leads to a cry for summary and complete suppression of the works. Notwithstanding the disgusting odors produced by fat rendering, it is doubtful whether the vapors and gas- es are actually in- jurious to health. A short exposure to the atmosphere of the rendering works accustoms one to the odor, while all the work- men seem to be in the most vigorous health. If not, however, d e t r i - mental to health, these smells are ex- ceedingly nauseat- ing to delicate per- sons, who, in hot weather, are often unpleasantly affected by the odors even from their own kitchen. Ballard says that in Southampton " one person stated that his work-women had to give up their work in the summer time, in consequence of their health being in- jured by the closeness of the room, arising out of the necessity of keeping the windows shut to exclude the in- tolerable smell. Others complained of being made sick, and one lady, not generally a delicate person, of frequently suf- fering from diarrhoea after about half an hour's exposure to the smell. As the statements are made by people who are trying to abate the nuisance, they should be taken with a reasonable degree of caution." In my own experi- ence I have not found any case of sickness which could be traced directly to fat rendering or any similar business. The sole method of abating the nuisance is to destroy the odors as soon as they are produced. The floors of the building should be made of concrete, the side walls covered with an impervious material to the height of six feet from the floor, and the buildings furnished with a plentiful sup- ply of water. The fat should be placed in the tanks as soon as re- ceived, and the rendering com- menced at the earliest possible moment. No wood or porous material should be allowed on the premises. A portion only of the gases can be consumed. All the steam or watery vapor carried over should be condensed and the gases then carried, either under the fur- nace fires, or, if the works are near the water, some distance be- low low-water mark. Ballard and many other authorities state that the odor can be destroyed by a simple passage under the furnace bars or through the furnace fires. This has not been found the case in New York and other cities. Every time the boiler is "fired" the fires are deadened and the gases pass up through the mass of coals unconsumed. In one case where bitumin- ous coal was used, the gases passed through the fires, es- caped through a chimney eighty feet high, and were dis- tinctly noticeable a thousand feet away from the works. The introduction of a proper condensing apparatus reme- died the cause of complaint. Condensers may be of various styles and shapes. The water may be introduced at the top and broken by means of a plate a short distance below. The showier may also be made by means of a rosette. The condenser itself may be made of iron, copper, or even of wood. It should be made as high as possible in proportion to the diameter. The gases should be introduced near the bottom, and pass- ing up through the water shower, be connected with the furnace fires by a pipe near the top. In New York the most satisfactory variety of condens- ing apparatus is that which is known as the " scrubber " (see Figs. 3984 and 3985). In this the upright cylinder is fitted with a series of wooden cross slats arranged to break joints. The slats are made 6 in. x 1 in. in size, resting on a strip lining the inside of the cylinder. These slats stand on their narrow edge, and the alternate rows are placed at right angles to each other. The " scrub- ber " is made of wood hooped with iron, so as to be kept perfectly water-tight. The gases produced in fat rendering and similar busi- ness are so corrosive that an iron condenser does not last long. The one just described has been arranged with a view to meet this objection. Its very cheapness and dur- ability will allow it to be introduced in places where econ- omy is a material object. In Figs. 3986 and 3988 are given a plan and sectional ele- vation, together with an enlarged section of the condenser of the deodorizing apparatus now in use at the new abat- toir in New York. It is made entirely of wood, all the conduits and condensers are fitted with slatted trays over which the water is thrown by means of pumps, the odors and vapors from the rendering tanks, cookers, and Fig. 3985.-"Scrubber" in Use in New York City. Horizontal Section A B. Fig. 3986.-Plan of System of Condensation at Abattoirs in East Forty-fifth Street, New York City. dryers being drawn off by fans. After thorough con- densation these vapors are delved into the East River, twenty feet below low-water mark. Various methods have been tried to prevent the nuis- ance from fat rendering. D'Arcet's method is to treat the fat with sulphuric acid ; one hundred pounds of fat chopped fine are rendered at a temperature of 200° F., 198 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Trades. Trades. with fifty parts water and one part sulphuric acid. This, though suc- cessful in parts of Europe, has not been adopted in the United States. The cost of the sulphuric acid and of the extra handling has prevented its economical adaptation. Cook's method, consisting in chopping the fat finely and melting at about 120° F., forms the basis of various processes of manu- facturing oleomargarine. It is a slow and expensive pro- cess, and therefore unadapted to ordinary tallow rendering. In the manufacture of oleomargarine the fat is washed for twenty-four hours in ice-water to remove the animal heat. It is then transferred to the "hashing" machine, heated for an hour to about 120' F., and allowed to settle for another hour. The melted fat is then si- phoned off to the cooling boxes, where it remains four days to "seed" or granulate. The mass is then pressed between plates covered with cloths to remove the stearine. The oil is run into tierces, and the stearine is sold to manufacturers of candles and re- fined lard. The residue from the melting, consisting of membrane mingled with fatty matter, is known as " sludge." This decomposes read- ily, becoming very offensive. It is rendered into tallow in a tank similar to those al- ready described, the odors from which should be controlled by a proper condensing apparatus. Lard Rendering.-The fat produced in a hog slaughter-house is usually rendered fresh, producing relatively very little nuis- ance. It is treated in a tank, and the fumes are condensed in the manner described un- der the head of Rendering of Fat. A serious evil, however, in New York and other large cities, is the rendering conducted by the small butchers in crowded neighbor- hoods. The butcher cuts up a few hogs, allows the fat to accumulate on the premises until he has enough to cook. This decom- poses in warm weather, creating a nuisance relatively worse than that from a large melting-house. Through ignorance and lack of means the rendering is usually conducted in an open kettle. The ket- tle (Fig. 3989) should be covered with an iron cover fitted with a hinged portion or door in front, through which the operation can be watched and the melted lard ladled out. The odors and steam are drawn off to the chim- ney through an ordinary iron kitchen boiler, through the top of which a stream of water is thrown against the roof by means of an elbow, so as to pro- duce a shower in falling. • The condensed steam is carried off to the sewer. The uncondensed vapors can either be passed into the fires or out of the chimney above the neighboring dwell- ings. The cover, condensing apparatus, and pipes should all be made of galvanized iron. The Refining of Lard.- The lard produced from the rendering contains too many impurities for general use. It is refined by remelting at a low temperature, stirring with wa- ter by means of revolving pad- dles, and then allowing the water and impurities to settle. It is at this stage that adultera- tion with cotton-seed oil and stearine is effected. Fig. 3987.-Sectional Elevation of System of Condensation at Abattoirs in East Forty-fifth Street, New York City. 1, Rendering Tanks ; 2, Blood coagulating Tank ; 3, Rawson Dryer ; 4, Condensers; 5. Exhaust fans. The vertical pipes have iron cloth placed inside, through which the foul air passes mixed with falling water to the condensing tank. As the temperature at which lard is refined is a low one, the odors from the lard refining es- tablishments are not generally offensive. The buildings should be kept clean, and the flooring made of impervious materials in the manner described under the head of rendering of fat. Of course, if any grease in which decomposition has set in should be refined, it is neces- sary that a proper condensing apparatus should be connected with the rendering tank. Manufacture of Soap.- The materials used in soap mak- ing are caustic lye of soda or potash and various animal or vegetable fats or oils. The ani- mal fats are chiefly tallow and " grease " made from the skim- mings produced by the boiling of bones and glue. Vegetable fats or oils are principally palm, cocoanut, and cottonseed oil. Rosin, silicate of soda, and other materials capable of com- bining with alkalies are also used. These fats and oils are chemi- cal compounds of a fatty acid with glycerine as a base ; sapo- nification therefore consists in combining the acid with soda or potash, the glycerine being separated. A "hard''soap is produced by the use of soda, "soft" soap by the addition of potash. If the materials were entirely fresh no nuisance would be pro- duced ; if, however, the decom- posed fat is rendered or ex- tracted from the casks on the premises, a nuisance arises as great as that in fat rendering. The fat mingled with the al- kalies is boiled in large iron pans, set in brick work, of suf- ficient size to allow of the mak- ing of many tons of soap at a time. In Babbitt's factory, in New York, the pan is five stories high and holds 1,750,000 pounds of tallow, or about 2,500,000 pounds of soap stock, and re- quires a week to boil. The following description of soap boiling, given by Professor Church,6 is so clear that I quote it entire. " Some of the oil or fat, or mixture of such matters, is first put into the pan, then some weak caustic lye (sp. gr. 1.05 to 1.08) is added, the mixt- ure being agitated and gently wrarmed at first, further quan- tities of lye, of increasing strength, being added from time to time, and the heating contin- ued until a kind of emulsion is formed ; then fat (and rosin in making yellow soap), and then more lye is added from time to time, while the boiling is con- tinued until the proper quanti- ties and proportions of each have been introduced ; and then 199 Trades. Trades. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. saponification, or action of the alkali upon the fat, is complete. Precautions against excessive frothing and boiling connected with copper condensers. The odors can be controlled if a sufficiency of water is provided. Gut Scraping, Gut Spinning, and Casing Mak- ing.-The smaller intestines of the sheep and hogs are used for the making of sau- sage casings and catgut. Those of the former measure about thirty yards, and of the latter about twenty yards, in length. The intestines are thrown into a tub of water and washed, a man meanwhile squeezing out the interior contents. The guts were, formerly, placed on a table where workmen, by means of blunt knives or wooden instruments, scraped them from end to end, removing all the softer parts and leaving only the peritoneum. This portion of the work is now performed by passing the gut through a scraping machine fitted with a series of circular knives. They are then again thoroughly washed and salted, if to be used for sausage casings. If to be used for musical strings or " catgut," the guts are sewn together and then spun upon an ordinary spinning-wheel. The number used varies with the desired thickness of the gut. Catgut i-inch in thickness will contain 700 strands of gut. They are bleach- ed, after being spun, by the fumes of sulphur, and then dried by stretch- ing over pegs in the open air. The business is one of the most offensive possi- ble. The air is filled with prod- ucts of putrefac- tion and the fetid odor from the in- testines. The premises are al- ways wet and sloppy from the constant use of water. There are cer- tain doubts as to whether the odors are absolutely detrimental t o health. The odors do not trav- el to any extent, and, though ex- over have to be taken, while the completion of the change must be ascertained by the occasional withdrawal and exami- nation of small samples from the pan. The next step of the process is the separation of the soap from the mass of the liquor, a separation or parting which is commonly made by the addition of about ten pounds of common salt to every one hundred pounds of fatty matter employed. Soap being insolu- ble in strong saline solutions, separates in a nearly dry and pure condition, floating to the top of the liquor. The layer of soap maybe drawn off, still melted or fused, at this stage of the operation, and separates further into a clear portion and a mottled portion ; or the more usual plan may be adopted, of running off the spent watery and saline liquor below, leaving the soap in the pan to be afterward treated in the following way. To the soap is added more lye, and the whole is once more heated ; then the mixture is allowed to settle for some hours. Next the liquor is run off to be used in the next charge, while the soap, which now contains more water than before and a slight excess of al- kali, is cast in iron frames and moulds, and when cold cut out into blocks or bars by means of wires." The offensive vapors from soap-boiling proper are best dealt with by covering the kettles with wooden covers and taking off the odors by a fan, through a suitable condensing apparatus, to the boiler fires. If the nuisance is generated by the storage of offensive fatty substances or by steaming out the casks, it can be controlled by ventilating the storage-room in a similar manner. The Refining and Distillation of Glycerine.-By the decomposition of the fats in soap-making large quantities of glycerine are formed in the waste liquors. These liquors are evaporated, redistilled, and filtered through bone charcoal, and the operations are repeated as often as may be necessary. These processes give rise to cer- tain sweetish, nauseous odors. All the operations should be con- ducted in tightly closed vessels Fig. 3988.-Section of Condensers. ceedingly d i s - gusting, probably produce no more than the minor and temporary disturbances re- sulting from ex- posure to any dis- agreeable odors. It is possible to prevent the nui- FlG. 3989.-Deodorizing Apparatus adapted to Small Fat Rendering Works using Open Kettles. 200 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Trades. Trades. sance by disinfecting the washing-tubs with a weak solu- tion of chloralum.1 The premises should be kept thor- oughly clean, the table should be made of stone, the walls and floor of asphalt or other impervious material arranged so as to drain thoroughly. An unrestricted supply of water should be furnished and all scraps and refuse removed daily. Tanning, Leather-dressing, and Wool-pulling.- The pulling of wool, in England called the trade of a " fell- monger," consists in the removal of the wool from the skins of the sheep and the liming of the latter for the leather-dresser and tanner. This business is usually con- ducted in the immediate vicinity of the slaughter-houses. Cattle and calf skins are cleaned and salted in a similar locality. The business of tanning and leather-dressing is usually carried on in the country and remote from dwell- ings. The nuisance produced in these trades consists in the odors given out from the " puer " vats, and from the disturbance of the old " soaks " when the hides are re- moved from them. " Puering " consists in soaking the skins for about an hour in a vat containing dog or pigeon dung. It is claimed that no other material will answer the purpose of softening the skins. The " soak " is the old liquor in which numerous hides have been tanned, and a certain amount of which has to be added to every vat when first placed in action. The nuisance can be remedied by having the yards properly drained and paved, by hav- ing the waste and spent liquors carried away in separate sewers unconnected with any dwellings, and chiefly by hav- ing the tanneries away from any hab- during the same six years, varied from 27.0 to 29.9, the mean being 27.9 ; and the death-rate from the five zymo- tic diseases mentioned, varied from 4.6 to 6.0, the mean being 5.4. Dr. Goldie tells me, from his knowledge of the district, that he is not aware of any conditions of lo- cality or character of population that could possibly ac- count for the great mortality about the glue-works, other than the presence of the offensive works themselves." "It is difficult to believe that this difference in the mor- tality is entirely due to the glue-works. It is more prob- able that it is due to bad food, bad air, and bad habits of life of the class of people who would be likely to live in the neighborhood of such an offensive factory."8 The kettles in which the glue is boiled'should be kept covered and connected with a suitable condensing appa- ratus. The yards and premises should be properly drained. The "scutch" should be packed in tight packages and removed daily, especially in warm or muggy weather. In one word, glue factories, like any other premises in which animal matters are handled, should be kept clean. The Drying of Blood.-In Europe a portion of the blood is beaten with a bundle of twigs to re- move the fibrin before it leaves the slaughter- house for the use of dyers. A small trade is also carried on in the removal of the serum from the blood-clot for use in the sugar refin- eries. This is done while fresh in the slaugh- itation. The reme- dy for the nuisance produced by the burning of thespent tan will be discussed under the head of Smoke. The Manufact- ure of Glue and Size. - The clip- pings of the hides, ears, hoofs, the pith of the horns or "sloughs," rabbit skins, shreds from furriers, and other waste scraps are used for the manufacture of glue. The material is first soaked in milk of lime to remove the flesh and oil, and the lime is then " killed" by washing. The materials are now boiled in large open pans or boilers. The liquor gelatinizes on. cooling, which is done in wooden troughs containing lumps of alum. The solid material is then cut into slices about a foot square, which are hung on nettings in the open sheds to dry. A final drying is made at about 120° F. The re- sidue left in the pan after boiling is called " scutch," and is used for the manufacture of manure. The most offensive part of glue-works consists in the odors from the decomposition of the " scutch " and from the boiling of the glue. What has been said before in regard to the effect on health of decomposing animal matter will apply equally to glue-works. Sanitary authorities vary in their opin- ions, the only positive statement being that of Dr. Goldie, Medical Officer of Health for Leeds, England, which is quoted by Ballard. He says that " during six years, in an estimated population of 1,935 persons exposed to the odors of the glue-works, the mean annual mortality from all causes amounted to 35.6 per 1,000, while that from the five zymotic diseases-small-pox. scarlatina, measles, fever, and diarrhcea-amounted to 9.12 per 1,000. Taking the whole Hunslet ward in which this little col- ony is situated, the annual death-rate from all causes, Fig. 3990.-Hogel Dryer. Longitudinal Section. A, Charging hole, fitted with hopper ; B, outlet for dropping dried material. ter-house proper, and if the residue is conveyed promptly to the drying apparatus the odors generated are too slight to require any special mention. The major portion of the blood in the abattoir flows through a gutter, as previously described, into iron trucks or other receptacles. It is then conveyed to a tight iron tank, connected with a condensing apparatus similar to those described under the head of rendering of fat, in which the albumen is coagulated by means of a jet of live steam. The residual material is then placed in the " driers." These vary in shape, but may be divided into two classes. The first, represented by the Hogel (Fig. 3990), consists of a wrought-iron jacketed cylinder, 14 feet in length and 4 feet in diameter, placed horizontally. A centre shaft fitted with arms at right angles serves to keep the drying mass in constant motion to prevent burn- ing. Steam circulates through both the jacket and the hollow shaft and arms of the " stirrer." The operation lasts from twelve to fourteen hours, and the resultant mass is dropped through the man-hole in the bottom into a closed cooling-box. The vapors produced in drying and those from the cooling box underneath should be drawn off by means of a fan to the condensing apparatus. A second and improved form of dryer is the Rawson, shown in Figs. 3991 and 3992. This is about 80 feet long, 3 feet wide, and 4 feet deep, and is capable of drying about one ton per hour. The coagulated blood is intro- duced at one end and carried out of the other in about twenty minutes, by means of a central reel. Steam cir- 201 Trades. Trades. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. culates through the reel as well as the jacket. Unlike that from the Hogel, the resultant material is delivered at a very low temperature, so that no cooling-box is neces- sary. The sole odors produced, being those in the dry- ing process proper, are conveyed to the condensing ap- paratus by means of a suitable fan. If the blood is dried while perfectly fresh, no offensive odors are evolved and no deodorizing apparatus would be necessary. If fermentation has once set in, the drying of ready condensability of both the bone-oil and the ammo- nia vapors, and the combustibility of the former, there is no difficulty in preventing the nuisance from these works by the aid of a suitable condensing apparatus connected with the furnace fires. In the reburning of animal charcoal the odors produced consist mainly of sul- phuretted hydrogen and sulpho- and hydro-carbons, produced by the decom- position of organic matter in the raw sugar. If the "char" is thoroughly Fig. 3991.-View of Rawson Dryer. Raw material is charged in a hopper at one end and discharged upon a rocking sieve at c; the steam and odors being taken by a condenser through the outlet d. blood becomes as great a source of offence as any business already described. The floors and buildings should be made of impervious material, the utmost cleanliness should be enforced, and a plentiful supply of water pro- vided. Disposal of Offal.-The offal is collected, cooked in a Wilson tank for about four hours, the water pressed out, and the residual scrap dried in the driers as described in the preceding section. The odors from the cooking tanks, the driers, and the cooling-boxes should all be car- ried into a condensing apparatus and the material han- dled in the manner described under the head of Blood Drying. Bone Boiling.-Bones are boiled for the purpose of extracting the fat and to prepare them for further use. In some places any bones are boiled indiscriminately, in others only those of a selected kind. The long bones of the larger animals are first cut through with a circular saw, so as to separate the ends from the shank and to open the central cavity contain- ing the marrow. They should be cooked in closed tanks connected with the condensing apparatus, as described under the head of Rendering of Fat. The cooked mate- rial should be dropped into a brick chamber called the " bone-hole." The steam and odors from this should be properly condensed, the premises should be kept in a cleanly condition, thoroughly washed, and the floor and walls should be made of an impervious material. Of the products, the grease is sent to the soap-maker, the gelatinous liquid or size to the felt-maker, the larger bones to the button and knife-handle maker, and the residue to the manufacturer of fertilizers. In many cases the bones are merely steamed instead of being boiled. This is the case when they are to be used for the manufacture of bone charcoal. The steamed bones, after the extraction of the fat, are then distilled in iron retorts somewhat of the shape of those used in gas-mak- ing. The resultant products are bone or Dippel's oil9 and ammoniacal liquor, which are condensed in the same manner as the similar products from gas-making. The bone-oil is used as fuel or for the manufacture of artifi- cial manure, the ammoniacal liquor for that of sulphate of ammonia. The peculiar odor given out in the distil- lation of animal charcoal can be perceived at a distance of over two miles from the works. It is true, however, that, beyond the ordinary functional disturbances occa- sioned by the offensiveness of the odors, it has been im- possible to discover' that they have proved injurious to the health of those exposed to them. Owing to the washed before reburning, most of these materials will be removed. The vapors from the remainder can be con- trolled by proper condensation and by connecting the kilns with the tall chimney. The Manufacture of Glucose.-Peculiar odors are produced during the treatment of the corn with sulphuric acid for the conversion of the starchy matter into sugar. The converters should be thoroughly covered and con- nected by means of a fan with a proper condensing ap- paratus. The water containing sulphate of lime in finely Fig. 3992.-Cross Section at a & of previous figure. divided condition, which is produced in the manufact- ure, should be run into settling-tanks before pass- ing into any stream or river. These tanks should be provided with cross slats so arranged as to collect the line material mechanically suspended in the wash-wa- ters. The Manufacture of Artificial Manure is one of the most important of chemical industries, on account of the capital engaged, the number of workmen employed, and the value of the resultant products. The materials used may be divided into the phosphatic, nitrogenous, 202 Trades. Trades. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. saline, and drying materi- als. These are coprolites, apatite phosphorites, South Carolina, French, and other mineral phos- phates, some having a bone origin and containing fos- sil bones; Mejillones, Som- brero and other phosphatic guanos; bones boiled and then crushed, bone char, and bone char-dust from sugar refineries and manu- factories of animal char- coal, calcined bones; sugar scum (the pressed residues of filtration of the solution of raw sugar), ammoniacal guano, blood, scrap from rendering works, dried fish, offal, leather, shoddy, scutch (refuse from glue- works) ; night-soil, nitrate of soda, sulphate of am- monia, common salt, po- tassium and magnesium salts from the Stassfurt mines of Germany, gyp- sum, soot, ashes of spent tan, sulphuric and hydro- chloric acids, etc. These are termed " bone man- ure," where bones are largely used ; " superphos- phate," where coprolites or mineral phosphates are the principal ingredients; " ni- trophosphate," or "ammo- niated phosphate," where the superphosphate is com- bined with nitrogenous ma- terials; "dissolvedor solu- ble guano," where guano is mixed simply with sul- phuric acid, etc. Other kinds are known as " blood manure," "scutch man- ure," "poudrette," etc. The mineral or bone phosphates are first ground to a powder, and then mixed in various propor- tions with chamber sul- phuric acid. The ammoniacal ingredients and pot- ash are subsequently mixed with this. The mixing is done by machinery in a covered box placed on a platform, and capable of turning out from one to five tons at a mixing. Within is a stirrer consisting of a horizontal iron axis with iron arms. The opera- tion usually lasts about ten minutes. A pasty mass is produced which falls through an opening in the lower part fitted with a flap-door. In properly con- structed works the manure is discharged from the mixer into a closed chamber beneath, known as the " hot den." Great heat is produced and an abun- dance of vapor given off when the sulphuric acid is run into the mixer. The manure is kept for some time in the hot den, the temperature often exceeding 240° F., and running as high as 180° F., for several days.' The vapors given off are water, sulphurous acid, chloride of arsenic, arseniuretted hydrogen, and fluoride of silicon.10 Examinations made by Dr. Dupre of gases evolved during the manufacture of superphosphate from South Caro- lina rock show that, first, the va- por evolved contains fluorine as tetrafluoride of silicon, and not hydrofluoric acid ; second, the watery vapor evolved decomposes it into silica and hydroflu- osilicic acid [3 Si F< + 4 H2 O = Si O2, 2 H2O + 2 (2 H F, Si F 4.)] ; third, the greater part of the fluorine originally present in the rock, and the ar- senic which is sometimes present in the sulphuric acid remain in the super- phosphate produced. The offensiveness of the odors varies with the mate- rial used in the wTorks. Those occasioned by the use of scutch, human ex- crement, putrid animal matter, or "sludge''acid (the refuse from the refin- ing of petroleum), are pe- culiar, unmistakable, and dreadfully offensive. The distance to which these odors will spread is very variable. Ballard states that " at Wolverhampton, Eng- land, they are perceived offensively one and a half mile away ; while thbse from the Erith Marshes "scutch" manure-works are an intolerable nuisance at Woolwich, a distance of four and a half miles." In New York City the odors from the works on New- town Creek, where sludge acid was used, were very offensive at a distance of five miles. In regard to the effect on health, no permanent injury has followed a fre- quent repetition of expos- ure to these odors beyond the ordinary impression on the nervous system of sen- sitive individuals made by any offensive odors. The workmen do not suffer, except from smarting of the eyes, during the production of the fresh manure. The nuisance generated by the stor- age of the raw material in the works can, of course, be easily remedied. It does not require great knowledge or ingenuity to keep the works in a clean- ly condition, and the piles of shoddy, scutch, and other material covered ■with tarpaulins. The principal odors are given off during the mixing and in the removal of the material from the hot den. In the making of plain su- perphosphate a long Hue will practic- ally control all the odors (Figs. 3993 and 3994). The passage of the va- pors through a series of chambers and flues will condense the steam, and, by cooling, will cause a silicate deposit. Fig. 3995 shows the arrangements for catching the acid deposit at the Man- chester works of Thomas Vickers & Sons. The use of the scrubber, such as already described, or one filled with perforated bricks, the water being sup- plied in a shower, adds greatly to the efficiency of the apparatus. The draft Fig. 3993.-Sectional Elevation. 203 Trades. Trades. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. is pro- ducedby the con- nect ion with the chimney and by the aid of a fan. In many cases the works are so si tuated that the fumes and vapors cannot be thrown into a suffi- cient depth of water after passing through the scrubbing appa- ratus. A portion of the odors may still escape. In this case the vapors should then be passed un- derneath the furnace fires. This arrange- ment requires two sets of boilers, so that during the process of " firing " one set, the odors should be switched off under the other. This op- eration is reversed when the second set is being "fired." Fig. 3996 shows this arrangement at the Plymouth Chemical Works, England. The plan of con- densation(Figs.3986, 3987, and 3988)shown under the bead of Blood Drying, at Schwarzschild & Sulzberger's works, New York, can be readily adapted to control the vapors pro- duced by the manufact- ure of fertilizers of any kind. The principle of destroy- ing odors produced in every manufacturing business is al- ways the same : Condensation by water of all condensable va- pors, combustion by tire of all those which can be burned. The principal faults of all appa- ratus are an insufficient supply of water and neglect in keeping it in order. The presence of a water-condenser on the premises is no evidence that it is used. If the spray is supplied by a rose-jet or a perforated plate, the holes may become rusted or choked up, and then an insuffi- cient quantity of water in pro- portion to the amount of mate- rial to be condensed may be supplied. In the attempt to con- trol the offensive vapors pro- duced in manufacturing estab- lishments, common-sense and honesty of purpose are as neces- sary as in any other business. In the roasting of malt, coffee, chickory, etc., smoke and a thin bluish-white vapor are produced during a greater portion of the process. The beans are roasted in a revolving iron cylinder open at both ends for the es- cape of vapor, and a hinged door in the middle for charg- ing and discharging. The cylinder is fitted with plates in the interior so as to keep the material in constant mo- tion. The cylinder revolves in a brick chamber at the bottom of which is the fire. When the material is suffi- ciently roasted the cylinder is slid out and the roasted material dropped on the floor to cool. A peculiar choking odor, irritating to the eyes, is given off during the pro- cess, and the fumes produce headache and a general loss of appetite. The remedy consists in drawing the fumes, by means of a fan, through a water shower, into a chimney discharging at a high elevation. In the boiling of oil, manufacture of varnish, oil-cloth, and similar material, disagreeable penetrating odors are caused, which can be perceived at a distance of half a mile from the works. The sources are the va- pors of acrolein while the oil is boiled, and a mixture of volatile oil and acetic acid during the "running" or melting of the gum. The most effectual method of abating the nuisance con- sists in covering or hooding the pan or pot in which the operations are conducted, so as to permit the vapors to be drawn off by a fan to a suitable condensing apparatus. These vapors are driven off through a series of pipes ar- ranged as a continuous condenser exposed to the cooling influence of the air, thence to the furnace fires. The ap- paratus (Fig. 3997) of Haywood and Lloyd's takes these vapors so far away as to avoid any risk of fire. Brickkilns, Cement-w'orks, etc.-In the burning of brick, manufacture of cement, baking of pottery, and the burning of lime, including that from oyster shells for use in gas-works, a nuisance is produced by the delivery of smoke at a low level. The coal burns in a smoulder- ing way, giving more offensive products than when a rapid and free combustion takes place. Mingled with this in some cases is sulphuretted hydrogen, caused by the presence of organic matter, increasing the offensive- ness of the smoke. The gases from the burning lime-kiln are, of course, exceedingly poisonous, and care should be taken that all these manufactories should be placed at as remote a dis- tance from dwellings as possible. The kilns should also be connected with tubes lined with fire-brick, and these with a tall chimney, the opening of each kiln being pro- vided with a damper. Fig. 3998 shows this arrangement at the works at Cliffe, England. An American improve- ment on this has been the introduction of a water-spray into the chimney. The chimney should be carried up to as great a height as possible to produce a thorough draught for the kiln, and to deliver the smoke and offen- sive odors at a high level. In the refining of petroleum the nuisances are caused by the general odors from the works, and espe- cially by the clarification of the distilled oil by sulphuric acid. The crude petroleum is fractionally distilled, the various products are condensed in pipes surrounded by water, and are run off into the receiving tanks without being exposed to the atmosphere. The distilled oil is agitated in large closed tanks with sulphuric acid, and a constant circulation is kept up by introducing a blast of air at the bottom of the tank. The escape of this air, loaded wfith the fumes, is, with one exception, the most serious nuisance in the entire manufacture. The refuse, or " sludge " acid, is run off into storage wells or tanks, the oil is again agitated with an alkaline solution to neu- tralize the remaining acid, and a final agitation with water is then made to remove all traces of alkali. In all three of these processes the escaping air is laden with the odor of hydro-carbons. The washed oil is fin- ally sprayed by the passage of air-currents through the mass while heated, in order to raise the fire point. It is then packed in barrels or cans for shipment. The "sludge" acid is used for the manufacture of super- phosphates, for which purpose it is mixed with water, the major portion of the tarry matter being thus removed. Fig. 3994. 204 Trades. Trades. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The wash-water from the agitators should be passed through a series of troughs furnished with cross slats, to retain all oily or tarry matters. The lighter naphthas produced in spraying should be drawn off through a surface condensing apparatus, so as not only to utilize all that can be saved, but to reduce the temperature of the escaping vapors as much as possible. The treatment of the " sludge" acid should be carried on at a distance from any inhabited neighborhood ; or, as in New York City, it should be conveyed out into the ocean at such distance as to prevent the tarry matter from floating to any spot where it can become a nui- sance. There has been as yet no successful means intro- duced for controlling the odors produced in the agitation of manufacture. Water-gas, as distinguished from coal- gas, is simply hydrogen loaded with luminant hydro-car- bons. With the exception of the manufacture of the hy- drogen, the process of making either water or coal gas is essentially the same. Figs. 3999, 4000, and 4001 repre- sent a hypothetical section of works for the manufacture of water-gas. The commencement of the manufacture of coal-gas would be at the point marked "Benches." The portions preceding these exist only in water-gas works. Everything subsequent is common to both. Steam produced in the boilers is passed into the " gaso- genes." These consist of iron shells lined with fire bricks, forming chambers which contain coal, lime, or other de- composing material kept in a state of high incandescence. The steam in its passage through the mass is decomposed into hydrogen and a mixture of carbonic oxide and car- bonic acid. The product passes out, through a pipe sealed with a few inches of water, into the hydrogen holder. When the temperature of the decomposing mass has been reduced the steam is shut off, a blast of air is introduced, and the temperature is again raised to the decomposing point. The hydrogen is passed from the holder through the "carburetter," consisting of a series of perforated iron trays placed one upon another. The trays are en- closed in a steam jacket by means of which the naphtha placed on the trays is vaporized. The mechanical mixt- ure of hydrogen and naphtha is passed into the re- torts, where it is "roasted" or con- verted into a fixed gas, instead of be- ing, as before, a mechanical load- ing of the hydrogen with naphtha va- por. Hencefor- ward the treatment is essentially the same, whether water or coal-gas is manufactured. Coal-gas is made by dis- tillation of bituminous coal in closed clay retorts. The volatile matter passes through the "ascension pipe" into the hydraulic main, a level horizontal pipe extending above the whole length of the bench of retorts ; this is half full of condensed tarry matter into which the end of the "dip-pipe" empties. This not only seals the dip-pipe when the cover of the retort is removed, but also pre- vents the entrance of atmospheric air into the main. When the retort is charged or the coke drawn out, a large amount of smoke escapes into the retort-house, and this, as well as an offensive steam, containing sulphuretted hydrogen, produced by quenching the resultant coke with water, escapes from the building through the ven- tilator which runs the wdiole length of the retort-house. As both the crude coal-gas and the enriched water-gas already described issue from the hydraulic main at a high temperature, they contain readily condensable matters which will separate as soon as the temperature is reduced. This reduction is produced by the passage of the gas through the condensers, which consist of a series of an- nular vertical tubes through which the gas passes, and Fig. 3995.-A, Wooden box; B, brick deposit in chamber; C, smaller similar chamber; a, partitions springing alternately from bottom and top of box ; b, cleaning-out doors ; c, communication between the two brick cham- bers ; d, opening from hot den regulated by a damper. of the oil. They have been lessened by delivering them at as high an elevation as possible, so as to be thoroughly disseminated. The " still-bottoms," or tarry matters left after the distillation, are used as fuel, producing a heavy black smoke. Proper care in " firing," which will be discussed under the head of Nuisances from Smoke, should control this. The Manufacture of Illuminating Gas.-When a rich bituminous coal is subjected, in a closed retort, to destructive distillation, volatile matter is given off and a solid carbonaceous coke remains. The condensable por- tions of the volatile matter yield coal-tar and ammonia- cal matter, and the non-condensable portion crude coal- gas. The introduction of "water-gas" throughout the United States has caused material changes in the process 205 Trades. Trades. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. which are cooled by a supply of water passing through the central space. The watery vapors and heavy oils are thus condensed, precipitated into the lower portion of the condenser, and carried away by the wash-pipes to the tar wells. The gas is drawn off from the retorts through the com denser, and forced through the remainder of the works by means of the "exhauster." The gas is still too impure to be used for illuminating purposes. These impurities is known as " gas liquor," and is the basis for the manu- facture of sulphate of ammonia. These scrubbers may also be filled with coke, brick, balls of scrap tin, or any material which will cause the stream of gas to break up and be thoroughly washed by the water. Adaptations of the same principle have already been described under the heads of Fat Rendering, Blood Drying, etc. The gas is then passed through the purifiers into the storage-holders for subsequent distribution, after being measured by the meter. The chief cause of the nuisance in gas-works is due to the action of the purifiers. These consist of iron boxes with removable covers. They are arranged in sets of four boxes connected by pipes with a common centre seal. Each box contains a series of slatted trays in layers, upon which is spread the purifying material, and through which the gas percolates to remove the carbonic acid and sulphur com- pounds. It is the handling and removal of this foul material which forms the basis of most of the complaints against the gas-works. The use of the "wet-lime" method of purification has been almost entirely abandoned. This consisted in mixing lime with winter to a cream and forcing the gas through the mass by means of a " stirrer." The horrible odors resulting from the handling of the " blue billy," or residue, caused the abandonment of this method. In the dry-lime method of puri- fication the lime is slightly moist- ened with water and placed on the trays of the purifier. The illuminating gas is passed through the mass until a reaction for sul- phur is obtained with acetate of lead paper held over a small pet- cock placed in the cover of the purifier. This process removes the carbonic acid, forming car- bonate of lime, and the sulphu- retted hydrogen, which has been converted into sulphide of calci- um and water. The centre seal is then turned, the illuminating gas switched off into a new box, and the cover of the "foul box" raised. The contents are then re- moved and the box refilled to be used again. This refuse lime is often used for filling waste lands. The oxide-of-iron method of purification consists in the sub- stitution of some compound of oxide of iron for the lime. It is based upon the property of hy- drated oxide of iron to decompose sulphuretted hydrogen, forming ferric sulphide. In some mixt- ures lime is used to separate the carbonic acid, and a certain per- centage of sawdust, breeze, or other material is added to render the mass more porous and absorb- ent, by increasing the surface of contact. After the iron has fouled, it is tested by lead paper as in the case of lime. It is re- moved from the purifier and revivified by exposure to the air, ferric sulphide decomposes, and the sulphur is deposited through the mass, which can then be used over again. The reaction will be understood by the follow- ing formula: Fea O3+ 3 II2S = 2FeS + S + 3 H2O. Fe S + 30 = Fe2 03 + 2 S. This process can be repeated until the accumulation of sulphur impairs the absorbent powers of the mixture. Elevation of Furnace. To test by smell the gases escaping to the chimney, the damper A is closed, and cap B removed. vary, of course, whether we are dealing with coal or water-gas. They con- sist mainly of carbonic acid, carbonic oxide, sulphuretted hydrogen, sulphide of ammonium, ammonia cyanide, bisulphide of carbon, cyanic com- pounds, tarry matter, vapor, etc. These are removed by passing the gas through the "scrubbers," which con- sist of iron shells containing a series of wooden slatted trays upon which a spray of water is allowed to play. The water is introduced at the top and the gas at the bot- tom of the apparatus, the outlet in each case being at the opposite end. In the coal-gas works the resultant liquid Fig. 3996.-Section of Furnace. 206 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Trades. Trades. This " spent" oxide is used by the sulphuric-acid mak- ers in place of pyrites for the manufacture of oil of vit- riol. There should be no material nuisance from the revivi- fication of the oxide of iron if the gas is properly scrubbed ; otherwise, there will be a slight evolution of ammonia mingled with some cyanogen compounds. In the case of the lime purification, volatile sulphur compounds are given off during the entire handling, and as long as the lime is subjected to the decomposing action of the atmosphere. The escape of the offensive odors will continue until the surface of the heap of "spent" lime becomes sufficiently hardened to exclude the air from the interior. The advantage claimed for the use of lime as a purifying material is its removal of the carbonic acid. One per cent, of carbonic acid diminishes the illuminating power of the gas five per cent. That is, the presence of two per cent, of carbonic acid will reduce the candle-power ten per cent. This can be remedied by the use of a little more enriching material, or by not " stripping" the coal, that is, not extracting the final portions of the gas.11 It has been found in New York that the oxide of iron purification for water-gas costs about one-half that of the lime method. This, of course, takes into con- sideration the final loss of the oxide of iron mixture, as well as the cost of the cartage and removal of the foul lime. The back pressure on the retorts, by clogging of the oxide with naphthaline, can be prevented by proper care. The removal of the bisulphide of carbon can be effected by passing the gas through sulphide of calcium, or by a slight alteration in the temperature of the retorts. Attempts have been made by one of the gas compa- nies in New York to abate the foul lime nuisance, by drawing air through the purifying box prior to raising the cover. This air is passed through a deodorizing purifier filled either with spent lime (sulphide of calci- um) or oxide of iron, and thence into the atmosphere through a tall chimney containing a water spray. At the Fulham Gas Works, in England, the lime is re- moved, after the air has been passed through it, in cov- ered wagons which are filled through a tight chute leading from the purifiers. None of these methods is efficient, and the words of Ballard, " there is not, so far as I am aware, any successful process, univer- sally applicable, by which the ma- terial has been safely made ino- dorous -without the creation of some fresh nui- sance," are fully confirmed by my own experience in New York. In 1869 a strong effort was made by the Metropolitan Board of Health to compel the introduction of the oxide of iron process in place of lime. It was partially successful, and several of the works adopted it.12 Another attempt was made in 1874, which resulted in the introduction of deodorizing apparatus in other works.13 None of these methods, however, as already said, has proved thoroughly success- ful.14 At the present time another contest is being waged on this same subject, the oxide of iron process being now in use in the works of all the companies supplying New York City except one, where experiments are being car- ried on with a view to its adoption in case a new deodor- izing apparatus proves unsuccessful.14 A nuisance is also created by gas works by the escape from leaky joints and water seals. This of course can be readily diminished. The nuisance of the smoke from the retorts and from the quenching of coke can also be materially abated by proper care. The "drips" produced by the condensation of the gas, and col- lected at different parts of the works and in the drip-wrells set at various places along the street mains, should be deposited in closed wells, allowed to settle, the water run off, and the oil and tarry matters used as fuel under the retorts. It is utterly impossible to prevent all nuisance in the manufacture of gas. This is rec- ognized by the English gas-works acts of 1847 and 1871, which pro- vided that ' ' no factory shall be allowed to make gas or work over the residues without the written permission of owners, lessees, or tenants residing within three hundred yards of the proposed works." Ammonia Works.-The ammo- niacal liquor produced in the gas works, that from the distillation of bones and of shales, from the burning of coke, and from the gases produced in blast furnaces in the smelting of pig iron, are all used for the manufacture of sulphate of ammonia and chloride of ammonium (sal ammoniac). The ammoniacal liquor is distilled in a closed vessel by means of free steam ; the greater portion of the ammonia is given off imme- diately ; milk of lime is then add- ed, the remainder of the ammonia is distilled over, and the residue is run off through a drain. The ammoniacal v a - pors are conduct- ed into the "sat- urator," which contains sulphur- ic acid if sulphate of ammonia is to be made, or hy- drochloric acid for the prepara- tion of sal ammo- niac. The liquor is then evaporat- ed and the salts are crystallized out. In the case of chloride of am- monium the sal ammoniac is sub- sequently roasted in pots. Works of this kind, if badly conducted, become an intol- erable nuisance. Sulphuretted hy- drogen mixed with offensive hydro-carbons is thrown into the atmosphere. The steam from both the " satura- tor" and "evaporator" produces odors similar to those arising from an ill-kept pig-sty. It has been found that exposure to the effluvia of these works produces feelings of depression, headache, nausea, and vomiting. The Fig. 3997.-Heywood and Lloyd's Arrangement for Collecting and Condensing Vapors from Varnish Making. A, Boiling tank ; B, hood; C, vapor pipe ; D, exhaust fan; E, condensing apparatus. 207 Trades. Trades. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. remedy consists in the removal of the waste from the still by means of close drains. The gases from the "evaporators" and " saturators " should be drawn off by fans through the scrubber, as already described, by which all the watery vapors and condensable gases may be removed and thence passed underneath the furnace fires. In the DISTILLATION OF TAR, the DIPPING AND VAR- NISHING OF IRON PIPE, the MANUFACTURE OF ASPHALT and lamp black, the principal causes of offence are the escape of uncondensable products of distillation, the odors from the pitch ovens, and the smoke from imper- fect combustion of the creasote oil and pitch bottoms used as fuel. The remedy for the former of these nui- sances consists in the introduction of a condensing appa- ratus of the character used in varnish works, and that for the latter is proper care in firing as described under the head of Smoke. No product is more extensively used than sulphuric acid. It is, in fact, the basis of the manufacture of nearly all chemicals. There are no waste or by-products of an offensive nature, and if any nuisance is created by the operation in these works it is entirely due to the escape of the acid vapors themselves, which is a direct loss to the owner of the factory. If the works are properly pro- portioned and constructed, no escape should occur. The remedies, therefore, lie in the prevention of leaks in the apparatus, and in the maintenance of a sufficient amount of condensing surface. In the manufacture of alkali by the ammonia pro- cess there are practically no serious nuisances. In Eng- land, where the Le Blanc process is still carried on on a large scale, mainly for the manufacture of chloride of lime or " bleach," the escape of acid fumes from the without his knowledge, in which case the agent, etc., is liable (26-27 Victoria, C. 124). The act has been subsequently extended to cover al- most all the various kinds of manufacturing establish- ments described in this article. The nuisance from the manufacture of glass is mainly that of smoke discharged from the chimneys at low levels. Acid fumes are also produced from the de- composing of sulphate of soda or chloride of sodium used in the process of manufacture. The former comes under the head of general smoke nuisance, and the fumes of the latter are too small in amount to be considered as being injurious to the health of human beings, though it un- doubtedly affects vegetation by the production of acid fumes, as in the case of other alkali manufactories. The process of galvanizing consists in covering iron Fig. 3998.-Cement Works at Clyffe, England. works gave rise to special legislation known as the alkali acts. The reports of Dr. Angus Smith, chief inspector, from the year 1864, contain a mass of material showing the good accomplished by proper supervision. The re- sult of this is shown not only in the material reduction of nuisance in the works, but also in the economical method of manufacture. The Alkali regulation acts of 1863 provided that ninety-five per cent, of the hydrochloric-acid vapors evolved should be condensed. The Alkali prevention act of 1874, on the other hand, limited the amount of hydro- chloric acid to one-fifth of a grain in every cubic foot of air escaping from the chimney. The same act classed as noxious gases, sulphuric acid, sulphurous acid (except that produced from the combustion of coal), nitric acid, offensive oxides, sulphuretted hydrogen, and chlorine (37-38 Victoria, C. 43). In these acts the owner is liable for any offence, unless he proves that the offence was committed by some agent, servant, or workman, and with a coating of zinc. The iron is first " pickled " or cleaned by being dipped into properly diluted hydro- chloric or sulphuric acid. The metal is then dipped in troughs containing the spelter, melted zinc, and from time to time sal ammoniac is sprinkled on the surface of the bath for the purpose of cleaning the melted spelter by absorption of the oxide. This viscous and inactive oxi- chloride of zinc is skimmed off. The galvanizer's scum is subsequently treated for the recovery of the sal ammoniac and spelter. Galvanizing works are a source of nui- sance on account of the production of a mixed odor, partly alliaceous from the arsenic in the zinc, partly acid, if the baths are heated, together with a peculiarly offen- sive one from the hydrogen which is always produced by the action of acid on iron. People complain of these odors as suffocating and producing headache and a feel- ing as if they were " blown up " (Ballard). It is almost impossible to control the odors. Hoods cannot well be placed so as not to interfere with the in- 208 Trades, Trades, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. CARBURETER. troduction of the large sheets of metal, which are to be galvanized, into the bath. About the best that can be done is to hang an iron hood from the roof of the work- shop and carry off the fumes at as high a level as possible, and to keep galvanizing works as far away from inhabited neighborhoods as possible. In the tinning of iron and tempering of tools, the peculiar acid odor of hydrogen, already spoken of, min- gled with the acrolein from the palm or other oils in the " grease" pans in which the metals are dipped prior to "annealing" and tempering, will travel about 300 yards from the works. The fumes should be drawn off by a fan and condensed by a scrubber. In both galva- nizing and tinning works the " spent pickle " is evapor- ated and the sulphate of iron is recovered. The vessels in which this is done should be covered and the steam condensed. Any residual acid liquors should be neutral- ized and allowed to settle before being passed into the sewer. In the smelting of copper the main nuisance is the escape of the arsenic and sulphurous acid during the cal- cination of the ores. Attempts have been made to con- dense the arsenic fumes by the use of a shower chamber in conjunction with long flues leading to high chimney- stacks. Here also the sulphurous acid is collected for the manufacture of sulphuric acid, care being taken that, in the attempt to control the nuisance from these works, the greater one of allowing the sulphuric acid fumes to escape is not permitted. Theoretically, 77^ per cent, of the sulphur should be saved ; actually, only about forty per cent, is utilized. The difference is due to the various accidental results of working on a large scale, such as losses from down-draughts, drawing of charge, escape from the vitriol chambers, etc. Nevertheless, the sul- phuric acid that does escape condensation is of little strength, being largely diluted by atmospheric air.15 Smelting of Lead and Silver.-It is difficult to find any available means of controlling the escape of fumes arising during this process. So many methods are in use that a description of each individual works would be necessary to convey an intelligent idea of what would be required for the condensation of the lead, sulphurous, and other acid fumes produced. Th$ remedies are mainly the adoption of long flues and a tall chimney, so as to de- liver the escaping gases at as high an elevation as possible. Many complaints have been made in New York owing to the escape of the fumes from refineries of gold and silver, notably the United States Assay Office, in Wall Street.1' The granulated alloy of gold mixed with the proper proportion of silver is boiled with sulphuric acid in a cast-iron pot. The foreign metals go into solution and the gold settles at the bottom in a powder. During the boiling, white fumes of steam, sulphuric-acid vapors, and sulphurous acid are evolved. The liquor is siphoned off and treated in lead-lined tanks with metallic copper. The silver separates and the solution of sulphate of cop- per is evaporated so as to cause the salt to crystallize. The gold and silver powders are washed thoroughly, pressed into cakes in a hydraulic press, and subsequently melted into ingots. The acid fumes appear as heavy white vapors irritating to the eyes and respiratory or- gans. The vapors should be drawn from the closely hooded kettle through a series of lead chambers fitted with cur- tains, so that the fumes will pass alternately up and down through the chamber while travelling from end to end. They should then be sprayed with water in leaden scrub- bers filled with coke or wooden slats, and finally deliv- ered in the air at as high an elevation as possible. A sufficiency of water and of condensing surface is all that is necessary to abate the nuisance. Jewellers.-Should nitric acid be used in the parting or in the manufacture of jewellery, the reddish-brown fuihes of nitrogen peroxide are produced and should be condensed in a similar manner. Similar fumes are pro- duced by manufacturing jewellers in parting the precious metals. A very disagreeable odor also occurs when they burn the "sweeps" or waste of the shops. It is mainly organic, from the dirt, rags, and other scraps of material NAPHTHA DI8TRIHUTINO TAN K. NAPHTHA STORAGE TANK. PUMP. WdhGOEN GAS HOLDER. BOILERS. ENGINE. BLOWER. GASOGENE/ Fig. 3999.-Hypothetical Section of Gas Works. 209 Trades. Trades. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. intermingled with the metals. The smoke should be delivered at a high elevation after passing through a water spray. Cream of Tartar Works. - Very offensive vapors are given forth in the manufacture of cream of tartar. During the boiling, especially if under pressure, and the filtering of the resultant solutions, a heavy, sickening stench is emitted which will be readily percepti- ble about half a mile from the works. A similar odor ema- nates from the waste products dropped from the stills. The remedy is to conduct all steam and vapors through large scrub- bers similar to those already described. The connections should all be made of copper, on account of the corrosive ac- tion of these vapors. Manufacture of Quinine. -Cinchona bark is subjected to the action of methylated spirit or of fusel oil in large percolators. The re- sultant liquid is run off into tanks and the spirits distilled off for use again. The spent bark is washed and the residual waste liquors redistilled. The nui- sance is caused by the Storage.-The storage of various kinds of animal, vegetable, and mineral matters in large cities gives rise to frequent causes of offence. Those of special moment are the storage of hides, which should be mainly confined to the business portions of the town. The storage of hoofs and horns, if limited to a single locality, or if they have been properly "sloughed," i.e., the core has been removed, can scarcely be considered a nuisance. When stored in large quantities, Limburger, handkase, and similar varieties of cheese, which have to be partially decomposed before being fit for the table, may become very offensive. They should be stored in a tight cellar ventilated by two shafts running to the roof of the building. If possible, the business should not be carried on near dwellings. If eggs are " candled" or sorted in crowded neighborhoods, the odor may be abated by sprinkling the rotten eggs with chloride of lime and by having the rotten mass removed as soon as possible. The storage of essential oils used in the manu- facture of perfumes, turpentine, resin, petrole- um, and other oils, in crowded neighborhoods creates more or less nuisance. Complaints are made that dizziness and headache are apt to result from the presence of a large amount of these or similar materials. The principal risk, however, is owing to the danger of fire rather than to that of injury to health. Rag and bone shops, known in England as marine stores, are unfortunately a serious cause of nuisance. The rags and bones are gathered from the street mud, garbage boxes, and heaps of kitchen refuse, and are carefully sorted, the rags being washed and dried. This is done in some part of the premises in which the rag- picker or "chiffonnier" resides. As decompo- sition has already set in among the bones, and as the rags give rise to a peculiar stale and musty odor, the premises in which the operation is carried on are filled with the most disgusting smell. The sole remedy is to stop the storage of the bones entirely, and to confine the rag- pickers to a particular quarter of the town. As neither of these is entirely practicable, it would seem as if the only way of regulating the nui- sance would be the periodical visit of the health- officer. The premises should be kept as clean as possible and repeatedly whitewashed. The removal of refuse from houses gives rise to more or less offence. The nuisance is one that can never be fully abated. If in a city, where alleys or narrow streets run in the rear of houses, the material can be removed through the back door. In Paris the dust is thrown into the gutter and removed during the night-. In London it is deposited in " dust-bins " and re- moved, when the bin is full to overflowing, by the contractor. In New York it is placed in boxes and barrels and left on the sidewalks until called for. All of these methods are faulty, and the inhabitants of each of these cities consider that the methods in vogue in the others are bet- ter than their own. Probably the only relief would be to have the garbage placed on the street late at night, removed before seven o'clock in the morning, and the empty barrels and boxes taken in before eight o'clock. Even this would be almost impossible in stormy and winter weather. As yet no plan has ever been devised which will entirely abate this nuisance. IV. The Combustion of Smoke.-In all large manufacturing cities, the escape of smoke from the many chimneys gives rise to frequent com- plaints. This is objectionable, not only by rea- son of the indirect loss occasioned by the waste PURIFIER. CENTER SEAL, PURIFIER. I ENGINE Fig. 4000.-Hypothetical Section of Gas Works; Continuation of Fig. 3999. EXHAUSTER. SCRUBBER. disagreeable smell of the sol- vent, due to the vapors emit- ted during the percolation and distillation, and other odors mingled with the steam escap- ing when the spent matters are run off from the stills. The remedy is to closely cover the receiving vessels, with a vent-pipe into the chimney. The whole of the factory should also be ventilated by means of a fan connected with the chimney-shaft. All the wash and products should be thoroughly cooled before run- ning them oil. The recent introduction of kerosene as a solvent has materially re- moved the cause of nuisance. The manufacture of nearly all pharmaceutical products gives rise to considerable of- fence. They are so numerous that it would be impossible to enter into the details of each case. They can all be remedied by the application of the principles already de- scribed. CONDENSER. BENCHES. 210 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Trades. Trades. of fuel and heat, but also because of the direct injury to health and property. A consideration of the subject of the nuisance from smoke would include that of the use of fuel in grates for household purposes. It is true that in the Eastern States, where anthra- cite is the main fuel, the resultant gases and unconsumed carbon, though polluting the air, do not produce the serious inconvenience felt in Euro- pean and in Western cities, where bituminous coal is employed. All investigations on the subject of smoke consumption have shown the almost absolute impossibility of en- tirely abating the nuisance arising from such a source in these locali- ties. In view of this fact, this article will be limit- ed to the dis- cussion of the question o f the smoke generated from fuel used in large quantities in manufactur - ing establishments. The principle upon which the so-called combustion, or rather prevention, of smoke may be effected is simple. " Smoke consists of vapors produced by the partial combustion of coal, carrying up small particles of fuel in mechanical suspension, and depositing carbonaceous matter in a fine state of di- vision." 17 The following analysis of gases from chimneys will give an idea of the composition of smoke produced by the burning of ordinary bituminous coal under boilers.18 last, however successful or valuable they may be, cannot be introduced to any great extent, their cost preventing their employment in the many small planing and saw- mills whose chief fuel is shaving and wood scraps. GOVERNOR. METER. GAS STORAGE HOLDER. Fig. 4001.-Hypothetical Section of Gas Works ; Continuation of Fig. 3999. Few of the applications of these methods are practi- cally successful, the inventors proceeding upon the idea that want of air is the cause of the smoke. In the analysis given above it will be seen that the oxy- gen is frequently in excess of that required. What is really needed is heat and time, and thorough mixture of the gases. Where an increase of the draught is produced, the air is carried away so rapidly that it has not time to combine. Herein lies the success of the method by which a jet of steam is introduced into the fire ; the water is decomposed and hydrogen and carbonic oxide are formed. No car- bon appears in the smoke, for it is burned by two pro- cesses instead of one, the flame extending itself forward under the boiler. We have an increase in the amount of time required for the operation. True, this method is not always successful, as its application is often such that there is not a good mixture, and air and smoke may rush through a flue side by side unmin^led for some time.20 The chief objection to this method is that steam must be first made in the boiler, thus rendering it practically inop- erative at the time of lighting the fire. One patent introduces a stream of oxygen directly, or mingled with steam, into the fire. This is a modification of that already described and labors under the same dis- advantage, but by a slight alteration it might be rendered available at all times. Another variation, successful in many cases, is the introduction of a water or a steam jet into the chimney.21 This acts mechanically, carrying the deposited carbon into a chamber situated at the bottom of the stack. In this method, however, the flue frequently becomes clogged and the apparatus ceases to work. A modification of this principle is in use in several fac- tories in Paris, and, according to the authorities, with marked success. It is thus described :22 "A sheet-iron cylinder is cut obliquely near the bot- tom of a thin plane, through the centre of which a cir- cular opening allows the passage of the chimney flue. No. 1. No. 2. No. 3. Carbonic acid 5.62 6.17 6.38 Carbonic oxide 0.02 1.55 0.20 Oxygen 13.24 12.22 12.17 Hydrogen 0.46 Marsh gas 0.77 0.52 Olefiant gas, etc 0.13 None Nitrogen 80.35 79.93 80.27 100.00 100.00 100.00 This shows that the black smoke contains not only car- bon mechanically suspended, but un burnt gases in large amount. It has also been found that carbonic oxide only exists in black smoke, resulting from imperfect combustion. The general method of preventing smoke is to effect the combustion of the carbonaceous matter when the vapors are of a sufficiently elevated temperature to unite entirely with the oxygen of the air. If the temperature be not sufficiently high the hydrogen of the vapors is alone consumed, and the carbon deposited. The gases produced by the entire combustion of fuel are colorless, and therefore are not classed as smoke.19 Based upon this idea, we find innumerable patents (over three hundred in number) for consuming smoke. Some introduce air over or under the grate-bars, to in- crease the draught ; others carry the air back of the fire bridge, causing the combustion to continue the whole length of the boiler ; others employ furnaces of various shapes, where the fuel is coked in one part, and the gases are directed over beds of heated coal in another. These 211 Trade*, Tragacanth. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. In the side of the cylinder is placed an opening through which the soot is allowed to fall into a flue closed by a box, which may be removed when filled. Within, the truncated cylinder is divided, by means of partitions de- scending a little below the upper end of the chimney flue, into four divisions. Each compartment is provided with an orifice for the passage of the smoke, the size of the four together being exactly equal to that of the chimney flue. The cylinder is covered by a double cover pierced throughout its circumference with holes, so as to allow to the external air free access between the two sheets form- ing the cover. These covers are bent in opposite directions in such manner that, as the soot is thrown against the curved in- terior cover, it is thence thrown down to the oblique bot- tom and directed by the partitions through the side flue into the reception box, the smoke escaping through the lateral openings of the compartments." Finally, we have the method of employing two fires, now in use in several Western cities. There is a fire un- der each end of the boiler, fed from the side. When one fire is fairly burning the second fire is kindled, and by shifting the draft the smoke from the new fire is carried over the live coals in the furnace first started, and is con- sumed. The fires thereafter are replenished alternately, and thus the consumption of smoke is continued. An application of this is shown in Fig. 3996 where it is used at the Plymouth Chemical Works for the destruction of the odors produced in the manufacture of superphos- phate. It will be seen how absolutely all these methods depend upon the care and skill of the stoker. No matter how perfect a smoke consumer may be, it requires the fireman to charge his furnaces in such manner as to keep the hot- test fire at the back of the grate. This is done by push- ing the heated coals at the back of the fire and intro- ducing the fresh fuel in the front. If this is done the unconsumed particles will always pass over a bed of hot coals before leaving the fire box. As it is easier, how- ever, for the fireman to throw the fresh fuel at the back of the grate, this latter practice is the one usually fol- lowed. In Europe it has been found necessary, for the preven- tion of smoke nuisance, to inflict fines upon the stoker as well as the owners of the factories. In endeavoring, therefore, to find a remedy for this nuisance, we must consider that smoke is caused, (1) by the want of proper construction and adjustment between the fireplace and boilers ; (2) by improper construction of the flues leading to a chimney of inadequate capacity; (3) by carelessness in stoking ; and (4) by the use of poor fuel such as shav- ings, etc.23 If it were possible to forbid the use of improper fuel, as recommended by Dr. Tracy,24 the matter would be greatly simplified. The remedies, therefore, for a smoke nuisance are: 1. The erection of a tall chimney to discharge the smoke and gases at a level above the neighboring dwellings. 2. The introduction of a smoke consumer adapted to the particu- lar circumstances under which it is employed. 3. After its erection, the infliction of a fine upon both owner and stoker, should its failure be due to carelessness in firing and keeping the apparatus in order. V. The Pollution of Water Courses.-Almost every manufacturing establishment has certain liquid waste products which have to be conveyed away through drains or sewers. No matter how much care may be taken by the introduction of settling tanks, the liquid and por- tions of the solid matters generally find their way into the water courses. Care should be taken, in the locating of factories, that no deleterious matter be allowed to flow into any waste water which may subsequently be used for domestic purposes. The reader desiring information concerning the amount of deleterious matter which may be allowed in such water, and the remedies for its pres- ence, may consult article on Water, Sanitary Aspects of. VI. Trades which are Offensive on Account of the Noise.-The noise of boiler or machine shops, and the constant jar of machinery, are probably the most offen- sive nuisances caused by manufacturing establishments. The constant pounding and hammering in inhabited neighborhoods during working hours is undoubtedly very annoying to any sick or nervous person. There is, nevertheless, no remedy save the removal of the offend- ing establishment. The common law regulates such matters. It would prevent the building of such factories in the midst of res- idences, while, on the other hand, the erection of dwell- ings in the midst of a collection of such factories would be equally indefensible. No general rule can be laid down to govern such cases. The cries of the street vender heard in the cities from morning until night, the yell of the milkmen at early morning, the ringing of the bells of junk dealers and knife grinders, the so-called music of street organs and bands, are all exceedingly distressing to nervous per- sons and invalids. It seems impossible to carry on these trades without more or less noise, and as they afford the means of living to multitudes of poor people, it is a ques- tion how far they should be suppressed. In New York a city ordinance prohibits street music between 9 p.m. and 9 a.m. If the time for carrying on all these noisy trades should be confined to such limits, and the evening limit made eight o'clock, it would probably be all that could be done. VII. Trades that are Offensive on Account of Dust.-As a rule, the dust generated in manufacturing establishments is more deleterious to the health of em- ployes than to that of the neighbors. In almost every establishment dealing with fine powders great trouble is experienced in controlling them. The packing of Paris green, of carbonate of magnesia, and even of baking powder or of flour, fills the air with a mass of small particles. Some of these are not alone poisonous to inhale, but dangerously explosive. A fine dust arising from the manufacture of candies and in the milling of wheat has produced explosions both in New York and elsewhere, causing the loss of many lives. Of course, it is impossible to confine this dust to the room in which it is generated, for the workmen must open the windows to obtain air, thus causing constant annoy- ance to the neighbors. In the case of a packer of Paris green the ground was found covered with the material for a distance of six hundred feet from the works. The escape into the open air might be prevented by fitting the windows with fine wire screens, which allow a circulation of air without the escape of dust. For the protection of workmen the work should be conducted, as far as possi- ble, under large hoods connecting with an exhaust fan. The entire air of the room should be changed frequent- ly by the aid of a fan, or of a spray condenser and a chimney. The usual method of etching glass is to expose it to the fumes of hydrofluoric acid, the portions which are to remain unaffected being painted with sesqui-oxide of iron or coated with wax or tin foil. A more economical method is to force a jet of sand by means of a powerful blast against the uncovered portions of the glass. The tremendous force of the air drives the fine dust and sand out into the room. It should be passed through a water tank where it is allowed to settle. The pressure of the air is so great that it is almost impossible to control the entire dust. The work should therefore be confined to the vicinity of establishments in which the bearings of the machinery will not be damaged by the particles. It will not travel over three or four hundred feet from the works. In Paris the noise and dust caused the removal of the carpet-beating establishments, first from the Quartier St. Avoye, and afterward from under the Pont Neuf. In New York very little complaint has been made, as the work is almost all done by machinery. " The ends of the carpet are pinned together so that it constitutes an endless chain, which rests upon a rubber platform, plush surface downward, being drawn along by two rollers betw'een which it passes. As it moves it is beaten by rods, and the heavier dust falls into a long piece of sack- ing spread beneath it; the lighter dust, which would 212 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Trades. Tragacanth. otherwise float out into the room, is drawn upward into a large hood which covers the whole machine, and thence into a flue by a powerful blower, which sends it forward into a lofty chimney " The sweeping of the streets of a large city should al- ways be done at night, and the streets should be sprinkled even though machinery is used. This dust, composed, as it is, of animal and vegetable, as well as of mineral matter, produces coughing, inflammation of the eyelids, and, it is claimed, nasal catarrh. Conclusion.-It is of course impossible to describe every trade which may become offensive, together with the remedy necessary in each case. The constant estab- lishment of new industries, and the discovery of new pro- cesses of manufacture, will give rise to new causes of of- fence. The situation of the factories and the amount of capital invested in them vary so greatly, that it would be impossible to design machinery suitable to each individ- ual factory without a special investigation. What has been attempted in this article is to outline certain general principles. It is the duty of a sanitary inspector to adapt them to each case, and it should always be borne in mind that, though the most effective remedy is in the end the cheap- est, it is but right that the owner of the offending factory should be allowed to introduce the most economical method of abating the nuisance. The simplest machin- ery is generally the best. All deodorizing apparatus should be so arranged as to be automatic, if possible. Nothing will prove satisfactory which depends for its efficiency upon the workmen. In addition to the works cited throughout this article, the following authorities may be consulted. Alkali Act, 1863. Annual reports by the inspector of his proceedings during the years 1864 et seq. London, 1864-1887. Blythe, H. Winter : Dictionary of Hygiene. London, 1876. Bunel: k tablissements insalubres, incommodes et dangereux. Paris, 1876. Bussy : Note sur 1'influence des fabriques de produits chimiques sur 1'hy- giene publique. Journ. de Pharm. et de Chimie, 1858. Braconnot et Simonin: Note sur les Emanations des fabriques de produits chimiques. Journal de Chimie medicale, 1848. Christiani: Technical Treatise on Soapsand Candles. Philadelphia, 1881. D'Arcet: Des rapports de distance qu'il est utile de maintenir entre les fabriques insalubres et les habitations qui les entourent. Annales d'Hy- giene publique, t. xxx., p. 321. 1848. Dictionary of Chemistry and Supplements, Watts. London, 1863-1881. Encyclopaedia of Chemistry. Philadelphia, 1877. Fleury: Cours d'Hygiene. Paris, 1852. Freycinet; Traite d'Assainissement industriel, etc. Paris, 1870. Gotel; Oeffentliche Gesundheitspflege in den ausserdeutschen Staaten. Leipzig, 1878. Goldschmidt, S. A.: Blood Drying, Senate Document No. 70. Albany, 1882. Hut: Krankheiten der Arbeiter. Leipzig, 1875. Motard : TraitE d'Hygiene gendrale. Paris, 1869. Pappenheiin : Handbuch der Sanitats-Polizei. Berlin, 1868. Payen: PrEcis de Chimie industrielle. Paris, 1878. Paven: Industrial Chemistry. Translated by B. H. Paul. New York, 1878. Reports Massachusetts State Board of Health, 1870. Slaughter-houses. Reports Massachusetts State Board of Health, 1874. Brighton Abattoir. Reports Massachusetts State Board of Health, 1875. Meat Supply. Reports Massachusetts State Board of Health, 1879. City of Cambridge vs. Niles Bros. Reports Massachusetts State Board of Health, 1884. Coal vs. Water Gas. Reports New York State Board of Health, 1882, 1883, 1884, 1885. Re- ports of Committee on Effluvium Nuisances. Reports Brooklyn Board of Health, 1875-1876. Newtown Creek. Roscoe and Schorlemmer: Treatise on Chemistry. New York, 1883- 1888. Snow: On Stinking Animal Matters, etc., Lancet, July, 1859. Spon : Encyclopaedia of Industrial Arts, Manufactures, and Commercial Products. London, 1879-1882, Ure. A. : Dictionary of Arts, Manufactures, and Mines. New York, 1887. Vernois: Traite d'Hygiene industrielle et administrative. Paris, 1860. Wagner: Chemical Technology. Translated by W. Crookes. New York, 1872. S. A. Goldschmidt. 1 Letheby: Noxious and Offensive Trades, London, 1875. American Chemist, 1875. 2 Cameron : Manual of Hygiene. London, 1874. 3 Report on Effluvium Nuisances, Parts I.. IL, III. Reports to the Local Government Board. London, 1876, 1877, 1878. 4 Report of the Council of Hygiene and Public Health of the Citizens' Association of New York. New York, 1866, 5 Tardieu : Dictionnaire d'Hygiene publique. Paris, 1872. 6 Church : Manufacturing Industries. London. 1876. 7 Rapport sur 1'Assainissement des Fabriques ou des ProcEdEs d'lndus- tries insalubres en France, Angleterre, et dans la Belgique et la Prusse Rhenane, par M. Charles de Freycinet. Public par ordre de son Excel- lence M. Ie Ministre de 1'Agriculture, du Commerce et des Travanx pu- blics. Paris: Dunod, 1866. 8 R. S. Tracy, M.D.: Public Nuisances, Treatise on Hygiene and Pub- lic Health. New York, 1879. 9 Thomas Anderson : Transactions of the Royal Society of Edinburgh, 1848. 10 James Adams, M.D. : On the Presence of Arsenic in the Vapors of Bone Manure. Edinburgh, 1876. 11 Report Health Commissioner of Brooklyn on Illuminating Gas, 1883. 12 C. F. Chandler: Gas Nuisance, Report Metropolitan Board of Health, 1869. 13 E. H. Janes: Offensive Odors from Manufacturing Establishments. Report New York Board of Health, 1874-75. 14 S. A. Goldschmidt: Gas Nuisance. Report New York Board of Health, 1874-75. 15 Report of Noxious Vapor Commission. London, 1863. ,6S. A. Goldschmidt: The New York Assay Office, City Record, June 20, 1882; The New York Assay Office, a Memorial, 1885. 17 Report of Playfair and De la Beche, 1846. 18 Angus Smith : Air and Rain. London, 1872. 19 Report of Select Committee on Noxious Vapors, 1876. 20 Kingzet: The Alkali Trade. London, 1878. 21 Richardson: Smoke Nuisance and its Remedy; Edwards: Smoky Chimneys. 22 Rapport, etc., du Conseil d'HygiEne, etc., au DEpt. de la Seine. Paris, 1866. 23 Reports of Select Committee on Smoke Nuisance, 1846. 24 Report New York Board of Health, 1874-75. TRAGACANTH (Tragacantha, U. 8. Ph., Br. Ph., Ph. G.; Gomme adragante, Codex Med.). A peculiar product of several species of Astragahis (Order, Legumi- nosa), consisting mostly of insoluble gum (bassorin) and produced by the change and degeneration of the pith and Fig. 4002.-Astragalus Gummifer Labill. (Bailion.) medullary rays of these plants. The section of the ge- nus yielding this product (sub-genus, Tragacantha) con- sists of shrubs, often low and much branched, with pin- nate leaves on stiff, pointed, persistent petioles which remain on the stems as permanent thorns for several sea- sons, after the leaflets have fallen. The flowers are small, axillary, solitary, or in groups of two or three, papilionaceous ; pods small, one-seeded, hairy. They are natives of Asia Minor, Syria, Persia, etc., and even of Southeastern Europe. Among the more important 213 Tragacanth. Transfusion. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. species are : A. gummifer Labill., A. adscendens Boiss et Haunsskr., A. microcephalus Willd., A. kurdicus Boiss, etc. An examination of the stems and older branches of these shrubs shows the medullary system to be more or less completely changed into a soft-solid mass of tragacanth into which, at its complete development, the very cell- walls themselves have become transformed. This mass, under a strong tension, maintained by the wood and bark of the stems, is pressed out through artificial or accidental openings, such as cuts, pricks, fractures, etc., in various shapes, and when dry is the Tragacanth of the market. If the branch is cut or broken off, the pith is forced out in a long cylindrical form ("Vermicelli Tragacanth ") ; from irregular spontaneous openings, it comes in various shapes, often dark and dirty (com- moner sorts). When obtained, as the best is now, by making short longitudinal incisions through the bark, it is in thin, curled ribbons and known as "Flake Trag- acanth." This method is shown in Fig. 4003 ; by it is obtained almost all the Tragacanth that is clean and white enough to be applied to pharmaceu- tical uses. After the gum has been press- ed out and dried, it is broken from the stems and sorted into a number of grades, in which the purity, size, and whiteness of the flakes determine the qual- ity. Flake Tragacanth of good quality comes in ribbons from a fourth of an inch to one inch in width, from half an inch to four or five inches in length, and from one-fifth to one-tenth of an inch in thickness. It has longi- tudinal markings, made by the edges of the cut through which it has passed, and, usually more evident, transverse ruga, indicating pauses or changes of rate in its exudation. It is of a creamy- white color (inferior qualities, brownish yellow), very hard and tough, with no odor, and a mawkish, mucilag- inous taste. It swells very much with water to a gelat- inous mass ; with excess of water, a portion is dissolved. Occasional traces of cellular tissue and a very little starch may be found by the microscope. It is very difficult to powder, unless dried artificially (when it loses about twelve per cent, of water) and then ground or pounded very cold. Tragacanth consists of from one-third to one-half its weight of bassorin (C6Hi0O5), an insoluble gum common to a number of • commercial products (Bassora Gum, Simaruba Gum, Cherry-tree Gum, etc.) and of extended occurrence in the vegetable kingdom. It is capable of absorbing a good many times its weight of water, when it becomes transparent, soft, and jelly-like, but wTill not dissolve clearly when more water is added. Bassorin can be seen reasonably pure by putting a piece of Tragacanth in a tumblerful of water and letting it remain, say, twenty- four hours until the soluble gum is dissolved out. About half of Tragacanth consists also of a soluble gum, of the arabin series. Water, mineral substances, and impurities constitute the remainder. Tragacanth has no medicinal, and very little nutritive value. It is very largely used in the arts for sizing, mucilage, etc., and has considera- ble employment in pharmacy, where it is used as a basis of emulsions, for the suspension in liquid of powders and insoluble substances in " mixtures ; " as a body for troches, etc. It appears in the following officinal prep- arations: Trochisci Acidi Tannici, Trochisci Ipecacu- anhce, Trochisci Potassii Chloratis, Trochisci Santonici, Trochisci Zingiberis, all U. S. Pharmacopoeia. There is a Mucilage of Tragacanth (Mucilago Tragacanth®, U. S.) consisting of six parts of Tragacanth, eighteen of glyc- erine, and enough water to make a hundred ; this, diluted with about as much more water, will emulsionize Cod- liver- or Castor-oil sufficiently well; the usual strength is to make the emulsion one-half oil. It may be flavored with peppermint, almond, or other fragrant substance. For desk purposes, as an adhesive mucilage, Tragacanth, soft- ened with Thymol Water and kept from evaporation, will not decompose or sour in the least, even after years. Allied Plants.-The genus is a very large one, com- prising several hundred species, but none of them, except- ing those producing Tragacanth, have the least economic value. For the Order, see Senna. Allied Drugs.-All gums and mucilages ; more re- motely, the starches. Flaxseed, Quince seed, and Salep, have forms of mucilage closely resembling that of Trag- acanth. Inulin and various amyloid substances (Liche- nin, etc.) resemble it in composition and some of its properties. Gum Arabic is the type of the soluble gums, as Tragacanth may be said less exactly to be that of the insoluble ones. IE P. Bolles. TRANSFUSION. The operation of transfusion, in its strictest application, means the transferrence of blood from the vascular system of one animal to that of another. In its wider application the term includes the injection of any nutritious liquid into the veins or arteries, or into any cavity or tissue in the body. Transfusion of blood is an exceedingly old operation. It was performed in ancient times, but in a very crude way. Ovid, in his " Metamorphoses," gives an account of its performance by the sorceress Medea, who took blood from young healthy men, mixed it with vegetable juices, and injected it into the veins of old men who longed to renew their youth. Savonarola, the celebrated Florentine monk, gives an account of the transfusion of Pope Innocent VII. The Pope had reached the average of life, and was suf- fering from a disorder which produced coma. Two young men in good health were obtained who were will- ing to give their blood to save the Pontiff. The patient was bled, and the blood which escaped was injected into the veins of the young donors. When the blood had circulated a short time, the young men were bled and the blood was transferred to the veins of the Pontiff. The operation proved fatal to both patient and donors. Though transfusion was an ancient tradition, we find that Jean Daniel Mayer, a German surgeon, claimed, in 1667, to have been the first man to perform the operation. In 1615 Libavius advocated arterial transfusion by means of silver tubes, passing from a blood-vessel of the donor to one of the recipient. There is, however, no authentic record of his cases. In 1665 Lower, of Oxford, performed the operation with success. He bled animals to a condition of syncope, and then resuscitated them by injections of blood from other animals. Denis, of Paris, followed Lower in these experiments. He transfused a patient who had been bled and purged for fever. Ten ounces of lamb's blood were injected and the patient recovered. Subsequently, he was called to an insane patient who had been bled and purged with- out changing the irregular current of his thoughts. He injected nine ounces of calf's blood, and recovery from the mental disturbance was the result. Three months later, the mental trouble returned, and Denis attempted to operate again, but on opening the vein in the patient's arm found that no blood flowed. He did not finish the operation, and his patient died. The wife charged the physician with killing her husband, and the latter retali- ated by saying that she had administered poison to him. The case created considerable excitement in Paris, the operation fell into discredit, and a law was finally passed forbidding its performance, unless the consent of all the faculty had previously been obtained. As a matter of Fig. 4003.-Gum escaping from Inci- sions in a Branch of a Tragacanth shrub. (Baillon.) 214 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tragacanth, Transfusion. course, this order was tantamount to a complete pro- hibition, and transfusion in France was for a time aban- doned. In 1655 two German surgeons, named Kaufmann and Purmann, claimed to have cured a leper by the repeated injections of lamb's blood. Dr. Schmidt, of Damrech, injected medicinal agents, as well as blood, with a cer- tain degree of success in exhausting diseases, and after luemorrhage. In 1825 Dr. James Biondell, of London, gave to the operation a new impetus. He operated upon dogs as his predecessors had done, first bleeding the animals until pulse and respiration ceased, and then injecting fresh blood. He established conclusively the already half- proven fact, that animals apparently dead could be re- suscitated by transfusion at the end of three or four minutes ; but that if the operation were delayed for more than five minutes, it proved of no avail. Dr. Biondell also tried injections of blood in dogs that had been kept without food for two or three w'eeks. After three weeks had elapsed, he found that the blood failed to sustain the animal. His first experiments upon men were not as successful as his experiments upon animals. Five consecutive failures resulted, probably because the operations were performed at too late a period, as indeed they very often are at the present day. Subsequently, velopment of such peculiar tissues as horn, etc., belong- ing to these animals, and that consequently these ele- ments would prove deleterious when in the vascular system of the human patient. At the present day there is scarcely any difference of opinion with regard to the use of blood from the lower animals ; it is regarded as dangerous, and it is seldom or never employed. Another question which has received much attention, is as to the value of defibrinated blood. Many believe that the fibrine of the blood possesses qualities of a poison- ous nature, which make it useless as a factor in restoring lost vitality, and that, therefore, this element should be removed by whipping and straining before the fluid is injected into the veins of the patient. Others believe in defibrinating the blood in order to remove the danger of coagulation in the venous capillaries of the lungs. Ma- gendie and Bernard, on the other hand, considered that the fibrine assisted capillary circulation, and that by it the blood was enabled to traverse the capillaries in a much more viscid and firmer stream. Panum, of Copenhagen, thought that no immediate or special nutritious effect would result from transfusing defibrinated blood. His experiments, however, do not prove his assertion. The fact is that both defibrinated and undefibrinated blood will save the life of an exsanguinated patient; I have used both with success. But it is much better to inject the blood without going through the process of defibrinating it. In the first place, whipping the blood makes it possible for poisonous germs to enter the liquid. If the whipping be performed in the wards or amphi- theatre of a hospital, the entrance of germs into the circulation could hardly be prevented. In the second place, the mass of fibrine taken from the blood carries off with it a large number of globular elements entangled in the meshes, which must necessarily lessen the restora- tive qualities of the blood. If we can do without this defibrination, then, so much the better. During the past fifteen years I have confined myself to the use of unde- fibrinated blood, without any unpleasant result. In a few of my cases the blood was injected as it flowed from the veins, but in the larger number I have used a solu- tion of carbonate of ammonia (ten grains to the ounce), adding two ounces of this to the blood before transfusing. Besides doing away with the possibility of the formation of coagula in the veins, one gets by this means the stimu- lating effects of the ammonia which in many cases is of great value. Operative Procedures. - There are five varieties of transfusion : 1, Immediate ; 2, mediate ; 3, peritoneal ; 4, auto-transfusion ; 5, injection of blood into the cel- lular tissue. In immediate transfusion the blood is transferred di- rectly from the donor to the patient, by means of con- necting silver or rubber tubes, or by the aspirator. In mediate transfusion the blood pours from the donor's arm into the basin of the instrument prepared to receive it, and is afterward injected (with, or without defibrination) into the veins or arteries of the patient. Peritoneal transfusion consists in the injection of blood into the cavity of the peritoneum. Auto-transfusion can scarcely be called an operation, but it is often of value in keeping up the supply of blood to the nerve-centres. It consists in bandaging the limbs of the patient and thus forcing the blood to the central organs. injection of blood into the areolar tissue is performed with a large hypodermic syringe. It is seldom employed. The nutritious and stimulating fluids employed in transfusion are : first, blood defibrinated and undefibri- nated ; second, milk from the cow, goat, or human mammary glands; and third, saline solutions. The indications for the operation of transfusion are : 1, excessive haemorrhage ; 2, malignant syphilis; 3, chronic or pernicious anaemia ; 4, prolonged suppura- tion ; 5, scurvy or purpura haemorrhagica ; 6, carcinoma ; 7, blood-poisoning from carbonic acid, illuminating gas, etc. ; 8, white softening of the brain or cord. When special instruments are not at hand for the per- formance of the operation, an ordinary rubber or glass Fig. 4004.-Avcling's Transfusion Apparatus. 1, 5, Hands of the assistant holding the cannulse in position ; 4, hand of the operator compressing the bulb ; 2, 3, hand of the operator compressing alternately the affer- ent and efferent tubes. however, he saved several lives, and thereby gave to the operation a character which it never had before. Edmund King, Thomas Coxe, and Russel, of Suffolk, also obtained many cures by means of transfusion, but none of them devoted so much time and money to the work, or accomplished so much, as Biondell. Surgeons have differed in the past with regard to the utility of taking blood from one animal and in- jecting it into another of a different species. In 1755 Michael Rosa, of Oden, made a number of experiments, and came to the conclusion that an exsanguinated animal might be resuscitated by the injection of blood from an animal of a different species. Russel, of Suf- folk, is said to have cured a case of hydrophobia by opening the veins of the patient, allowing some blood to flow, and then transfusing the blood from several lambs. Blondell satisfied himself that the blood of a dog would resuscitate a dog, but that the blood taken from a human biped had no beneficial effect whatever. Laing believed that the blood of calves and other animals con- tained particles of various kinds necessary for the de- 215 Transfusion. Transfusion. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. syringe may be used. If it is considered necessary to defi- brinate the blood, the best basin for the purpose is a china or glass finger-bowl. The most prominent vein in the patient's arm should be selected, either the median basilic, aspect of the arm. In patients who are very fat this vein may not be visible ; in such cases the median ce- phalic, or median basilic, may be opened. When the ce- phalic vein is not perceptible, a little pressure upon it for a few moments will often suffice to bring it into view'. When the position of the vein has been determined, the integument over the vein is to be pinched up with the thumb and forefinger and incised with a bistoury or scalpel ; the fingers then being removed, the elastic skin retracts on each side, exposing the fine delicate blue line of vein embedded in the cellular tissue beneath. A few scratches with the scalpel, on each side of the vein, ex- poses it more and separates it thoroughly from the cellu- lar tissue, making it easy to pass a director underneath and lift it above the level of the integument. Some surgeons before opening the vein place a liga- ture around it below the point of opening, in order to prevent the escape of blood, but this is altogether an un- necessary procedure. The fingers of an assistant answer the purpose equally as well, and less injury is done to the vein. The vein is now pinched up from the director by means of dressing-forceps, and is carefully opened by a few transverse scratches with a scalpel. The cannula is inserted and retained by the fingers of an assistant, who holds it in position during the whole of the operation. With regard to the donor and his necessary preparation, I would lay down this rule, viz.: Never take the blood from an anxious relative of the patient. I have done so sev- eral times and have always had occasion to regret it. The nervous agitation, or perhaps the previous anxiety of the relative, in some unknown way, exerts a peculiar influ- ence upon the blood. In some cases the blood coagulates almost immediately af- ter exposure to the air. In all cases there is a greater tendency to co- agulate than when the blood is taken from a stranger; and even when this tendency is diminished by medici- nal agents, it seems not to have the same re- storative effect as the blood taken from a person not specially in- terested in the patient. In the second place, it is not uncommon for the donor, if a relative, to faint before suffi- cient blood has been obtained to make the transfusion a success. In all such cases it would be much better to inject saline solu- tions than to risk a fail- ure by taking the blood from an over-anxious relative. Noris itwise to allow the donor to witness the operation of opening the vein of the recipient. When the vein is opened he can be brought in and seated beside the patient, the eyes of the latter mean- while being shielded by one of the assistants or nurses standing be- tween the two. A roller bandage two or three inches wide is now placed around the arm near the bend of the elbow, and tightened sufficiently to obstruct the circulation through the veins without interfering with the arterial current. A piece of wood, or other hard substance, is then firmly grasped by Fig. 4005.-Glass Funnel and Tube employed in Transfusion. or the median cephalic-it matters little which. If a glass rod can be obtained to whip the blood with, so much the better ; if not, a few pieces of straw from an ordinary clean new whisk-broom will answer. After stirring the blood vigorously, large clots form and are removed, and then the additional precaution is taken of straining the blood through a piece of muslin into another finger - bowl prepared for the pur- pose. The bowl of blood thus prepared is then placed in a basin con- taining water at 110° F. and allowed to remain there until an opening is made in the cephalic vein, or in any other vein in the arm which is easy of access. The blood is then injected with an ordinary rub- ber or glass syringe, or allowed to flow from an ordinary glass fun- nel connected with the vein by a rubber tube and cannula. The glass funnel, however, is much bettef suited for the transfusion of milk than for the trans- fusion of blood. See Fig. 4005. When the operator has nothing but a sy- ringe to perform the operation with, he will find that a small goose- quill is very useful as a cannula. The blood can be injected through it with ease. As a rule, the vein selected for transfusion is the cephal- ic vein. If that is not accessible, any other vein at the bend of the elbow may be chosen. The cephalic vein, even in exsanguinated patients, may generally be seen as a faint blue line under the integument on the outer and anterior Fig. 4006. Dieulafoy's Aspirator prepared for Use in Transfusion, 216 Transfusion. Transfusion. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the patient, with the forearm flexed so as to increase the distention of the superficial veins. The median basilic, or the median cephalic, may now be opened and the blood allowed to flow into any basin or vessel that the operator may have selected. It may be well here to mention that, if a small opening or punct- ure is made in the vein the blood will coagulate rapidly ; if a large opening is made it will coagulate slowly. An opening half an inch in length will cause a free flow of blood and lessen the tendency to coagu- lation. In my first operations I employed Dieulafoy's aspirator, with tubes the tube. The stylet is then withdrawn from the cannula in the patient's arm, and as it is withdrawn the blood follows it, forcing out whatever air is in front of it. The cannula attached to the instrument is then introduced into the cannula in the vein of the patient, and the blood is slowly injected. Some surgeons employ Aveling's apparatus for direct transfusion. ' ' This instrument is made on the principle of David- son's syringe, and consists, like it, of a rubber tube with a bulb in the centre. To each end of the tube there are attached bevelled metallic cannula;. The air is forced out of the bulb and tubes by tilling them with a warm saline solution. The patient and the donor are now placed side by side and the cannula, still filled with water, is inserted into an opening made in either the median cephalic or the median basilic vein. When this is accomplished the oper- ator compresses the bulb as well as the tube from the donor's arm and the saline solution is forced in. Then pressure is made on the tube connected with the patient's arm and the blood passes from the vein of the donor, filling the bulb. Pressure is again made on the bulb and on the tube from the donor's arm, as before, and so on until sufficient blood has been injected." I have used the instrument twice, but in both cases, before I had injected sufficient blood, coagula were formed in the tubes. Dr. Thomas G. Morton employs an instrument which is a modification of that of Dr. Allen. " It con- sists essentially of a blood receiver, syringe, and cannula. The receiver is a cylindrical vessel, made of German sil- ver, six inches in diameter and six inches in height, hav- ing at its upper edge a short metal tube closed by a screw top, and one-half inch in diameter, through which warm water is introduced into the lower part of the ves- sel. On the outside is a thermometer, the curved bulb of w'hich lies in the chamber, and by which the tempera- ture of the water is regulated. In the interior of this re- ceiver is an inverted cone, gilded on the exposed surface, and dipping down so as to be surrounded by the hot water, though there is, of course, no connection between the water and the interior of the cone. The syringe is of glass, five inches long by one in width, metal bound, with hard rubber at each end, and holding two ounces, a tapering rubber nozzle one and one-half inch long pro- jecting from one end, while at the other is the ring at the end of the piston-rod. Besides these there is a steel can- nula, two inches long and one-twentieth of an inch in di- Fig. 4007.-Colin's Transfusion Apparatus. and hollow curved needles adapted to transfusion. The aspirator is first placed in a basin of warm water, the air exhausted by turning the handle to the right, and the solution of carbonate of ammonia previously spoken of drawn up into the cylinder. The curved hollow needle, connected with a rubber tube of small calibre, is now inserted into the distended vein of the donor, the stopcock is turned, and the blood is allowed to pass through the solution of ammonia and to fill the cylinder. While the blood is passing into the instrument it is well, occasionally, to compress the rubber tube with the thumb and forefinger in order to prevent the vein from collapsing. When the instrument is filled the handle of the aspirator is moved from left to right, and some blood passed through the tube and the cannula, which has already been introduced in the usual way into the vein of the patient. When the connection is made, the handle of the aspirator is again turned and the blood forced slowly into the vein of the patient. The operation with this instrument requires much delicate manipulation, and more carethan can ordinarily be given, and though I have used it in thirteen successive cases I have discarded it for Colin's apparatus, after giv- ing the instruments of other operators a fair trial. There is no doubt that Colin's in- strument is the simplest and safest yet invented for the purpose of transfusion. Colin's instrument consists of a reservoir or basin for the blood, to which is at- tached a syringe working like any other ordinary syringe. To the lower angle of this is attached a rubber tube with a cannula at its end. The entrance to this tube is guarded by a hollow ball- valve made of aluminium, which completely excludes the air. The cannula which is inserted into the vein con- tains a probe-pointed stylet, which enables the operator to enter the vein with great ease. (Fig. 4007.) Another important point with regard to this instru- ment is that the cannula connected with the tube fits ac- curately the cannula in the vein, and when the stylet is removed the connection is easily made. The instrument is immersed in warm water ; the solution of ammonium carbonate previously spoken of is first poured into the basin of the instrument. The blood from the donor's arm flows into, and mixes with, the solution. The blood is drawn into the syringe, and then forced out through ameter, to which is at- tached a conical metal neck, into which the end of the syringe fits. The cannula is, of course, fit- ted with a trocar." There should also be at hand a tumbler or bowl, sur- rounded by hot water, a fine piece of linen for straining the blood, and some half- dozen little bundles of broom straw, which can, as I have before mentioned, be easily made from a new whisk- broom. Roussel, of Geneva, who has had a large experience in transfusion, uses an apparatus for direct transfusion which requires a great deal of practice before the operator can be perfectly sure of its efficacious working. See Fig. 4010. Fig. 4008.-Aveling's Instrument. 217 Transfusion. Transfusion. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. It consists of a receiver which contains a lancet, and to which is fitted a pump which exhausts the air and produces a vacuum. The receiver is filled with the so- dium solution, the vein in the donor's arm is punctured, and the blood fills the receiver and is injected into the vein of the patient. I have had no experience with it. While a patient is being subjected to the opera- tion of transfusion, various symptoms may arise which it will be well to understand. After the first ounce or two of blood has entered the circu- lation the patient may complain of vertigo, and dimness of vision. In such a case a few moments should be allowed to elapse before another syr- ingeful is injected. The patient may also com- plain of a constriction of the chest and some slight difficulty in breathing. Here again the operation should be suspended until these symptoms are re- moved. There are also in some cases coma, pains in the loins, and often a very severe pain in the lumbar region. The pain in the lumbar region I have noticed more frequently when milk was transfused than when blood was used. The patient may complain of prickly sensations in the ex- tremities, especially when the operation is approaching comple- tion. In all cases it is well for the operator to stop and ask questions before the next syringe- ful is used. If the pa- tient is unable to speak he will always get a negative or affirmative movement, which is all that is necessary. It is not necessary to trans- fuse more than seven or eight ounces of blood, and four or five will often save a life. Some cases are on record in which the patient was restored by an ounce or two, but no case of this kind has occurred in my practice. While that amount would doubtless be productive of some little benefit, it would not suffice to save a patient who had been bled to a state of syncope, either by accident or design. Following the operation there is also a train of peculiar symptoms. As a rule, if the patient is going to revive, the 1 he other febrile symptoms, such as headache, pains in the loins, thirst, etc., are also present to a greater or less degree. The chill and fever arise from the increased chemical action in the tissue, started by the influx of healthy blood. The flow of urine is sometimes increased, and it may contain albumin. In some it becomes scanty and high-colored, especially when the temperature has been much in- creased by the opera- tion. In some cases coma occurs. Transfusion of blood is commonly consid- ered a dangerous opera- tion, especially by those who have never per- formed it. But al- though the operation is generally made on a pulseless and moribund patient, a death occur- ring during or from the operation is of very rare occurrence, which is a sufficient evidence that this opinion is not well grounded. The dangers from the for- mation of coagula in the veins, and from the entrance of air, are al- most impossible with the instruments in pres- ent use; and with or- dinary precaution the danger of overpower- ing a feebly pulsating heart with an overload of blood is scarcely worth mentioning. In any event, all that is necessary for success is to inject the blood slow- ly, carefully watching its effects. The first and fore- most indication for the performance of trans- fusion is excessive loss of blood. Whenever the phy- sician is called to an exsanguinated patient, where the pulse is absent or scarcely perceptible, with sighing and irregular respirations, a face of ghastly pallor, extremities cold and clammy, with all the signs of rapidly approach- ing dissolution, he has a typical case for transfusion, and a case where failure on his part to perform the opera- tion, if proper instruments are at hand, should be con- sidered criminal. In such a case the injection of a few ounces of healthy blood might within half an hour change the whole condition. The pulse would become full and regular, the respirations would become normal, and the face and extremities would assume a more natural ap- pearance. An interesting case, ultimately making a complete re- covery, occurred among my early operations of trans- fusion. The patient was under the care of Drs. Reynolds and Comstock, of New York, who sent for me to perform the operation. She had had a miscarriage two weeks before, and profuse haemorrhage every day since. Her physicians had been in close attendance night and day, doing everything in their power to keep her alive. I saw her at 7 a.m. She had all the symptoms of loss of blood previously enumerated, but in addition she was insensible and evidently dying. As there was no time to lose I injected seven ounces of undefibrinated blood, un- mixed with ammonia, by means of Colin's instrument. In a few minutes afterward the patient articulated with- BLOOD RESERVOIR HOTWATER COMPARTM ENT . Fig. 4009.-Morton's Transfusion Apparatus. Fig. 4010.-Roussel's Apparatus for Transfusion. pulse and voice will be restored together. Usually within an hour the patient has a well-marked chill, followed by a febrile movement which lasts some hours, the tempera- ture rising from one to three degrees. The rise in tem- perature is greater when the operation is performed in phthisical cases than in any others. 218 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Transfusion. Transfusion. out any difficulty, her pulse returned at the wrist, she swal- lowed a little beef-tea, and kept on gradually, from that time, gaining strength until complete recovery took place. Dr. T. G. Morton, of Philadelphia, has employed trans- fusion in three cases of purpura haemorrhagica with suc- cess. " The first case was a child, eleven years of age. She had three attacks of purpura, with bleeding from the nose. She had never during these attacks been alarm- ingly ill, but early in 1874 she was suddenly seized with haemorrhage from the nasal mucous membrane. The skin from head to foot presented the usual characteristic spots, some of which were of enormous size. When she was nearly exhausted transfusion was performed, as a dernier ressort, with a happy result. Some two months afterward a recurrence of haemorrhage, with all the for- mer symptoms, obliged me to transfuse again, for an im- mense amount of blood had been lost before I saw the case. The very rapid recovery which took place after both these operations presented a marked contrast with the tardy convalescence following the previous attacks, which, although much less severe, in the amount of blood lost, had confined the patient to bed for many months. Three years have elapsed since the transfusion, and during this period she has had but one attack of na- sal bleeding, which was early controlled by plugging." Such cases as these may be found recorded year after year in medical journals on both sides of the Atlantic, and it seems as if no further evidence could be needed to show the efficacy as well as the necessity of resorting to transfusion, in all cases of haemorrhage, without delay. The following cases afford an illustration of the pecu- liar effects of the operation in the advanced stages of phthisis: Mr. P., aged forty ; occupation, lawyer ; residence, Brooklyn, was operated on in February, 1875. He came of healthy stock, but from early life had lung disorders of various kinds. At the age of nineteen he developed pneumonia, from which he never recovered fully. Since then, at various intervals, he has suffered from all the symptoms of consumption, such as dyspnoea, cough, hae- moptysis, and night sweats. In 1868 he became very much emaciated, cavities formed in his lungs, and his life was despaired of. Dr. Vrooman, his family physi- cian, had him removed to a Southern watering-place, where he remained till his renewed strength enabled him to resume the active business of his profession. His astonishing endurance enabled him to continue at work until January, 1875, when a severe diarrhoea set in, which in a few weeks destroyed all hopes of even partial recov- ery. On February 11, 1875, I first saw him. He was then sinking rapidly. His pulse was extremely weak, rapid, and sometimes scarcely perceptible. The hands had a clammy feel. The capillary circulation in both upper and lower extremities was considerably interfered with. Large cavities existed in both lungs, in front and behind, and there was some pleuritic effusion on the right side. The medical gentlemen present at the time (Drs. J. C. Hutchinson, Vrooman, Catlin, and Barber) agreed with me that the case was a hopeless one, and that the operation of transfusion would be of little or no ser- vice ; but as the patient anxiously desired to have his life prolonged a few hours, if possible, it was decided to per- form it. The instrument then employed by me in transfusion (Dieulafoy's aspirator) was used in this case. A solution, containing ten grains of carbonate of ammonia to one ounce of water, was placed in the aspirator, and the whole instrument immersed in a basin of warm water held by an assistant. Dr. Vrooman having volunteered to furnish the blood, a bandage was placed around his right arm above the elbow, in the manner previously described, and when the veins were fully distended I inserted the hollow needle connected w'ith the tube of the aspirator into the basilic vein, turned the stopcock of the aspira- tor, and allowed the blood to flow into the cylinder and mix with the ammonia solution. Five ounces of blood wrere drawn off in this manner and slowly injected. When two ounces had been injected the pulse became imperceptible at the wrist, and the respiratory movements were more hurried. The eyeballs twitched from side to side, and the patient became partially unconscious. By pressing repeatedly in the epigastric region so as to force up the diaphragm, the respiratory movements became more natural, and tlie pulse perceptibly fuller. Two ounces more were then thrown in, with a similar result. The insensibility was, however, more marked, and for more than an hour after the operation was completed he remained in a semi-conscious state. The respiratory movements seemed to be natural, but the pulse was feeble and intermittent. Subsequently the pulse grew stronger, his senses returned, and the rest of the day he seemed to be much better than before the operation. On the twelfth day he expressed a desire for food, but could keep little on his stomach. On the thirteenth day he grew more feeble, gradually sinking until the fourteenth, when death took place. No post-mortem was made. While very dangerous symptoms accompanied the opera- tion, and all present thought he would die, it certainly prolonged his life beyond all expectations. The second case of transfusion in phthisis wTas in Charity Hospital. The operation was done in the amphi- theatre of the hospital. The patient was a laboring man, aged thirty-five. He had had phthisis two years. Both lungs contained large cavities. He suffered greatly from dyspnoea. His temperature was 103° F. ; pulse, 120; respiration, 30 per minute. Not being able to sit up, he was carried into the amphitheatre on his bed. I injected the same amount of blood as in the previous case, and in the same manner. As the operation proceeded, he ex- claimed : " Oh, that feels good ; it is so nice and warm, I can feel it all through me." He had no unfavorable symptoms during the operation. His pulse dropped to 112, and the respiratory movements became much easier. On the evening of the same day his temperature rose to 104° F., and the pulse increased to 140 per minute. Three days after the transfusion the temperature had fallen to 101° F., and the pulse to 105. For two weeks he seemed much improved in every way. At the end of that pe- riod, however, the disease took a fresh start, and he died four weeks from the day of the operation. Transfusion is always indicated in tertiary or malignant syphilis, where other means fail to effect a cure. One of the first patients that I operated on in Charity Hospital had been under treatment for several months in the hospital; his body w'as covered with large ulcers which did not show the faintest attempt at healing; large black spots of pigmentation covered his trunk and limbs; he had, in addition, cavities in his lungs from which there occurred daily more or less haemorrhage ; he was exceedingly weak and emaciated, and I had very little hopes of benefiting him. I injected seven ounces of undefibrinated blood, mixed with ammonia, through Colin's instrument. The patient bore the operation well, and was taken from the table feeling better. On the fifth day after the operation Professor Van Buren brought the same patient before the class in order to show the changes which had occurred during that short interval. The ulcers were then nearly filled with healthy granulations, some of the pigmented spots had disappeared completely, and the rest were much paler. The patient's appetite had improved also, and he ex- pressed himself as feeling better than he had been for months previous to the operation. He continued to im- prove until the ulcers had completely healed, then he had another haemorrhage from the lungs, and the trans- fusion was again performed as before ; he improved the second time, and soon afterward left the hospital; then I lost sight of him. This case was a remarkable one, the results were un- usual, and I am quite sure that every case of malignant syphilis would be more benefited by transfusion than by anything else, and if repeated in a year it might entirely cure the disease. 1 have employed transfusion also in cases of cancer, prolonged suppuration, etc., with excellent results; but in none have I witnessed so much and so sudden improve- ment as in exhaustion from excessive haemorrhage and malignant syphilis. 219 Transfusion. Transfusion. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Transfusion of milk had, at one time, many advocates. I formerly thought it was possible that it might become an excellent substitute for blood, and, being more easily obtainable than blood, would make the operation a more common occurrence than in the past, and 1 gave it a thorough test. In 1850 Dr. Hodder, of Toronto, treated three cases of Asiatic cholera by intravenous injection of milk. The patients were in a state of collapse ; one died and two re- covered. Dr. Hodder considered the recovery due to the injection of milk, which not alone diluted the thickened blood, but furnished nutriment to sustain the failing strength. The operation was not performed again until the year 1873, when I performed it in Charity Hospital, on a patient suffering from tubercular disease of the stomach and mesentery which prevented him from re- taining either solid or liquid food. He was in a very low condition when I first saw him, literally starving to death. It was evident to all who saw him that he would last but a few days. I intended to use blood in the case, but not being able to obtain any, I procured some goat's milk in the city and had it carried to the hospital. I opened the cephalic vein of the left arm and injected four ounces of the milk. The operation was at- tended by vertigo, dimness of vision, twitching of the muscles, and dyspnoea. On the evening of the same day, the house-surgeon injected four or five ounces more. The milk used by him had been in the ward all day. The morning after the operation I saw the patient again. He said he felt better, but I saw no improvement. There was nothing whatever in his condition to justify another operation. Death took place on the fourth day. In 1875 Professor T. Gaillard Thomas removed a large ovarian tumor from a patient in Brooklyn. Some days after the operation she had several haemorrhages which brought her to death's door. She was sinking rapidly when Dr. Thomas saw her. He determined to transfuse milk. Accordingly eight ounces of fresh milk, not more than five minutes from the cow, were injected into the median basilic vein of the moribund patient. To make the story short, she recovered rapidly, and six weeks from the date of transfusion she was able to go about and attend to her ordinary duties. On learning of this exceedingly interesting case from Dr. Thomas, I concluded to renew my experiments in the same direction, and, a day or two after, I operated on a patient in the last stage of phthisis in St. Francis' Hos- pital. In this case I opened the internal saphenous vein of the right leg and injected six ounces of milk, which had been taken from the cow three hours previously, and which seemed perfectly pure and sweet. During the operation the patient complained of intense pain in the lumbar region; his eyes twitched from side to side, and toward the last his respiratory movements were spasmodic and difficult. All these unfavorable symptoms disappeared in a few minutes, and the patient walked downstairs to his ward. He seemed to have suffered nothing from the operation in any way. Not long afterward, however, he became comatose, and died four hours after the operation. A post-mortem examination was made, but no cause for the coma was discovered. There were no clots in the heart, great vessels, or lungs. There was no indication that the injection of milk caused death. Both lungs contained large cavities. After this I repeated the operation on several dogs, with peculiar results. The milk injected into the veins of these animals was about two hours old. It seemed, as in the previous case, to be perfectly fresh and sweet. It gave no evidence of any abnormal change. Dog No. 1 was a poor, ill-fed animal; eight ounces of blood drawn from the femoral artery sufficed to produce syncope. Before consciousness returned, seven ounces of cow's milk were injected into the femoral vein. The passage of the liquid into the circulation caused irregular and gasping respiratory movements and nystagmus. These symptoms, however, disappeared in a few min- utes, the pulsations of the heart grew stronger, and a small quantity of blood, having a whitish color, escaped from the cut end of the femoral artery. This showed plainly that the milk had passed through the pulmonary- capillaries into the general circulation without difficulty. After ligature of the artery the dog was removed from the table. Death occurred seven hours after the opera- tion. No post-mortem examination was made. No. 2 was a large, well-fed slut; she was placed under the influence of chloroform, and the femoral artery was cut. Eleven or twelve ounces of blood escaped before the heart's action was noticeably affected. Eight ounces of milk were injected as before, accompanied, also, by the same difficult respiratory movements and twitching of the eyes. The animal recovered in a short time, and was able, with a little assistance, to get off the operating- table. Death took place ten hours after the operation. A post-mortem examination showed that the lungs were extremely pale and anaemic. No clots were found either in the pulmonary artery or lungs. The heart was firmly contracted, and contained a small quantity of dark blood in a fluid state. No. 3 was a small but vigorous black and tan dog. Chloroform was administered, and the femoral artery cut. Eleven ounces of blood came away before the cur- rent ceased. Six ounces of milk were injected. During the injection the respiratory movements almost ceased, and the respiratory sounds heard on auscultation were very loud and harsh. Death took place ten minutes after the operation. A post-mortem examination was made immediately. The lungs were pale and contained neither blood nor milk. The heart was contracted, and the right auricle and ventricle contained about a table- spoonful of milk mixed with blood. The liver was en- larged, and of a milky color. On cutting into it about three ounces of milk, slightly colored with blood, flowed from the cut surfaces. When this was collected the blood separated from it and sank to the bottom of the vessel, leaving the milk of a natural color on the surface. The spleen was dark colored, but contained no milk. The accumulation of milk in the liver is a curious cir- cumstance, and is not easy of explanation. The milk was injected through the femoral vein; there was no communication between the portal system and the fem- oral or iliac veins ; there was no milk in any of the ves- sels, but it was all in the liver. It seems to me that the milk must have regurgitated from the right side of the heart into the inferior vena cava, and from thence found its way through the hepatic veins into the liver. No. 4 was a medium-sized, healthy dog. Chloroform was again employed. Nine ounces of blood flowed from the artery before the current ceased. Eight ounces of milk were injected ; the dyspnoea accompanying its in- troduction was more marked than in any of the previous cases, and there were added to it convulsive twitchings of the muscles of the head and neck. Death occurred five hours after the operation. The post-mortem appearances ■were the same as in the second case. No. 5 was a large and powerful animal. When the femoral artery was opened sixteen ounces of blood came away before the flow ceased. Ten ounces of milk were injected, with the same characteristic effects as before mentioned. The dog got off the table without assistance and did not seem to be much affected by the operation. Death occurred eight hours subsequently. The post- mortem appearances were the same as in the second and fourth cases. No. 6 was a medium-sized dog in good condition. Ether was used to produce partial anaesthesia. Eleven ounces of blood produced syncope. Eight ounces of milk were injected. Death took place six hours after the operation. The post-mortem appearances were the same as those found in the previous case. No. 7 was a counterpart of No. 6, both as regards operation and results. No. 8 was a large dog, with little flesh on his bones. At least twelve ounces of blood flowed from the femoral artery before syncope occurred. No milk was injected. The dog recovered. No. 9 was operated on in the same manner. The amount of blood lost before syncope occurred could not be estimated, as the animal was running around the 220 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Transfusion. Transfusion. -floor while the bleeding was going on. No milk was in- jected. On the fourth day after the operation he seemed to be in perfect health. My assistant, Dr. Saunders, killed him on that day on account of his viciousness. Now, we have here seven dogs bled to a state of syn- cope, milk was injected, and not a single recovery took place. We have two dogs bled in a similar manner- no milk was injected, and recovery occurred in each case. There is only one conclusion that can be drawn from this: that is, the milk killed the dogs. Professor T. G. Thomas is decidedly of the opinion that the milk was decomposed, and the animals poisoned by it. He may be right. But it seems to me hardly probable that milk would decompose, in the short space of two hours, sufficiently to act as a deadly poison when thrown into the circulation. Besides, it will be remem- bered that, in my first case, the milk remained in the ward all day before the second injection was made. It is more likely that death was due to the quantity of milk injected, and not to any poisonous change. Eight ounces of milk for an ordinary-sized dog would be the equivalent of thirty or thirty-five ounces of milk in a healthy adult, and I don't believe that any human being could be bled to syncope, and then have thirty ounces of milk injected with impunity. Transfusion of Saline Solutions.-The great difficulty which is often experienced in obtaining blood for trans- fusion has led many operators to use saline solutions in- stead. Drs. Sands, Weir, Bull, Jennings, Little, and others have employed them with success. In the trans- fusion of the saline solutions the same instruments are used as in the transfusion of blood. I have only used the saline solution once, and that with a good result. The case was one of secondary haemorrhage from the femoral artery, which had been tied for aneurism. Fifteen days after the operation there was some oozing from the wound, and a tourniquet was put on by Dr. Spence, the house-surgeon of St. Francis' Hospital. The tourniquet slipped on the night of February 11th and a profuse haemorrhage occurred. On February 12th something went wrong with the tour- niquet again, and another severe haemorrhage took place, and although the tourniquet was rapidly tightened, the patient was exsanguinated before the flow of blood ceased. The pulse could scarcely be felt at the wrist. There was a great thirst, unrelieved by liquids, twitch- ing of the muscles, and restlessness. Not being able to obtain blood I injected ten ounces of Little's solution, prepared by the house-physician, Dr. Hodenpyl. There was some relief from the collapse after the operation, but on the following day he seemed to be as low as ever, so I injected into the same vein sixteen ounces of the sa- line solution. This latter injection was followed by im- mediate and well-marked relief. The pulse became fuller, and the voice stronger. The pain in the lumbar region disappeared, and the patient expressed himself as " feeling first-rate." There was no doubt about the effi- cacy of the operation. The members of the house staff of St. Francis' watched the patient night and day for three weeks; the tourniquet was then taken off, and there was no recurrence of the haemorrhage. I employed the saline solution in this case because I •could not obtain blood. I had no faith in its efficacy when I used it, but the result convinced me that next to blood a saline injection is the best solution to use in transfusion. Little's solution consists of sodii chlor., 3 j.; potassii chlor., gr. vj.; sodii phosph., gr. iij.; sodii carb., gr. xx.; alcoholis, 3 ij.; aq. dest., § xx. Jennings' solution is made of sodii chlor., gr. j.; po- tassii chlor., gr. iij.; sodii sulph. and sodii carb., aa gr. ijss.; sodii phosph., gr. ij.; alcoholis, 3 ij.; aq. dest., Oj. Peritoneal Transfusion.-In 1879 Ponfick, of Breslau, injected defibrinated blood into the peritoneal cavity of a patient suffering from great loss of blood. The pa- tient recovered. He subsequently operated on others, and found that the blood was immediately absorbed, and that the red globules in the circulation were increased in number. His experiments seem to have been confirmed by Golgi and others, but the operation at the present day is seldom performed. In 18831 instituted a series of experiments upon dogs, with various liquids, the results of which, given below, furnish a fair idea of the valhe of the operation. No. 1. A dog weighing thirty-five pounds, well nour- ished and active, was etherized until all active move- ments bad ceased. The cylinder of Dieulafoy's aspira- tor was charged with eight ounces of warm milk at a temperature of 96° F. The hollow needle attached to the tube of exit was passed through the abdominal walls below and to the left of the umbilicus, then, by turning the handle of the aspirator slowly, the milk was injected. The operation was succeeded by a series of clonic spasms, very violent in character, which lasted about half a minute. Six hours later the dog was killed, and a post-mortem examination made by Dr. Collyer, house- surgeon of Charity Hospital. The abdominal cavity contained ten ounces of liquid, consisting of the milk previously injected, and a bloody serum, which gave the whole liquid a reddish tinge. The peritoneum was injected in patches near the seat of the puncture. The other organs were normal. No. 2. A larger dog than the preceding, but not so well nourished, was etherized, and five ounces of warm milk were injected into the peritoneal cavity by means of the aspirator. No unfavorable symptoms developed during or after the operation. The animal was kept under observation for four weeks, without exhibiting any signs of inflammation. So far as I know, the ani- mal may yet be alive. No. 3. A large, powerful slut, in an advanced state of pregnancy, was anaesthetized, and eight ounces of nutri- tious liquid, consisting of equal parts of warm milk and bouillon, were injected in the same manner as before. At the end of five hours the dog was killed. Sixteen ounces of liquid, composed of milk, beef-tea, and bloody serum were found in the abdomen. The peritoneum was congested throughout. No. 4. This animal was operated upon at the same time. Seven ounces of warm water were injected into the peritoneum. Six hours afterward the animal was killed, and six ounces of reddish-brown liquid were found in the cavity. The peritoneum was much more congested than in any of the preceding cases. The kid- neys were congested, and a few ecchymotic spots were found underneath the capsule. No. 5. A large muscular dog was etherized, and two loose ligatures were placed around the femoral artery. The vessel was then cut between the ligatures and allowed to bleed freely. A two-ounce solution of carbonate of ammonia, containing ten grains to the ounce, was added to seven ounces of the blood, and eight ounces of the mixture injected as before. Two hours subsequently the ligature slipped from the artery and the dog bled to death. Eighteen hours afterward a post mortem ex- amination was made by Dr. Collyer. Three ounces of bloody serum were found in the cavity. A thin, reddish film covered a portion of the peritoneum. No lesions except those due to decomposition were found in other organs. No. 6. The femoral vein of this animal was ligated and opened. Eight ounces of blood were collected and mixed as before with a solution of carbonate of am- monia. Seven ounces of the mixture were injected. Eight hours afterward the dog was killed. Two ounces of liquid blood were found in the cavity. A reddish film covered the intestines, as in the previous case. No. 7. Eight ounces of warm water were injected into the peritoneal cavity of this animal. When she had recovered from the ether she gave evidences of pain by rolling around the floor and whining. In half an hour these symptoms subsided and the dog remained com- paratively quiet. Twenty hours after the operation a post-mortem examination was made. Fourteen ounces of a dusky colored liquid were found in the abdominal cavity. The peritoneum was injected throughout its whole extent. Small patches of lymph were also found 221 'Transfusion. Transportation. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. studding the membrane. There was no difference be- tween the peritoneum at the point of injection and other parts. No. 8. Twelve ounces of blood were taken from the femoral vein, and the fibrine removed by whipping the blood with a glass rod, and afterward straining it through a piece of muslin. Five ounces were injected into the peritoneal cavity. Twenty-two hours later the dog was killed. No liquid was found, but the peritoneum was covered with a thick reddish coating, consisting probably of globular elements and coloring matter of the blood. No. 9. Eight ounces of defibrinated bullock's blood were injected into the abdomen of a very large and powerful dog. The animal seemed to be in great pain after the operation, and it did not seem to rally from the effects of the injection as the other animals did. Eight hours subsequently a post-mortem examination was made and four ounces of blood collected from the cavity. There was the same reddish coating of the intestines as in the preceding cases. The foregoing experiments prove, 1, that the peri- toneum will absorb blood, and that the blood so absorbed must assist in sustaining the functions of life ; 2, that the operation of peritoneal transfusion is liable to excite a limited amount of peritoneal inflammation ; 3, that if the blood of an animal of a different species be injected there is danger of exciting general peritonitis ; 4, that the injection of plain water is more dangerous than that of any other liquid. Granting the advocates of peritoneal transfusion that the peritoneum will absorb blood, and that the vital forces of the patient are sustained by it, I cannot see the utility of the operation. It is reasonable to suppose that organs such as the stomach and intestines, espe- cially designed by nature for purposes of absorption and nutrition, would take up nutritious liquid as fast, if not faster, than the peritoneum, which, so far as we know, was not designed for such use. It seems to me also that any condition of the system which would prevent absorp- tion by the stomach and intestines, would also prevent absorption by the peritoneum or any other organ capable of performing that function. Joseph IE Howe. TRANSPORTATION OF THE DISABLED ON LAND.* The organization of his companies of Brancar- diers, at the beginning of the present century, by Baron Percy, then surgeon-in-chief of a division of the French army, marks the dawn of a new era in the treatment of the wounded in war. Previous to that time, although the world had been slowly emerging from the barbarism which found expression in the maxim, " Victory or death," no organized efforts looking toward the proper removal of injured soldiers from the line of battle had been made. As early as 1792, however, Baron Larrey had established his system of flying ambulances, ■which were the immediate precursors of the organization of Percy. The value of Percy's plans was so apparent that, in 1813, his system of litter-bearers was adopted by an imperial decree for the entire French army. Other countries fol- lowed in the way thus indicated, until at present every important European power possesses an ambulance corps or its equivalent, operating under the powers and immu- nities accorded by the Geneva convention. During the War of the Rebellion the necessity for the establishment of an ambulance corps became evident in the United States army, and an organization was com- pleted, as related in the article of Smith (Vol. III.), which did excellent service during the latter days of that con- flict ; but in the reorganization of the army after peace had been declared, this corps was eliminated as an active factor in the military establishment, although the rules for its government still stood in the army regulations. From this time until 1887 the sick of the army were dependent for care upon men temporarily detailed for the purpose from their commands, the Hospital Stew- ards being the only enlisted men attached to the medical department. In March of that year, however, a law was enacted providing for the establishment of a Hospital Corps upon a liberal and satisfactory basis. The Hospital Corps consists of Hospital Stewards, ranking as ordnance sergeants and receiving an average of fifty dollars a month pay, with allowances of clothing, rations, and quarters ; Acting Hospital Stewards, with twenty-five dollars a month pay and the allowances of a corporal ; and Privates, with an average of fourteen dol- lars a month pay and the allowances of a corporal. ^Vll hospital service in garrison and in the field is to be per- formed by the members of this corps, who are regularly enlisted for, and permanently attached to, the Medical Department. In time of war the corps is to perform the necessary ambulance service under such officers of the Medical Department and assistants as may be detailed to direct and supervise it. The men are not required to perform any military duties other than those pertaining to their corps, and are not required to attend reviews, parades, or other military ceremonies. Prior military service is essential in a member of the Hospital Corps, which is formed, as far as practicable, by the voluntary transfer of enlisted men who have served at least one year in the line, preferably as " company bearers." In time of peace, recruits for the Hospital Corps, who have not previously served at least one year in the line, are attached to companies stationed at one of the three post-graduate military schools, and required to perform all the duties and be subject to all the drill and discipline required of privates in the organization to which they are attached ; after one year of such service they may be assigned to duty in the Hospital Corps. Candidates for the Hospital Corps are required to pass not only the usual physical examination for enlistment, but are obliged also to give evidence of their ability to read and write, and of general intelligence and aptitude for their proposed duties. Privates who have served one year or more in the Hos- pital Corps and have displayed particular merit, are to be recommended by medical officers to the Surgeon-General for promotion to the grade of acting hospital steward. Candidates for this position must pass a satisfactory ex- amination as to their physical condition, moral character, and general aptitude ; in the general principles of arith- metic, including decimal fractions and the rules of pro- portion ; orthography and chirography ; the Articles of War and the regulations affecting enlisted men ; phar- macy ; care and use of meteorological instruments and hospital and field appliances furnished by the medical department; methods of rendering first aid to the sick and wounded, and the ordinary modes of cooking. After one year's satisfactory service in that grade, an acting hospital steward is eligible to appointment as hos- pital steward. Candidates for this grade are required to possess a more advanced knowledge of the branches de- tailed in the preceding paragraph, and, in addition, to pass an examination in the elementary principles of hy- giene, including ventilation, heating, and disinfection ; the principles of materia medica, therapeutics, and minor surgery ; the administration of anaesthetics, and the reg- ulations of the Medical Department. These examinations are conducted by a board consisting of all the commis- sioned medical officers of the post at which the applicant may be serving, and are both oral and written ; the latter upon a series of questions prepared under the direction of the Surgeon-General. The duties of hospital stewards and acting hospital stewards are, under the direction of the medical officer, to look after and distribute hospital stores and supplies ; to care for hospital property ; to compound and admin- ister medicines; to supervise the preparation and serv- ing of food in hospitals ; to maintain discipline, and to look after their general police ; to prepare the various hospital reports, and to perform such other proper duty as may devolve upon them. * In Vol. I. of the Handbook, pages 332-340, Surgeon Charles Smart, U.S.A., treats casually of transportation in time of war; and in Vol. III., pages 139-155, Surgeon Joseph R. Smith, U.S.A., treats at considerable length of the transport of the sick ; while in vol. i., pages 128-133, Dr. George W. Leonard treats of ambulances with special reference to work in cities. It is intended that the present contribution shall not intrude upon the ground covered by them. 222 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Transportation. Transportation. As an auxiliary and source of supply for the Hospital Corps, four privates in each military company are desig- nated, with the concurrence of the post surgeon, as " com- pany bearers." These men are required to be under in- struction for at least four hours in each month in litter- ances are hand-litters and wheeled litters to be manipu- lated by men, and wheeled and other vehicles to be moved by draught animals. The essential parts in a hand-litter are the bed and the handles. Experience has shown that four is the most convenient number of handles, since two, three, or four bearers may then be utilized, and that these are best ob- tained by passing along the side of the bed two poles, projecting anteriorly and posteriorly, these projections constituting the handles. To these may be added, as de- sirable for held purposes, traverses to hold the side poles apart, and legs, to keep the litter from contact with the ground. Percy advocated the separation of the litter for field service into two equal divisions, to be carried separately by the brancardiers or bearers, believing that they should always have at hand the material for forming a litter, without being dependent upon the supply wagons. He accomplished this by arming each bearer with a pole eight feet long, having a ferule upon one end and on the other a lance-head, which could be removed when it was desired to form a litter. Each man carried one lit- ter-traverse, with its legs fitted into leather sheaths at the upper portion of his knapsack, while around his waist he wore a sash consisting of one half of the bed of the litter divided longitudinally. The litter was set up by lacing together the two halves of the litter bed by means of eyelet holes and cords provided for the purpose, at- taching the poles to the free edges of the litter bed, and passing the poles through the apertures in the traverses. A similar form of litter, which, by its cheapness, sim- plicity, and convenience, recommends itself for use in hospitals in removing a patient from bed to bed or from bed to operating-table, or the reverse, consists of two rectangular pieces of canvas, three by two feet, with a broad hem on each of the longer sides, and two poles eight and a half feet long by an inch and a half in diameter, which are to be passed through the loops formed by the side hems. When the patient is to be placed upon this litter, it is first decomposed into its component parts, then, the upper portion of his body being raised, one square of canvas is slipped under it, after which the other is slipped under the lower ex- tremities in the same way, care being taken to have the hems parallel with the body and in the same line ; the poles are then thrust through the hems, and the litter is thus reconstructed with the patient upon it. He is re- moved from it by reversing this procedure. Experience has demonstrated, however, that a litter consisting of detachable parts is not desirable for field service on'account of its liability to become entirely un- serviceable by the loss of one of these components. The qualities essential in a litter for this purpose have been very succinctly stated by Longmore, substantially as follows: 1. A support for the patient, firm and comfortable, but capable of being readily cleansed. 2. Lightness, to facilitate carriage by bearers. 3. Strength, to resist shocks from rough usage. 4. Simplicity of construction, combined with- 5. Capability of being folded up to economize space in stowage and to lessen liability to injury. Fig. 4011.-Posterior and Anterior Views of Percy's Brancardier fully Equipped. The pole is carried in the hand, the half of the bed as a sash about the waist, and the traverse above the knapsack, while below is seen a traverse detached. bearing and first aid in medical and surgical emergen- cies. During an engagement or in an emergency company bearers are to extend first aid to the disabled and carry them from the field until relieved by the mem- bers of the Hospital Corps. Although not prescribed in orders, it has long been customary in action for musicians to be employed in rendering first aid to the injured ; it is therefore sug- Fig. 4012.-The French Litter, Folded. gested that, when practicable, these men be instructed with company bearers and utilized in emergency in the same way. In the National Guard of a number of States, the be- ginning of an ambulance corps has been inaugurated, and it is believed that the entire militia establishment of the United States will soon fall into line in this respect. In civil life, as well as in war, the red cross societies have extended work in the same direc- tion into almost all countries-most effi- cient work having been accomplished by the St. John's Ambulance Association in England, the Samaritan Societies in Germany, and similar organizations in other countries, who have carried the work of the Sanitats-Soldaten and the Soldats-panseurs into the time of peace as well as war. For the proper removal of the wounded from the field of battle, or for the conveyance of the sick from one point to another, two factors are essential-thoroughly drilled men and suitable appliances. The first having been provided, the second should follow. These appli- Fig. 4013.-The French Litter, Opened. 6. Such a connection of the component parts as to pre- vent risk of loss, as noted above. 7. Provision for keeping the patient a certain distance above the ground when the litter is laid down. 8. Economy in cost. 223 Transportation. Transportation. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The regulation litter of the French army fulfils these indications excellently, consisting of a canvas bed fas- tened to the side poles and resting upon four feet, one pair of which is so arranged as to elevate one end of the bed and form a pillow. I do not consider this latter feature an advantage, however, for in some cases it is not desirable to raise the head, and in those where it is advisable the means for extemporizing a pillow from a folded garment or the like are always at hand. In certain other respects, also, it is inferior to the Hal- stead * litter, which has endured the test of a quarter of a armies, has failed to discover a more generally satisfac- tory one. An ambulance litter, intended to be used only with wheeled vehicles, may consist of a fixed framework, and will have no legs. For ordinary purposes a litter can be carried by two bearers, holding the front and rear handles respectively ; but in case of any emergency, such as loading a litter upon an ambulance, ascending stairs, etc., that number is not sufficient. At one time the number of bearers to a litter in the British service was three, and that is the number now required by the rules of the St. John's Am- bulance Association, the ambulance corps of the National Guard of the State of New York, and some others. But practical experience in modern war has demonstrated that a less number than four bearers is insufficient for the proper manoeuvring of a litter, and at the present time this is the rule in all the great armies. In carrying a patient over level ground, where the co-operation of the entire four bearers is not necessary, two of them march one on either side of the litter, keeping w'atch over the patient in order to render any aid that may be desirable. The litter should ahcays be carried in the bearers' hands, the arms hanging by the side, or at that level, if it is sup- ported by straps, and never on their shoulders. The ne- cessity of having the patient within sight of the bearers, in order that a demand for checking haemorrhage or ex- tending other aid may be promptly appreciated, would make the latter position improper. The height, also, is liable to cause anxiety on the part of the patient, and, in case of the fall of one of the bearers, actual injury may occur to the patient from the litter falling or careening so as to throw him to the ground. It will be remembered that Stonewall Jackson was carried off the field at Chan- cellorsville in this way, and suffered serious injuries from falling from a litter carried upon the shoulders, when one of the bearers was cut down by a stray bullet. The litter should be held level; this is obtainable on level ground by having the bearers as nearly as possible of the same height, and can be readily obtained in mili- tary manoeuvres by the method prescribed in the litter exercises to be given presently. If, however, for any reason, it is impossible to obtain bearers nearly of the same height, the shoulder straps should be arranged to secure this end. In passing over uneven ground, the bearers should act in concert so as to still maintain the level-the bearer on the higher ground lowering his end, and the bearer on the lower ground raising his. If the descent is very marked, as in case of a stairway, the four bearers should co-operate in maintaining the level as shown hereafter; if this is impracticable and a level can- not be secured, the litter should be carried so that the patient's head is higher than his feet, unless he is suffer- ing from a fracture of the lower extremity, when the feet should be held the higher. The litter should be borne with the patient's feet to the front, except in carrying a patient up an ascent, or in carrying a patient with a fracture of the lower extremity down a declivity, when the position should be reversed, in order to prevent pressure upon the injured part. The bearer's step should be firm and not springy, with the knees slightly flexed and the hips moved as little as possible, and should be about twenty inches in length. The ideal gait is one in which the four feet of the bearers fall upon the ground in succession, as in the trot of a "single foot" horse; but this is not practicable except after prolonged training exclusively in litter-bearing. The influence of ordinary marching upon the bearers is to render this gait still more difficult. However, the " break step," in which the front bearer starts off with the left foot, and the rear bearer with the right foot, is highly esteemed by many authorities, and is unquestionably the best practicable method of preventing the unpleasant rolling motion produced by both bearers stepping in time with the same foot. Bearers should be thoroughly drilled in avoiding all jolting movements, or swinging or rocking of the litter. The litter should not be carried over a fence or wall, or across a ditch or similar marked depression, if it can be Fig. 4014.-Halstead Litter. century's constant use in peace and war in the United States Army, and still remains more nearly the ideal lit- ter than any that has ever been devised. The Halstead litter consists of two poles of seasoned white ash, eight feet long and an inch and a half square, the ends of which are rounded off for handles. These poles are connected by braces, one at either end, each consisting of two pieces of wrought iron one inch wide and three- eighths of an inch thick ; one piece is fifteen and the other twelve inches in length, hinged in the centre of the litter, as shown in Fig. 4015, the longer one overlapping Fig. 4015.-Halstead Litter, Partly Closed. the shorter three and a half inches, and, when the litter is open, shutting on a bolt or pin, forming a stiff shoulder for the hinge and preventing the stretcher from ac- cidentally closing. The braces, attached to the under side of the poles just external to the legs, so as to form a shoulder against which the legs impinge, are fastened to the side-poles with heavy screws, pieces of common hoop-iron being placed underneath them to prevent their wearing the wood. The legs, made of seasoned white ash like the poles, are fourteen and a half inches long, one inch thick, one inch and seven-eighths wide at the top, and tapering to one inch and three-eighths at the bottom ; they are fastened to the poles with screw bolts, having washers under the heads and rivets through the upper end of the legs to prevent their splitting. Over the top of this framework is tightly drawn a strip of canvas which is fastened on the outer side of the poles with six-ounce tacks, forming a bed five feet and eleven inches in length and twenty-three and a half inches in width, allowing the poles to project as handles for a dis- tance of thirteen inches at one end and twelve inches at the other. The shoulder-straps weigh eight ounces, and are made of striped cotton-webbing two and a half inches wide by fifty inches long, with a five-inch loop at one end, and at the other end a leather strap twenty-two and a half inches long by one inch and a sixth wide, with a buckle to loop around the handles of the litter at any length desired. A hair pillow covered with canvas also accompanies it. The litter complete weighs only twenty- three and three-quarters pounds. It is evident that this litter combines to a marked de- gree all the qualities essential in a hand-litter for field service. An examination of a number of other varieties, including the regulation patterns of the principal foreign * In the preliminary report on the material for a medical and surgical history of the war to the Surgeon-General, United States Army,'Circular No. 6, 1865, this litter is erroneously called the Smith hand-litter ; the litter there called the Halstead litter was a stretcher issued by the Sani- tary Commission. Longmore (Treatise on the Transport of the Sick and Wounded) repeats this error, which also appears in the contribution of Dr. Smith in Vol. III. of this Handbook. The corrected description may be found in the third surgical volume of the Medical and Surgical History of the War of the Rebellion. 224 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Transportation. Transportation. avoided. The bearers should find a gate or bridge ; if this is impossible, they should remove part of a fence or wall, or construct a temporary bridge; but, if this cannot be done, they must carry the litter over the ob- struction according to the method to be detailed here- after. The litter should be manipulated by synchronous con- certed movements. This is absolutely necessary to prevent discomfort, and, perhaps, injury to the patient. It has been suggested that these movements be executed in si- lence, according to a prescribed rhythm. I have no doubt as to the value of this plan, provided that the bearers can be trained to accomplish it. To do this would involve, however, an exceptionally great amount of drill and an exceptionally bright class of bearers, with incessant prac- tice. In civil life, except in hospitals, as well as in mili- tary life, this would be impossible, because of the limited amount of time available. We are forced, then, to the con- viction that in order to secure concerted synchronous movements, manoeuvres with the litter must be divided into clearly marked motions, to be performed in obedience to distinct commands. The following requisites for proper carriage of the disabled by military bearers, which also cover the demands of civil purposes, have been formu- lated : 1. A Definite System.-A system of manipulation of the hand-litter should first be established and the execu- tion of extemporized methods adapted to it. 2. Easy Execution of Manoeuvres.-The manoeuvres should be so arranged as to prevent confusion and pre- serve smoothness, and the commands should be so ex- pressed as to bring this about. 3. Adaptability to Varying Numbers.-In this connec- tion the small number of men commonly available for drill should be considered, as well as convenience for ex- pansion in case of an increase of forces. 4. Distinctness of Commands.-The commands should be so expressed as to convey to the bearers in the clearest possible manner the idea of the manoeuvre to be executed. Experience in military tactics has shown that this is best accomplished by (a) a preparatory command, to give the men warning of the impending movement, followed by (b) a command of execution, to cause the manoeuvre. 5. Brevity of Commands.-It is essential that the com- mands should be expressed in as few words as possible, consistent with the necessary preparation and execution. 6. Individuality of Commands.-The same commands should not be applied to different movements in bearer exercises. The mention of this point may seem super- fluous, but the repetition of this error in nearly every scheme for bearer drill that I have seen, has impressed its importance upon me. 7. Analogy with the Authorized Tactics.-There should be no conflict with the authorized tactics for other arms of the service, (a) When the same movement occurs in bearer drill and in the drill of other arms of the service, the movement should be executed in the same manner and in obedience to the same commands, (b) The same commands should not be applied to different movements in the other tactics and in bearer exercises, because the use of commands conflicting with those of other arms of the service would be a constant source of confusion and demoralization to the company bearers, who are re- quired to be familiar with both. The Formation of the Bearer Company.-For purposes of organization and drill, the bearers should be united into a company. In forming this company at a military post, all bearers, regardless of corps, should be made by the senior Hospital Steward, to " fall in" in single rank, without arms, according to height, the tall- est at the right of the proposed line and facing to the right. Junior Hospital Stewards and Acting Hospital Stewards act as file-closers and take their posts two yards in rear of the line, the senior at the right, the next in rank at the left, and the others in order of rank from right to left. The senior Hospital Steward commands, Left, face, upon which the bearers face to the left. He then calls the roll, after which he commands, Count, fours, where- upon, beginning at the right, the bearers announce their numbers, the first being No. 1, the second, No. 2, the third, No. 3, the fourth, No. 4, the fifth, No. 1, etc., un- til the entire company has been numbered in fours, and the bearer squads composing it thus indicated. He then commands, Twos left, march,; at march, the twos swing about to the left on Nos. 2 and 4 respectively as pivots, until they arrive at right angles with the orig- inal line, when he commands, Halt. He then follows with Right, face, upon which the bearers face to the right, i.e., to the front. He then commands, Right, dress, whereupon each man, excepting the one at the extreme right of the line, casts his eyes to the right so as to see the coat buttons of the second man from him, keeping his shoulders square to the front and touching with his elbow that of the man on the right without opening his arms ; when by this means the ranks are aligned, the Hospital Steward commands, Front, and the men cast their eyes to the front. By this means, he has obtained a two-rank formation, with the odd numbers (1 and 3) of each set of fours in the front rank, and the even numbers (2 and 4) of each set of fours in the rear rank. The advantage of this ar- rangement will appear in marching the various squads to the litters, when it will be seen that without any confusion, and in the simplest manner possible, the bearers nearest the same height will be paired. The company then being formed in this manner, the senior Hospital Steward passes down the front of the front rank to the centre, ad- vances six yards, salutes, and reports to the medical offi- cer in command, who stands twelve yards in front of the centre of the line and who then commands, Take your post, upon which the senior Steward faces about and re- turns to a position in and at the extreme right of the front rank. The medical officer then assumes command. At the conclusion of all drills and ceremonies the med- ical officer, having brought the company back into the position just described, addresses to the senior Hospital Steward the command, Dismiss the company. The Stew- ard then marches the company to the point where it is to be dismissed, takes his post six yards in front of the cen- tre and facing it, and dismisses it with the command, Break ranks, march. The Management of the Hand-littek.-The med- ical officer having assumed command of the company as prescribed in the preceding section, sees that a number of litters corre- sponding to the number of complete sets of fours pres- ent, are placed in a line parallel to the company, the litters perpendicular to the line and three yards apart. These 1 i t - ters are preferably opened and set up when put in place. If closed, they should be opened by the front and rear bearers as here- after prescribed. He also assigns to the Hospital Stewards such duties in connection with the drill as he may consider advisable. If there is an incomplete squad, a steward may be as- signed to fill the vacancy, or the squad may act as injured men in the drill, practise the extemporized methods of carrying the disabled described hereafter, or perform such other duties as may be considered advisable. Each set of fours constitutes a bearer squad and forms a unit for action, complete in itself, as I have already re- marked. Nos. 1 and 2 are the bearers proper, and Nos. 3 and 4 are the relief party. No. 4 is the chief of squad and gives all the commands to it. If No. 4 is absent or disabled, the command devolves upon No. 3, and if the Fig. 4016.-Position of Bearers just after the Command, To your posts, march 1 The rela- tion of the lines of the company to the line of litters is also shown. 225 Transportation. Transportation. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. bearer squad is reduced to two the rear bearer is the commander. The company and litters then being arranged as indi- cated, the medical officer commands, Right, face. This command having been executed, he follows with, To your posts, march. At march, Nos. 1 and 3 move forward un- til Nos. 2 and 4 are able to fall in directly behind them. They then march to the left side of the litter and pass, No. 1 com- pletely around it, taking his post between the front handles ; No. 3 follow's to the middle of the right side of the litter ; No. 2 to the rear handles; while No. 4 stops at the middle of the left side of the lit- ter and faces about. Now, it will be observed that in forming the company, the men were sized from right to left, and that conse- quently Nos. 1 and 2 are more nearly the same size than Nos. 1 and 3, or 1 and 4. In the same way, Nos. 3 and 4 are more nearly the same size than Nos. 1 and 4, or 2 and 4. We have, then, both our bearers proper and our relief party matched in height, and this without the least confusion or conflict. This was the end had in view in devising this formation, which was selected from a large number subjected to experiment, because of its simplicity and ease of execution. To bring the company back into company formation, the litter squads should be made to bring the litters into a line parallel with and facing the proposed line of the company and three yards from it. The senior Hospital Steward then takes a position at the extreme left of the proposed line, and on the proposed line of the rear rank. The medical officer then commands, Into ranks, march. At march, the bearers pass about the litter, marching in the reverse of the direction taken in "To your posts, march ; " No. 4 of the right-hand squad advances and takes his position in the line indicated by the Hospital Steward and facing to the left; No 2 follows and takes his place immediately behind No. 4 ; No. 3 follows and takes his position at the right of No. 4 ; and No. 1 follows and takes his place at the right of No. 2. The other squads advance in the same way and simultaneously with the right-hand squad, but each forms on No. 2 of the squad just to the left of it, instead of on the Hospital Steward. The medical officer then commands, Right, face, in obedience to which the men face to the right, and the Hospital Steward passes in front of the line to his place on its right. As individual action is necessary for the litter squads when bearing litters, it is deemed unnecessary to present here exercises for the company under these conditions. If it is desired to manoeuvre the squads with litters in com- pany formation, the commands and movements of light artillery drill may be used, the litter squad being sub- stituted for the gun detachment. When not bearing lit- ters and in ranks, the bearer company is manoeuvred according to infantry tactics. The Manipulation of the IIand-litter.-The company is now fully formed, and the officer may assign parts of it to any desired duty, or cause them to be dis- missed in the manner already stated. By the order, "To your posts, march," the company is resolved into its com- ponent elements, the litter squads, and the command of each one of these is held by No. 4. The litter squad have now been marched to their posts, the litter preferably having been previously opened and prepared for use. If it is closed, however, No. 4 com- mands, Open, litter. At litter, the entire squad face to- ward the litter and assume a stooping posture ; (Two) Nos. 3 and 4 unwind the carrying straps from about it, while Nos. 1 and 2 grasp the front and rear handles re- spectively ; and (Three) open the litter, Nos. 3 and 4 at the same time seeing that the legs are in proper position and the traverses firmly spread ; (Four) placing the litter upon the ground, the entire squad arise and resume their proper posts. To close the litter, the litter being lowered, No. 4 com- mands, Close, litter. At litter all face toward the litter, and Nos. 1 and 2 lift the litter ; (Two) Nos. 3 and 4 flex the front and rear traverses respectively, Nos. 1 and 2 at the same time pressing the side-poles together; (Three) Nos. 3 and 4 then close the legs and wind the carrying straps about the litter, and (Four) Nos. 1 and 2 place it upon the ground, and all resume their proper posts. The litter being opened, then, and the squad at their posts No. 4 commands, Lift, litter. At litter, Nos. 3 and 4 stand fast, while Nos. 1 and 2 stoop, adjust the straps Fig. 4017.-Position of Bearers about the Litters. Fig. 4018.-" Lift, Litter." about the neck and shoulders, and grasp the handles of the litter, as in Fig. 4018 ; (Two) they gently lift the litter by resuming an erect posture. To place the litter upon the ground, No. 4 commands, Lower, litter. At lower, Nos. 3 and 4 face in toward the litter and grasp its legs, as in Fig. 4019. At litter, all four gently stoop until the litter rests upon the ground, Fig. 4019.-" Lower." Nos. 3 and 4 guiding the legs, and (Two) resume an erect posture, all facing in the direction of the litter. In all marching, it should be remembered that the rear bearer steps olf with the right foot, the others with the left foot. If it be desired to march directly forward, No. 4 commands, Forward, march ; if it is desired to turn at a right angle, the direction is changed by the command, Litter left (or right), march ; or if it is desired to turn obliquely, the direction is changed by the com- mand, Litter half left (or right), march. When the desti- nation is reached or when it is desired to rest or change bearers, No. 4 commands, Litter, halt. To change bearers, the litter being lowered, No. 4 commands, Change, march; halt. At change, No. 4 faces to the rear. At march, the squad marclies about the litter in the direction taken when they marched to their posts. When No. 1 reaches the place vacated by No. 4, No. 4 that vacated by No. 2, No. 2 that vacated by No. 3, No. 3 that vacated by No. 1, the command, halt, is given. Nos. 3 and 4 thus become the bearers proper, and Nos. 1 and 2 the relief party. When it is desired to resume the original position, after the same command the march is continued in the same direction. 226 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Transportation. Transportation. the command halt not being given until the desired posi- tion is gained. The Management of the Litter at the Ambu- lance.-To load a litter upon an ambulance, the same general line of ac- tion may be pur- sued, care being taken to differenti- ate the commands from those of lit- ter exercises. A litter having been brought with its front handles at the rear of the am- bulance, its long axis in the long axis of the ambu- lance, No. 4 commands, Prepare to load, march. At march, No. 1 steps to the left side of the litter at the front legs, while No. 3 advances to the same point on the right side ; No. 2 passes to the right side at the rear legs ; while No. 4 steps back to the same point on the left side. No. 4, having ascertained that the ambulance is in con- dition to receive the litter, and that the litter is in proper condition to be loaded, commands, liaise, litter. At raise, the squad face toward the litter ; at litter, they stoop and with the palms upward grasp the side poles of the litter, the ambulance. If the ambulance contains four litters, the first should be carried nine yards to the rear before being set down ; if it contains three litters, the first should be borne six yards to the rear ; if it contains two litters, the first should be carried three yards to the rear ; if but one, it may be stopped directly in rear of the ambulance. No. 4 then commands, Depress, litter. At litter, the bearers gently stoop and lower the litter to the ground, each bearer seeing that the leg adjacent to him is in proper position ; (Two) arise to an erect posture, and (Three) as- sume their proper places about the litter. In case it becomes necessary for a squad to assume entire charge of an ambulance, when the litter has been brought to the ambulance. No. 3 takes his place as am- bulance driver ; No. 4 sees that the ambulance and litter are prepared and gives the commands as before. In this case, No. 2 passes forward on the right side to the front legs, while No. 4 assumes sole charge of the rear ends, standing between the handles. The litter is then loaded by the same commands as with four bearers, Nos. 1 and 2 remaining at the side of the litter after the front han- dles have been deposited upon the rollers and helping to push it into the ambulance. The ambulance is unloaded Fig. 4020.-Position of Bearers after the Com- mand : Prepare to Load. Fig. 4021.-" Raise, Litter," Preparatory to Loading upon an Ambulance. and (Two) gently raise it to the level of the rollers of the ambulance, upon which it is to be placed. No. 4 then commands, Load, litter. At litter, each bearer folds up the leg adjacent to him, and the litter is gently passed forward on to the rear roller, when (Two) Nos. 1 and 3 step back to the right and left one yard, while Nos. 2 and 4 gently push the litter in its full length, and (Three) step back facing distance, while Nos. 1 and 3 return to their places and face toward the ambulance. The squad may now be marched to a new litter or into ranks. In the former case, Nos. 1 and 3 face to the left and Nos. 2 and 4 to the right, and march as if about a central point, falling-in in the order 1, 3, 2, 4. In the latter case the movement is reversed. To unload a litter from an ambulance, a squad should be marched to the rear of the ambulance and formed about the central point as indicated in the preceding para- graph, Nos. 1 and 3 in the front rank and Nos. 4 and 2 in the rear rank. No. 4 then commands, Unload, litter. At litter, Nos. 1 and 3 face inward and step back one yard to the left and right, respectively; (Two) Nos. 2 and 4 step forward and, grasping the rear handles, draw the litter gently out, seizing the litter poles at the rear legs with the palms upward ; (Three) Nos. 1 and 3 advance and grasp the litter poles at the front legs with the palms upward, and (Four) the litter is drawn clear of Fig. 4032.-Carrying a Litter up a Marked Incline. One of the rear bearers is almost entirely concealed in the photograph by his vis a-vis. by three bearers with the same commands as for four, the bearers being assigned to the same posts as when loading. The Carriage of a Litter upon a Marked In- cline.-When a litter is brought to a marked ascent or descent, such as is presented by a flight of stairs ora hill, two bearers are not enough to carry it up or down. In this case, the relief party must co-operate with the bearers proper, as in loading a litter upon an ambulance. When the litter has been brought to the foot of the stairway or hill, it is lowered and No. 4 commands, Prepare to load, march, following with, Baise, litter, and that with, For- ward, march. Great care should be taken by the bearers to maintain the litter on a level-the front and rear bearers co-operating to this end by simultaneously ele- vating one end and depressing the other respectively. The Carriage of a Litter across a Ditch.-In car- rying a litter across a ditch, if there be no bridge and none can be extemporized, nor can crossing it be avoided, if it be narrow enough to bestride, the litter should be brought to its margin and No. 1 should cross over, while Nos. 8 227 Transportatlon. Transportation. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. and 4 stand astride of it. The litter should then be lifted by Nos. 2, 3 and 4, and the front handles passed across to No. 1. When the rear handles arrive at Nos. 3 and 4, they grasp them and pass them across the ditch, and the litter is lowered. No. 2 then crosses and the entire squad assume their posts and proceed. If the ditch be a broad one, the litter being brought to its margin and lowered, No. 4 commands, Prepare to load, march, followed by, Raise, litter ; it is then set down as near the edge as pos- possible, on the opposite side ; (Three) all arise first upon one foot and knee, then upon both feet. Or, Nos. 2 and 3 take positions at the patient's left and right elbows respectively, and at patient all kneel upon one knee ; (Two) No. 1 passes his hands as above, while Nos. 2 and 3 each pass one hand under the patient's but- Fig. 4023.-Carrying a Litter across a Ditch. Fig. 4024.-First Method of Lifting the Patient in Transferring Him to or from a Litter. sible, while Nos. 1 and 3 climb down into the ditch and carry the front handles forward until the rear ones are brought to the edge, when Nos. 2 and 4 climb down and lift the rear handles down. The litter is borne in this way across the ditch, and carried up the other side by a reverse procedure. The Carriage of a Litter over a Fence or Wall. -When the obstruction is less than seven feet in height, the following plan may be adopted; if it is more than seven feet high, its passage should not be attempted. The litter being brought to the fence, the bearers should take the position of Prepare to load, following with Raise, litter, and that with Forward, march. The litter is then passed forward and rested upon the fence, with the front handles extending over the other side ; Nos. 1 and 3 then climb over the fence and the litter is drawn forward un- til the rear handles rest upon the top of the fence. Nos. 2 and 4 then scale the fence, and the four bearers unite in carrying the litter forward until it is clear of the ob- stacle. Their usual positions are then resumed in obedi- ence to the command, Depress, litter. The Transfer of a Patient to or from a Lit- ter.-Perfect familiarity with the manipulation of an empty litter having been obtained, bearers should be taught how to transfer a patient to or from a litter. Af- ter a considerable number of experiments, the following methods have been selected as the most satisfactory. The patient lying at full length on his back, if the char- acter of his injuries permits, the empty litter is brought with its front handles at his head, and its long axis in the direction of the patient. No. 4 then commands, To the patient, march. At march, Nos. 1 and 3 pass on the right of the patient, No. 1 to his knees, and No. 3 to his elbow, while No. 2 passes on the left to his waist, all facing to- ward the patient. No. 4 steps to the left to permit No. 2 to pass between him and the litter, then he takes charge of the injured part or supports the head. No. 4 then commands, Lift, patient. At patient, all kneel; (Two) No. 1 passes his hands with the palms upper- most, the left under the patient's calves and the right under his ankles, the fingers hooking up on the opposite side of the patient; No. 2 passes his hands, with the palms uppermost, the right under the back between the loins and the shoulder-blades, and the left under the thighs at their junction with the body, the hands, if possible, hook- ing up on the farther side of the patient's body; No. 3 passes his hands similarly, the left under the shoulders and the right under the loins, the hands hooking up, if tocks and the other under the back close up under the armpits, the left palm down and the right palm up. Each bearer then grasps his companion's corresponding wrist, and (Three) all arise. This grip will be referred to again in speaking of the two-handed seat. The first of these methods is the best adapted to a per- fectly helpless patient, and is the more easily performed in transferring a patient from litter to bed or from bed to litter ; while the second is the more easily performed in transferring a patient from ground to litter, and is rendered still more easy if the patient can help himself by placing his hands upon the bearer's shoulders. The patient being lifted, No. 4 commands, To the litter, march ; halt. At march, the bearers move gently with Fig. 4025.-Position of Bearers in the Second Method of Transferring the Patient to or from a Litter, also showing the peculiar Grip. The grip is also well shown in Fig. 4038. side-steps until the patient is held over the litter, when, at halt, they stop. No. 4 then commands, Lower, patient. At patient, the bearers gently stoop until the patient rests upon the litter, (Two) withdraw their arms, resume an erect posture, and (Three) take their proper posts. No. 4 sees that the patient and the injured parts are disposed in the most convenient and comfortable position possible, and that the head rests easily upon a pillow formed by a 228 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Transportation. Transportation. coat, knapsack, blanket, or other similar article, if there is no pillow with the litter. In removing a patient from one litter to another, or from a litter to a bed, the litter should be placed with the patient's head at the foot of the new litter or the bed, and the procedure just described followed. The Action of Bearers when under Arms or Mounted.-When a bearer squad is under arms, it should be formed as without arms, their rifles being held at " carry arms." The men of the squad are marched to their posts in the ordinary way. No. 4 then commands, Transfer, arms. At arms, Nos. 1 and 2 grasp the piece with the left hand, the forearm horizontal, and let go with the right hand; they then pass the piece with the left hand, No. 1 to No. 3, and No. 2 to No. 4, who take and carry the extra piece in any position which may be the most comfortable, preference being given to one in which the pieces are carried under the right arm in a position similar to that of " secure arms." When it is desired to change bearers or to return into ranks, the litter being lowered, No. 4 commands, Re- sume, arms, when Nos. 3 and 4 return the extra pieces to Nos. 1 and 2, and the squad resumes the position of " carry arms." When the co-operation of all four bearers is required, the litter being lowered, Nos. 3 and 4 stack the arms in a safe place before proceeding with the move- ment. In case of a mounted bearer squad, No. 4 causes it to dismount by the order, Prepare to dismount, dismount. He then continues with, To act on foot, into ranks, march. At into ranks, Nos. 1, 2, and 4 hand their bridle reins to No. 3, who is to stand fast. At march, No. 1 steps forward two paces in front of No. 2, who advances one step, while No. 4 advances and takes his position at the side of No. 2. This brings the squad into the position of " into ranks," leaving a vacant place for No. 3. The or- dinary hand-litter exercises can be performed by this incomplete squad. Where necessary, two incomplete squads can be united into a single one of six bearers. The Inspection of a Bearer Company.-A periodi- cal inspection is necessary, not only of a military bearer company, but also of civilian bearer organizations. The following is offered for the purposes of the former, and can readily be adapted to the latter. Hospital Stewards and Acting Hospital Stewards carry a sword, while pri- vates of the Hospital Corps and company bearers carry a knife of approved pattern. One-fourth of the hospital privates carry hospital knapsacks or dressing-cases, and all company bearers and the remainder of the hospital privates carry a simple package of dressings. In order to inspect the bearer company of any organization, the company is formed as already directed, except that in- stead of falling in according to height, they form as fol- lows, from right to left: 1, Privates of the Hospital Corps ; 2, Company Bearers ; 3, Musicians - the men of each class being arranged according to height from right to left. » After the company has been formed and reported by the senior Hospital Steward, the Steward having re- sumed his proper post, the officer commands, Rear open order, march ; front. At rear open order, the senior Hospital Steward steps briskly three yards to the rear, to mark the new alignment of the rear rank. At march, the front rank dresses to the right, while the rear rank steps back a little to the rear of the new line indicated by the senior Hospital Steward, and dresses to the right upon that line ; the file closers place themselves in line three yards to the rear of this rank, and the officer veri- fies the alignments. At front, the senior Steward re- sumes his place in the front rank and the men cast their eyes to the front. The officer now commands, Inspection, arms. At arms, swords and knives are drawn, the sword is held in the position of "carry sword," the handle being held between the fingers and thumb of the right hand, the arm extended by the side, and the blade held perpendic- ular with its back against the shoulder ; the knives are held in the hand hanging by the side. The officer now proceeds to inspect the arms, clothing, and general appear- ance of the men-first passing along the front of each line from right to left, then along the rear from left to right ; as the inspector approaches each man from the front the hand containing the sword or knife is thrown up in front of the chin, the weapon being held perpen- dicular and turned so as to show both sides, first one, then the other. After the inspector has passed, the swords are returned to their scabbards and the knives to their sheaths. The officer then commands, Inspection, equipments. At equipments, the men bearing knapsacks, medicine cases, or dressing-cases, unsling them, deposit them upon the ground in front of them with the flap to the front, unfasten the flap, open the knapsack or case, and resume an erect posture; the men having dressing packages produce them and hold them in the right hand at the level of the chin, turning them so that both sides may be seen. The equipments having been inspected, the officer commands, Replace, equipments, wdiereupon the knapsacks and cases are repacked and slung, and the packages returned to their places. The inspection having been completed, the officer commands, Close order, march. At march, the rear rank closes to within facing distance from the front rank, each man covering his front rank man ; the file closers move forward with the rear rank and take their original position, two yards in the rear of it. The officer then turns the company over to the senior Hospital Steward for dismissal. Extemporized Methods of Bearing the Disabled. -Every old campaigner will remember that it was rather the rule than the exception that the supply trains were left behind, and he will readily realize that, as occurred in Lord Wolseley's Soudan expedition, the paraphernalia of the ambulance corps may be wanting in the emergency. The necessities of a forced march in mountainous dis- tricts may cause the pack train carrying the litters and other apparatus to be left behind, and in any instance, it is impracticable on such a march to carry the ordinary means of transportation. Again, small scouting parties of from two to ten men will not be burdened with litters. The regulations for the government of the Hospital Corps of the United States Army provide that each company of the line shall be equipped with one hand-litter, but it is evident that in active hostilities twice that number would be insufficient, since, after a great battle, the occasion when an abundance of prepared apparatus was at hand has yet to be recorded in history. The occasions when, upon hunting or other pleasure excursions, the injury of one of the party demands means of transportation, are familiar to every one. And it is not alone in the country that ready assistance in case of an injured or insensible person is required, but riots and conflagrations in the city make large drafts upon the experience of bystanders. So distinguished an authority as Surgeon D. L. Huntington, U. S. Army, has remarked that in these cases, " under the urgent demands of neces- sity, the fruits of ingenuity are sure to come to the res- cue." It is possible that in such a case the untaught officer or man may be able to devise a makeshift by which he may limp through an emergency, probably awkwardly on his part and painfully on the part of the patient; but the satisfactory performance of this duty, as well as any other, requires study and training. And upon the ready and rapid execution of it may depend not only the comfort and health of the disabled man, but his life itself. The study of extemporized means of transporting the disabled, then, is of equal, if not greater, importance than the manipulation of the regulation apparatus. In view of this fact, it is surprising that so little attention has been devoted to this branch of the subject. In the execution of extemporized means of transporta- tion, as in litter bearing, the utmost gentleness and care should be observed. For practice, they should be divided into well-marked steps, each of which should be distinctly performed, also, as in litter bearing. I have divided these methods into four classes : A. Methods by a single bearer. 229 Transportation. Transportation, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. B. Methods by two bearers. C. Methods by three or more bearers. D. Methods by wheeled and other vehicles. A. Methods by a Single Bearer.-I consider these to be really the most important of all methods, both to the soldier and the civilian. The instances where famili- arity with the means of carrying a disabled person by one bearer may be the means of saving life, in case of fires and other accidents in towns and cities, will readily occur to the reader; while one who has had experience in the country, or upon the frontier, cannot fail to remem- ber numerous occasions where they might have been of vital service. What is true in this respect in time of peace is doubly so in time of war. These methods naturally fall into four groups : I. Where the bearer simply assists the patient to walk. II. Where the patient is carried in the bearer's arms. III. Where the patient is carried on the bearer's back. IV. Where the patient is carried on the bearer's shoulder. I. Where the Bearer simply Assists the Patient to Walk. -These methods are available when the patient is suffer- ing from a comparatively slight injury, not affecting the lower extremities. To accomplish this, the pa- tient standing by your side, draw his uninjured arm over your shoulder back of your neck and grasp his hand with your own; then pass your arm around his waist to assist in supporting him. Assistance of this kind may be extended with- out the patient's arm over the shoulder, sim- ply supporting him with an arm about his waist. By this method, it is pos- sible for a single bearer to assist two slightly in- jured men off the field at the same time. In the remaining three classes, the most impor- tant question is, how to lift the patient into a position in which he may readily be carried - a matter of no little diffi- culty when the patient is insensible or unable to assist, and particularly if he be a heavy adult. A year or two ago, I made a large number of experiments with a view to devising a method of facilitating this procedure. The fact that in a large cavalry and infantry post I could find no officer or soldier who could suggest a feasible means of unaided lifting an insensible patient into a position where he could be conveniently carried, afforded a striking commentary upon the wisdom of neglecting the education of the sol- dier in this respect. These experiments have been con- tinued during the past year, until the following proced- ures have finally been fixed upon. II. Where the Patient is Carried in the Bearer's Arms. -These methods are adapted to carriage for short dis- tances, and for those cases in which it is thought neces- sary, for any reason, to have the patient under the eye of the bearer. They are also the more comfortable for the patient, but without assisting apparatus it is imprac- ticable to employ them for any considerable time or dis- tance. There are four of these : 1. The patient lying on the ground, (1) turn him face downward ; (2) stand astride of him and, with your hands in his armpits, raise him to a kneeling posture ; (3) shift your hands about his body and clasp them in front; and (4) lift him upon his feet; (5) then, still holding him erect, shift yourself so that his right side will be against you and your hands under his left armpit; (6) then retaining your left hand and arm in place, pass your right arm be- hind his thighs and (7) lift him into your arms. By this Fig. 4027.-Standing Astride. Second Motion of Lifting into Arms. plan, a man can be lifted into the arms who could not ordinarily be raised twelve inches from the floor. To lay the patient down from this posi- tion, (1) keeping the left hand and arm in place, lower the patient's in- ferior extremities by depressing the right arm ; (2) the heels resting on the ground or cot, the left hand should be clasped in situ by the right, and (3) the patient gently lowered on to his back. 2. The patient may be carried with somewhat greater ease by the method of Heyfelder, in which a sheet, shel- ter-tent, or similar article is taken and the two opposite corners tied together ; then, (1) passing the broad centre of the sheet under the patient's loins and buttocks, and (2) the knot over the bearer's head with his right arm through the loop, (3) and slipping the left hand under the patient's shoulders and the right under his thighs, (4) the bearer arises to an erect posture. To lower the patient, the bearer sim- ply bends forward until liis burden rests upon the ground or cot. 3. A sort of harness has been devised by Hos- pital Steward Harbers, U. S. Army, to be sub- stituted for the sheet in the preceding method. III. Where the Patient is Carried on the Bearer's Back.-A patient can be carried upon a bearer's back with much less ex- ertion than in his arms. These methods are con- sequently better adapted to carriage for any con- siderable distance. There are four principal varie- ties of these methods: 1. The patient pick-a- back.-This is the oldest Fig. 4028.-Lifting into Arms. Sixth Motion. Fig. 4026.-Bearer simply Assisting the Patient to Walk. Fig. 4029.-Patient Carried according to Heyfelder's Method. 230 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Transportation. Transportation. of these methods, and was the common mode of remov- ing the comparatively slightly wounded until the organi- zation of proper litter-bearing facilities. Baron Percy, the distinguished French military surgeon, once carried a dangerously wounded officer across a pontoon-bridge over the Rhine, in this way, while the bridge was being broken up by the fire of twelve Austrian guns. The patient can be mounted upon the bearer's back, without other help for the practice of this method, only when the patient is able to assist by clasping his arms about the bearer's neck. It is best performed in the following manner : (a) Let the patient, seated upon the ground facing you, clasp his arms about your neck ; (2) with your hands under his armpits raise him to a kneeling posture ; (3) then shifting your arms about his body, raise him to his feet; (4) then, letting him sup- port himself by his arms about your neck and assisting him with your hands, face carefully about; (5) then grasp the patient's thighs on either side and draw him astride of your loins. The patient can be lowered by reversing the motions of lifting him. (b) An insensible patient can best be carried by the methods to be described presently, but if for any reason it is desired to use this method, after the patient is gotten upon the back with the help of other assistants, he may be kept in place by passing a broad strap-a belt, for ex- ample-about his back, under his arms, and up over the bearer's forehead or about his chest. (c) Fischer, an instrument-maker of Heidelberg, de- vised a saddle, by the use of which the weight of the patient is carried suspended from the bearer's shoulders, sique, and I only mention it as a curiosity, and to call at- tention to the fact that a trial of it would involve a useless waste of time. It is as follows : (1) Seat the patient with the knees and hips hent, the head resting on the knees; (2) then pass a long band-a belt, for example-about the pa- tient under his knees and arms ; (3) then, crouching down behind him, back to back, pass the strap over your fore- head and (4) arise. The strap should be short enough to bring the weight upon the shoulders and the upper part of the back of the bearer. 4. The following method is a modifica- tion of one recommend- ed by Captain Shaw, of the London Fire De- partment. It is com- fortable for the patient and easy for the bearer, and is of particular value when the patient is not insensible, but at the same time is unable to render any assistance to the bearer : (1) Turn the patient face down- ward ; (2) seize h i m under each armpit, as shown in Fig. 4027, and raise him to his knees ; (3) shift your arms about his waist, clasp your hands in front of Ins body, and lift him to his feet; (4) then, re- taining the right hand in position, grasp the patient's left hand with your left hand and draw' his left arm back about your neck, bringing the hand down in front of your chest; (5) then, stooping slightly, pass your right arm around in front of the patient's right thigh and grasp it, and he will then fall across your back ; (6) resume the erect posture and balance the body on your back. IV. Where the Patient is Carried over the Bearer's Shoulder.-This method is of advantage because of the ease with which the patient can be carried, and because it leaves one hand free for other purposes. Another im- portant feature is that it enables the bearer to completely control the patient, a point of no little advantage in case of a delirious or refractory patient. (1) Turn the patient upon his face; (2) standing at his head, seize him under his arm pits, taking- care to pass your hand under from above (Fig. 4034), and lift him to his knees, facing you ; (3) shift your arms- about his waist, clasp your hands be- hind his back, and raise him to an erect posture.(4) at the same time plac- ing your right shoulder against his stomach, so that his body falls over upon your back ; (5) pass your right hand forward between his thighs ; (6) with your left hand, grasp the pa- tient's right hand and draw it under your left armpit until you can grasp his right wrist with your right hand ; (7)resume the erect posture (Fig.4035). In case of a female, where the skirts would make it in- convenient to pass the arm between the thighs, if the pa- tient is not too large, the right arm can be passed around both thighs. To lower the patient (1) the bearer drops on his knees, (2) bends gently forward until the patient rests upon his buttocks, and (3) withdraws his hands and resumes an erect posture. These methods for a single bearer are sufficient to meet any emergency which may arise, and afford a sufficient Fig. 4030.-Shifting Po- sition Preparatory to Lifting the Patient " Pick-a-back." Fig. 4032.- Fourth Motion of Mounting the Patient upon the Back. while he is kept in place by a strap passed about his back, the ends of which are held in the bearer's hands. (d) A similar purpose is fulfilled, although not as com- pletely, by the so-called " mountain-chair." A strong objection to both of these methods (c and d), in addition to the fact that they require special apparatus, is that the assistance of other bearers is necessary in order to mount the patient upon the bearer's back. 2. The patient may be carried in a chair strapped upon the bearer's back. This method, however, is hardly practicable, for, in order to maintain his equilibrium, it is necessary for the patient to bend so far forward as to render locomotion very difficult, and a single misstep would entail the fall of the bearer and his burden. The " chair of the Knights of Malta," a combined chair and litter, was planned so that it could be carried in this way. 3. Another method is much advocated by foreign au- thors, and may be of advantage in countries where the people are accustomed to carry heavy burdens upon the head. But it is wholly unadapted to the American phy- Fig. 4031.-Fischer's Saddle and Strap. Fig. 4033. - Patient across Bearer's Back. 231 Transportation. Transportation. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. variety to give to a bearer the rest to be derived from a change of position. grasps with his left hand the right forearm, and with his right hand the left shoulder, of his fellow. 3. Two-handed seat with back. - This method I consider the most comfortable for the patient and the least fatiguing for the bearers, and in every way the most desirable of the methods by two bearers. The right-hand bearer grasps with his right hand the left wrist, and with his left hand the right shoulder, of his fellow ; the left-hand bearer grasps with his left hand the right wrist, and with his right hand the left shoulder, of his fellow. The peculiarity of this method of forming the seat lies in the grip. The plan of inter- locking the fingers, advocated by Longmore, and of hooking the fingers taught by others, renders the two-handed seat described by them practical- ly useless, owing to the fact that the weight of the patient is thrown almost entirely upon the fingers, which are unable to sup- port it for any length of time. 4. Bearers at knees and shoulders. -The front bearer, taking his posi- tion between the patient's thighs, grasps them on either side, and, on lifting, elevates them to just above his hips ; the rear bearer raises the patient's head until its back rests upon his breast, then passes his arms under the patient's armpits from behind, and interlocks the fingers of his two hands in front. This method is comfortable for the patient, but not as easy for the bear- ers as some of the others. It is well adapted to the carriage of exceed- ingly weak patients. II. Where the Patient is Carried upon Apparatus Ex- temporaneously Constructed for the Purpose.-The proced- ures under this head may be grouped into three classes. In the first two the patient is seated, in the third he is recumbent. In the first two the patient should be gently lifted by one bearer, while the apparatus is placed be- neath him ; then he should be lifted and carried as in transferring a patient to or from a litter. In the third class the patient should be transferred to the extempo- rized litter, and this litter should be manipulated in the same way as the regulation hand-litter. 1. A seat may be con- structed («) by forming a ring of leather, rope, twisted cloth, canvas, etc. The bearers grasp the opposite sides of this ring, while the patient sits upon it. For ordinary purposes this is inferior to the two-handed seat already described ; when, however, bear- ers are engaged in carrying the sick for a considerable length of time, the hands become cramped and fa- tigued, and in this case the ring is of service. (I)) The flexible ring is apt in its turn to draw upon the hands and tire them, a difficulty which can be obviated by the addition of rigid handles. An excellent seat may be extemporized by taking two short rods, cut from a tree or other conven- ient source, and connecting them with two handker- Fig. 4037.-Three-handed Seat with Back. Fig. 4034.-Second Motion of Lifting Patient over Bearer's Shoulder. B. Methods by Two Bearers.-While in many in- stances it is really easier for one bearer to carry a patient by the methods which I have given than for two to unite in carrying him, yet it is usu- ally rather more comfortable for the patient to be carried by two, and for any considerable distance it is easier for the bearers. The methods by two bearers may be considered in three groups: I. Where the patient is carried without as- sisting apparatus. II. Where the patient is carried upon ap- paratus extemporaneously con- structed for the purpose. III. Where the patient is carried upon articles diverted to that use. I. Where the Patient is Car- ried without Assisting Appara- tus.-In the execution of these methods the action should be divided as in transferring a patient to or from a litter, and be performed in obedience to the same commands, substituting Forward, march, for To the litter, march. 1. Four-handed seat.-This is the " lady's chair " or "sedan- chair" of the children, and makes a very comfortable seat for a pa- tient who is able to help himself to some extent. To form it each bearer grasps his own left wrist or forearm with his right hand, and with his left hand grasps his fellow's right wrist or forearm. The patient, sitting upon the seat thus formed, helps to sup- port himself by throwing his arms over the shoulders of the bearers. 2. Three - handed seat with back.-This is recommended by Longmore as being the most de- sirable of these methods, but, while it is undoubtedly useful, my own observation has taught me that it is inferior to the two-handed seat. To form the three-handed seat the right bearer grasps his own left forearm with his right hand, and the left fore- arm of his fellow with his left hand ; the left-hand bearer Fig. 4038.-Two-handed Seat with Back. Fig. 4035.-Patient over Bear- er's Shoulder. Fig. 4039.-Bearers at Knees and Shoulders. Fig. 4036.-Four-handed Seat. Fig. 4040.-Seat Formed by a Ring of Rope. 232 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Transportation. Transportation. chiefs. The writer submits this as a new use for the tri- angular bandage-handkerchief, as shown in Fig. 4041. On the battle-field, baypnets, knives, etc., may be used for rods, and, if the handkerchiefs are not forthcoming, strips torn from the clothing of the dead or wounded may be substituted for them. (c) The principle of the foregoing apparatus has been utilized in the Bavarian Trag-sitz or bearing seat, consisting of a piece of canvas folded over at both ends so as to form loops in which are secured round pieces of wood, each of which is left uncovered in the middle, to permit the formation of a handle, the whole constituting a seat 22 inches long by 14 inches wide. In using these seats, if the patient is too weak to assist in supporting him- self, a back may be formed as prescribed for the two- handed seat, the seat being held in the bearers' outer hands. If the patient can assist in supporting himself, the seat will be held by the inner hands, w'hile the pa- tient will steady himself by hooking his arms about the bearers' arms. 2. On the battle-field rifles are liable to be the most con- venient material to be utilized as side poles in extemporizing litters, while the bed may be formed from the debris which is to be found in abundance in the vicin- ity. (a) A convenient litter may be con- structed from two rifles with their gun- slings. To form this, the slings should be let out to their greatest length, care being taken to have them of the same length. The sling of the first rifle should be unhooked from the ring near the muzzle ; that of the second should then be passed over the first, and the unbooked sling of the first should then be passed over the second and hooked again. The litter is now complete and is carried, as shown in Fig. 4044, by two bearers, the rear bearer holding the guns near the muzzle, while the front bearer grasps the breech, and the pa- tient sits leaning upon the rear bearer. (b) In the absence of the gun-slings, a litter may be ex- temporized by turning the sleeves of an overcoat inside out, passing two rifles through these sleeves, and buttoning the coat around them. The buttons are carried underneath and the litter is managed precisely like the one from rifles and gun- slings. Instead of gun-slings or overcoats, the pieces may be connected by two blouses, belts, straps, knap- sacks, and other similar articles. (c) It is a matter of no inconsiderable difficulty to lash the ends of two rifles together with sufficient firmness to warrant the ex- temporization from four rifles of a litter to be car- ried by two bear- ers, permitting the patient to be borne i n a recumbent posture. When the lashing is satis- factorily accom- plished, however, the bed may be formed by gun- slings, coats, straps, shelter- tents, etc. The formation of a lit- ter from rifles, to be carried by four bearers, is to be de- scribed hereafter. 3. To carry the patient in a recumbent posture, (a) two poles of suitable length may be taken and connected Fig. 4041.-Seat Ex- temporized from Two Sticks and Two Triangular Bandages. Fig. 4045.-Litter of Two Rifles and an Over- coat. Fig. 4042.-Trag- sitz or Bearing Seat. Fig. 4046.-Litter of Two Poles thrust through the Sleeves of Three Blouses. The middle blouse is left open to show the disposition of the sleeves. by coats, through the reversed sleeves of which the poles are passed, the coats being buttoned around them. Two overcoats or three blouses used in this way form an ex- Fig. 4043.-Litter of Two Rifles and Gun-slings. Fig. 4047.-Litter of Two Poles thrust through Two Grain-sacks. cellent litter. These litters should be carried with the buttons down. (b) Grain-sacks, pillow-cases, and other bags of a simi- lar size, where they can be obtained, form a still better bed for an extem- porized litter, the poles being passed in at the mouth and thrust through either corner of the bottom of the sacks. (c) The litter poles may be con- nected by a variety of other materi- als. The resulting litter may be framed or not. If framed, the two side poles are joined by two traverses or end poles nailed, or more probably tied, across. Any of the materials already named may be utilized for the bed. Boards may be nailed across the side poles, in •which case a bed of some kind would need to be made up for the patient to lie upon. Straps and belts may be utilized to form the bed of a litter by interlacing them about the poles. Similarly, a picket rope or a clothes-line forms an excellent foundation. The poles may be connected by a blanket or tent-fly, the edges of which are fast- Fig. 4044.-Method of Using the Litter of Rides and Gun-slings. 233 Transportation. Transportation. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ened together, making a long bottomless sack. Band- ages torn from clothing make excellent cords for fasten- ing these together. Still another method of extemporiz- ing a litter from a blanket and poles consists in rolling the poles up in either side of the blanket until the inter- val between them is of the proper width for a litter. vided into two groups, according to the attitude of the patient. 1. The patient, sitting, may be carried upon a board, a rifle, a carbine, a cane, a broomstick, a chair, or other similar articles. 2. The patient, recumbent, may be carried on a litter Fig. 4048.-Litter of Two Poles with a Rope Interlaced about them. Then through button-holes cut at suitable distances just within the poles on either side, pass cords extemporized from any available source, and tie them about the poles rolled in the blanket. (d) By driving crotched stakes into the ground at suit- able distances, a litter extemporized in any of these modes may be utilized as a bed on coming into camp. (e) Surgeon-Major Smith, of the Norwegian Army, has extemporized litters from boughs which have the decided Fig. 4052.-Hammock Litter. extemporized from a broad board, a door, a shutter, a cot, and other articles of that kind. C. Methods by Three or More Bearers.-It is not infrequently the case that the paraphernalia of litter- bearing are deficient, while there is an abundance of men for bearing the disabled. It is, moreover, not infrequently the case that patients are so injured that, in the absence of regularly constructed litters, or the impracticability of extemporizing them on account of the lack of time or other reasons, the services of three or more bearers are necessary in order to carry them comfortably to any dis- tance. If the distance over which the patient has to be borne is considerable, it is also frequently desirable, in order to prevent fatigue, in the absence of a satisfactory litter, to divide the weight of the patient among several bearers. I. By Three Bearers. -In case of a wound of the lower extremity, the patient may be carried by two bearers upon a two-, three-, or four- handed seat, or upon a bearing seat, in which case a third bearer must be employed to support the injured limb. The methods df carrying a patient in transferring him to or from a litter, the services of No. 4 being omitted, are also examples of these meth- ods. II. By Four Bearers. - 1. The procedures prescribed for convey- ing a patient to or from a litter, Nos. 1, 2, and 3 being the bearers proper and No. 4 supporting the head or the injured part, are methods of this kind, and they may be utilized for bearing a patient in the absence of a litter. 2. Blankets, tent-flies, and the like, carried by four bearers, one at each corner, have constituted a common extempore method of carrying the disabled, but the method is inconvenient and laborious for the bearers, and awkward and uncomfortable for the patient. It is diffi- cult to conceive of an instance where it would be both impossible to obtain rigid poles or frames such as have been enumerated in this article, and to practise the meth- Fig. 4049.-Litter of Two Poles Rolled in the Sides of a Blanket. advantage of possessing legs. He cuts four cross-pieces like the one shown in Fig. 4050, the length of the long branch being a trifle more than the width of the pro- posed litter, the shorter branch is a little more than the thickness of the side poles in length, while that of the other branch is the desired length of the leg. He also procures two poles eight or nine feet in length for the side poles. The cross-pieces are then bound together in pairs with a leg at either end. These pairs are then bound at suitable distances apart to the side poles, which are placed in the outer notch of the cross-pieces. Over the framework thus formed, a bed may be constructed of canvas, blanket, straps, rope, boughs, or any similar available material, a covering of some- thing soft being laid over any rigid material. (/) Hammocks are frequently available, particularly when the emergency occurs in the vicinity of shipping. They are best arranged as litters by being suspended from a single pole, the ends of which are to be carried upon the bearers' shoulders. The objections to carrying the litter upon the shoulders are obviated in this case by Fig. 4050.-Cross-piece of Smith's Extempo- rized Litter. Fig. 4051.-Smith's Extemporized Litter. Fig. 4053.-Patient Carried upon a Two- handed Seat with a Third Bearer at the Legs. the fact that the hammock hangs below the pole and not at an uncomfortable distance from the ground, nor above the view of the bearers. Litters of this kind were used with great satisfaction by the British in the Ashantee War of 1873 and 1874, each litter being provided with a pillow formed from a spare hammock, which was also used for a litter when emergency dictated. III. Where the Patient is Carried upon Articles Di- verted to that Use.-In carrying a patient upon these ar- ticles, the manoeuvres and commands prescribed for the hand-litter should be employed. This class may be di- 234 Transportation. Transportation. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ods without assisting apparatus, so that a resort to the blanket would be necessary. 3. A litter may be constructed by forming the poles on either side by two rifles lashed together at the muz- zles and connecting these poles by a blanket, tent-fly, coats, or similar articles. As has already been remarked, the objection to the formation of litter-poles by lashing together two rifles lies in the difficulty of lashing the pieces so firmly as to provide sufficiently rigid poles. In case of the absence of more suitable materials, however, wagon, upon which the litter or the patient himself may be laid. 2. A bed with a certain amount of spring may be formed by interlacing ropes, straps, or similar articles about a wagon-box. A method of this kind is shown in Fig. 4055. 3. If elastic rods of wood are laid across a wagon-box, they will provide an excellent springy surface. The rods should be green and comparatively slender, since the single wands are not required to support the disabled man, the weight being upheld by their united strength. The elasticity may be equalized by notching the stiffer rods. 4. Where there is time, and suitable saplings are available, (a) springs constructed according to the method of Surgeon-Major Smith, of the Norwegian Army, are of advantage. One end of a rough pole (A, Figs. 4056 and 4057) is lashed to the top side-rail (aa) of a wagon outside the side bars, to the front, as in Fig. 4056 ; another (B) is similarly lashed to the rear, this being done on both sides. To the free ends of these poles are lashed cross-poles (CC), upon which the stretchers are placed and lashed. By this method the disabled have the advantage of the spring of the longi- tudinal poles, which is limited by bands (dd) drawn loosely around them and the top siue-rail of the wagon. (5) The plan of Smith has been advantageously modi- fied by Miihlvenzl, as shown diagrammatically in Fig. 4058, the same materials being used. The Miihlvenzl- Smith method is the more firm and durable, and applica- Fig. 4056.-Profile View of Smith's Extemporized Springs. Fig. 4054.-Litter, the Side Poles of which are each Formed by Two Rifles Lashed together, Carried by Four Bearers. a litter may be constructed in this way, and, the bearers being numbered and located as in hand-litter exercises, Nos. 3 and 4 assist in carrying the litter by grasping the poles at the weak point, where the rifles are lashed. 4. In case of a very heavy patient, in loading or un- loading a litter at an ambulance, in ascending or de- scending declivities, etc., the four bearers will co-operate, one at each corner of the litter. III. By Five Bearers.-A patient may be carried by five bearers, one on either side supporting the head and shoulders, one on either side supporting the pelvis, and one supporting the legs. A greater number of bearers than five cannot act conveniently. I). Methods by Wheeled and Other Vehicles. -The ambulance has been very fully discussed, both from a civil and military stand-point, in the articles of Drs. Leonard and Smith, to which reference has a ready been made. It is desired here to say a few words upon Fig. 4057.-Smith's Extemporized Wagon Springs. ble to a greater variety of vehicles. The diagram, con- sidered in connection with the description of the Smith method, gives a clear idea of its construction. II. Two-wheeled Vehicles.-1. These are represented by two-wheeled ambulances, artillery caissons, carts, and wheeled litters. The transports of the celebrated ambu- lances volantes of Larrey were mounted upon two wheels, and it has been a favorite form in many countries. Dur- ing the War of the Rebellion, however, the results ob- tained by the use of the two-wheeled variety were not such as to cause it to be preferred to those running upon four wheels. 2. Artillery caissons and two-wheeled carts may be utilized for the transport of the disabled in the absence Fig. 4055.-Rope Springs. (After Robert.) a similar phase of the subject, without, however, in- fringing upon the field occupied by them. While a properly appointed ambulance is undoubtedly the most suitable vehicle for the removal of the disabled, many instances must of necessity arise where, in the absence of an ambulance, other vehicles must be adapted to the purpose. I. Four-wheeled Vehicles.-1. Where possible, vehicles having springs should be obtained, and if the springs are very stiff, they may be supplemented in one of the ways provided for wagons without springs. In either case, a bed of straw, hay, leaves, rushes, or other avail- able material should be prepared upon the body of the Fig. 4058.-Profile Diagram of Miihlvenzl's Modification of Smith's Ex- tempcrized Wagon Springs. of better conveyances. The means suggested for adapt- ing four-wheeled vehicles to this use may be applied also to this variety. 3. Wheeled litters have not met with marked favor in time of war, owing to the fact that they are not adapted 235 Transportation. Transportation. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. to rough country, such as is apt to be chosen for a battle- field. For this reason, they have been found to be en- tirely useless in case of Indian hostilities. But on mod- with automatic pillow and movable cover, with an under- carriage of two wheels on elliptical springs. The par. ticular advantages in this form are (1) the readiness with which the hand-litter can be detached from the wheels, the rear bearer being enabled to walk directly forward between the wheels, easily stepping over the crank axle, as shown in Fig. 4062 ; (2) the fact that a number of hand- litters may be used with the same under-carriage. III. One-wheeled Vehicles.-The representative of this style of conveyance is the common wheelbarrow, which has done excellent service in transporting the sick in an emergency. As far as the writer is aware, no serious effort has yet been made to construct a one-wheeled lit- ter, although the suggestion of Dr. Smith, as to the utili- zation of the principle in the construction of a wheeled litter, would seem a useful one. IV. Vehicles without Wheels.-Under this head fall vehicles upon runners-for travel over snow or ice,- travois or sledges, and horse-litters. The various varieties of sleighs and sleds, all of which are superior to wheeled conveyances upon good roads over the snow, are too numerous to mention in detail and need no more than a casual reference. Travois and horse-litters have already been thoroughly discussed in the valuable article of Dr. Smith on Field Surgeons, in Vol. III. of the Handbook, and the reader is referred to it for a consideration of the subject. Posture of Patients during Transportation.- Disabled persons (1) may be assisted to walk in an erect posture, or (2) carried sitting, (3) semi-recumbent, or (4) recumbent. Where the distance is comparatively short, the posture may not be of much importance; neverthe- less, says Longmore, to whom we are indebted for most of the facts presented under this head, "even under these circumstances the position in which a wounded soldier is carried may have an important influence on his pres- ent safety or future welfare. But the question becomes greatly more important when a recently wounded man has to be carried a long distance, such as one or two miles, for his primary treatment; and still more so when, as not unfrequently happens, the transport occupies several days before the hospital to which the patient has to be sent for his secondary and prolonged treatment can be reached." 1. Walking in an Erect Posture.-After an action, it has been observed that a considerable number of the wounded find their way to the field hospital without as- sistance. A considerable number more are enabled to come with the assistance of a single man, supporting them as described in the section on extemporized modes of conveyance. The exact character or location of the wounds which permit this mode of progression cannot be indicated, for much of the power to act lies in the mental qualities of the patient. Wounds of an exceedingly se- vere character, such as injuries of the skull, the trunk, and even the loss of one of the upper extremities, have not prevented men from accomplishing considerable journeys. Ordinarily, however, patients with simple wounds only attempt to resort to the hospital without be- ing carried. Some appliances have been invented for assisting such a patient, with a view to rendering aid in particular to patients suffering from injuries of the lower extremities, but their practical application has not been attended with success. Where additional support is needed, the injured man will extemporize a cane from a sabre or sword, or crutches from two rifles, etc. 2. The Sitting Posture.-The conditions which would permit a patient to walk to the hospital, with or without assistance, would apply equally to his ability to endure carriage in a sitting posture. This position is particu- larly applicable, however, to injuries of the upper part of the body, such as simple wounds of the head and trunk, or the upper extremities. Even quite severe traumata affecting the hand and forearm,, where the patient is not greatly prostrated by shock or loss of blood, and the in- jured extremity is suitably supported in a sling, need not prevent carriage seated. Wounds of the foot and slight simple injuries of the lower extremities also, when unac- companied by general symptoms of a dangerous charac- erately level ground they may be of the utmost value. They are particularly useful in case of accidents in towns and cities. Villages, where accidents are not frequent enough to justify the establishment of an ambulance sys- tem, should be provided with a number of wheeled litters Fig. 4059.-The Tompkins Wheeled Litter. Fig. 4060.-Tompkins Litter, folded. AA, Side bars; B, joint in side bars ; CC, legs ; D, iron support for legs ; E, springs ; F, upholstered arm-rest; G. canvas pocket for pillows, etc. ; H, roll of canvas to be drawn up to protect the patient. located at convenient points, where they can be obtained in case of necessity. The qualities essential in a wheeled litter for field ser- vice are, as well stated by Longmore, that it must pos- sess all the qualities of a good hand-litter; that the litter must be readily mounted or dismounted from the wheels ; that it must be readily manageable by a single bearer ; it must possess springs ar- ranged to diminish jolting; it must be light enough to be readily carried over an obstacle ; it must be capa- ble of stand- ing alone, and must be sus- ceptible o f being readily folded into a limited space without the separation of small parts, which are lia- ble to be lost; and it should not be expensive. These essentials are fully met in the litter devised by General Charles H. Tompkins, U. S. Army (Figs. 4059 and 4060), consisting of a canvas bed fastened between two folding side bars, with a folding hood at its head. These litters could be sold profitably a t twenty- five dollars. In Figs. 4061 and 4062 is shown the Ashford litter, invented b y Mr. John Fur- ley, of the St. John's Ambu- lance Associa- tion of England, which is excellently adapted to town and village work, and in many respects meets the indi- cations excellently. It consists of a folding hand-litter Fig. 4061.-The Ashford Wheeled Litter. Fig. 4062.-The Ashford Wheeled Litter, showing the Detachment of the Hand-litter. 236 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Transportation. Transportation. ter, do not necessarily contraindicate this position. It may be said, in a general way, that recourse should be had to these positions only when the demands upon avail- able transportation are so heavy as to render it necessary to relieve the pressure by every possible means, it being possible to carry four men seated in the space required for a single one recumbent. 3. The Semi-recumbent Posture.-This position may be maintained (1) upon one of the extemporized chairs with backs constructed from the bearers' hands and arms ; (2) upon apparatus constructed for the recumbent posture and modified by pillows ; and (3) upon apparatus con- structed for the purpose. In the first case, it may be con- venient to carry patients in the semi-recumbent posture for a short distance, but otherwise there are no practical advantages over the entirely recumbent position, except in cases of dyspnoea from wounds of the thorax or other causes. Even in these cases the provision of apparatus constructed for the purpose is unnecessary, for the proper attitude may be secured upon apparatus arranged for a recumbent posture, by the introduction of pillows, actual or extemporized, to provide the desired elevation. 4. The Recumbent Posttire.-Aside from the exceptions noted in the preceding paragraph, the recumbent posture is the safest and most comfortable position for a patient disabled by any cause. Every part of the body being equally supported, and no part being obliged to bear the weight of another, the necessity for all muscular exer- tion ceases, the minimum of concussion is received by the various parts of the body, the amount of shaking in carriage being distributed over the entire frame, and the most perfect repose is obtained. " If the balance of the circulatory system," continues Longmore, " has been disturbed under faintness, from the effects of chills or from any other cause, it is the position most favorable for its restoration. If haemorrhage from divided vessels has been arrested by some of the ordinary natural meth- ods through which this is accomplished, or temporarily stopped by the accumulation of coagulum, the horizontal position is the more effective for preventing dirturbances of these favorable circumstances, by doing away with the need of moving the injured parts and by lessening the weight of the column of blood in the vessels leading to them. Fracture of any of the bones, or wound of the ar- ticulations of the lower extremity, severe wounds of the head, chest, or abdomen, and, generally, extensive injuries of the shoulder-joint, usually completely disable men from moving themselves for help. Such patients should always be transported in a horizontal posture. If the means of carrying them in this manner be not at hand, the best plan is to carry them temporarily to a place of shelter until the necessary conveyances can be obtained." The foregoing rules apply to hand-carriage, where more than one bearer is available, and to conveyance by vehicles. Where but a single bearer is present, no choice is left but a resort to one of the methods taught for that purpose. Where the patient is badly wounded and the distance is short, he may be carried in the bear- er's arms, but in other cases he must be borne upon the back or shoulder according to the methods rehearsed in this article. Conclusion.-The importance of the provision of proper transportation in war is shown by the large num- ber of deaths which can be directly traced to the lack of suitable facilities for the removal of the disabled to places designated for the treatment of the injured. At the battle of Antietam alone, says Agnew, five hundred lives were lost from the want of proper transportation. The same story could be told of nearly every battle under the old regime-starvation and thirst, added to the excru- ciating suffering attending the neglected injuries of the wounded, combining to form an ensemble of unspeakable torture. No effort should be omitted to obviate this un- fortunate condition hereafter. And as the broader hu- manity of the age is leading to a higher conception of our duties to the fallen, whether comrade or enemy, there is a hope that such a result may be realized. Societies of succor are organized to lend their aid to the regularly established corps of assistance in war, and to afford prompt aid to the injured in time of peace, and in many directions efforts are being put forth to extend a knowledge of and provide facilities for the proper trans- portation of the disabled, which must inevitably culmi- nate in an incalculable diminution of future suffering and a vast decrease in the death-rate of future cam- paigns. * Bibliography. Bacmeister: Handbuch fur Sanitatssoldaten. Braunschweig, 1867. Bedoin : Note sur un nouveau systeme de brancard, Congres International de Bruxelles. Burgkly: Manuel d'hygiene et de premiers secours, a 1'usage des sous- officiers et des soldats (traduit de i'allemand). Baris, 1872. Chenu, J. C.: Aper<,u historique, statistique et clinique sur le service des ambulances et des hopitaux de la socidte franfaise de secours aux blesses de terre et de mer pendant la guerre de 1870-71. Paris, 1874. Chenu, J. 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Rapp. Edi- tion revue et notablement augmentee par 1'auteur. Paris, 1875. Hogg, W. D.: Premiers secours aux malades et aux blesses. Paris, 1886. Huguenard: Guide theorique et pratique de I'infirmier, du brancardier, et de 1'ambulancier sur le champ de bataille. Paris, 1881. Landa y Alvarez, N. : Nouveau systeme pour 1"enlevement des blesses dans la ligne de bataille. Pamplona, 1865. Larrey, D. J.: Memoires de chirurgie militaire et campagnes. Paris, 1812. Larrey, D. J. : Memoirs of Military Surgery and Campaigns. Translated by W. R. Hall. Baltimore, 1814. Laurent: Histoire de la vie et des ouvrages de P. F. Percy. Versailles, 1827. Le Fort: La chirurgie militaire et les societes de secours en France et a I'dtranger. Paris, 1872. Legouest, V. A. L.: Traite de chirurgie d'armde. Paris, 1863. Leonard, G. W. : Ambulances and the Ambulance Service in the Larger Cities. Handbook, Vol. I., p. 128. Levy, M.: Art. Ambulance, Dictionnaire Encyclopedique des sciences medicales. Paris, 1865. Locati: Description des brancards. Turin, 1879. Longmore, T.: Treatise on the Transport of Sick and Wounded Troops. London, 1868. Marmonier, L. : Guide medical de 1'officier detache. Paris, 1879. Martin, J. H.: Ambulance Lectures. London, 1886. Michaelis: Ueber den Verwundeten Transport im Gebirge. Inaugural dissertation. Berlin, 1877. Millingen: The Army Medical Officer's Manual upon Active Service. London, 1819. Moore, S. : Manual of Exercises for Training Stretcher Bearers and Bearer Companies. London, 1878. Morton, B.: Handbook of First Aid to the Injured. New York, 1884. Nanda : Du transport des blesses. Bruxelles, 1866. Neudorf er : Handbuch der Kriegschirurgie. Leipzig, 1864. Otis, G. A.: Report on the Transport of Sick and Wounded by Pack- animals. Washington, 1877. Otis, G. A., and Huntington, D. L.: Medical and Surgical History of the War of the Rebellion. Part III., Surgical volume. Washington, 1883. Otis, G. A., and Woodward, J. J. : Report on the Nature and Extent of the Materials Available for the Preparation of a Medical and Surgical History of the Rebellion. Circular No. 6, S. G. O., Washington, 1865. Percy, F.: Art. Despotats, Diet. des. sci. m6d. Paris, 1814. Pilcher, J. E. : The Transportation of the Disabled, with Special Refer- ence to Conveyance by Human Bearers, Journal of the Military Service Institution, vol. ix.. No. 34. New York, 1888. Pilcher, J. E.: An Exercise in the Extemporization of Litters from * The illustrations of this paper are mainly reproductions of photo- graphs for which the writer wishes to acknowledge his indebtedness to the skill and courtesy of his friend, Lieutenant-Colonel Anthony Heger, Surgeon, United States Army. 237 Transportation. Transportation. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Rifles and Gunslings. Boston Medical and Surgical Journal, June 7, 1888. Port, J.: Taschenbuch der Fertzlicheu Improvisationstechnik. Stutt- gart, 1884. Porter, J. H.: The Surgeon's Pocket-book. Philadelphia, 1887. Redford, G. : Plan of Equipment for the Medical Staff Corps. London, 1858. Riant, A.: Le materiel de secours. Paris, 1878. Robert, A.: Traite des manoeuvres d'ambulance et des connaissances militaires pratiques a 1'usage des medecins de Farmfee active et de Farmee territoriale. Paris, 1887. Roberts, R. L.: Illustrated Lectures on Ambulance Work. London, 1885. Rossignol, S. : Traite 61ementaire d'hygiene militaire. Paris, 1883. Salter, Simpson et al.: How to Carry Unaided an Insensible Man, Lan- cet, March 21 and 28, 1885. Sarazin, C.: Art. Ambulance, Nouveau Diet, de m6d. et de chir. prat. Paris, 1864. Schiller: Verband-und Transportlehre fill-Sanitatstruppen. Wurzburg, 1870. Shaw, E. M.: Fire Protection, London. Shepherd, P. : First Aid to the Injured. New York, 1882. Smart, C. : Art. Army Field Hospital Organization. Handbook, vol. i., p. 332. Smith, C. : Noglenye Transportmidler for Saarede. Kristiania, 1877. Smith, C.: Chariot a foin completement fequipe pour deux soldats grieve- ment blesses. Christiania, 1880. Smith, J. R.: Art. Field Surgeons, Duties of, in Time of War. Hand- book, vol. iii., p. 139. Tactics, Artillery, U. S. Army, Assimilated to the Tactics of Infantry. New York, 1885. Tactics, Cavalry, U. S. Army, Assimilated to the Tactics of Infantry. New York, 1885. Upton, E.: Double and Single Rank Infantry Tactics of the U. S. Army. New York, 1885. Van Domelen : Essai sur le transport et les secours en general. Haag, 1871. Webb, H.: Conversation Lessons on Prompt Aid to the Injured. Bury, 1888. James E. Pilcher. TRANSPORTATION OF THE DISABLED ON SHIP- BOARD. The transportation of the sick and wounded in military operations on shore depends so much on cir- cumstances of time, place, and character of force engaged, that it has not been thought possible to provide an ap- paratus or appliance available for every possible occasion. Where the regular field ambulance could not be used, as when small bodies of men operate on detached service in wild countries, the ingenuity of the medical or other offi- cer in charge has been depended upon to improvise, from such material as might be at hand, some sort of carriage or means of transport that would meet the exigency of the moment. Whence, the number of single and two- (1) the transportation of wounded men from the spar- and gun-decks during action, and men accidentally dis- abled at other times, through a narrow hatchway to the cockpit or sick-bay on a lower deck ; (2) the sending wounded or injured men down from the tops to the spar-deck, and thence below to the cock pit or sick-bay ; and (3) the transportation of the sick and wounded from the sick-bay to the spar-deck and thence over the ship's side into a boat, by which to be taken on shore, landed, and carried to hospital. Various apparatus have been Fig. 4063a.-Wells's Improved Ambulance Cot. 1, Ready for service; 2, rolled up. proposed serving one or all these purposes, but they are little known outside the navy. In the passenger and merchant services, in which no provision is made for them, occasions requiring them occur so often, that an apparatus adaptable to every possible need is a desidera- tum. The method of carrying the injured or invalid upon the hands of two strong men, crossed after the fashion of the "lady's chair" of children's play, on which the person sits with legs dangling, supporting himself by his arms around the bearers' necks, or, when unable to do this, being held in place by other assistants, answers where there is no confusion, when the decks are unob- structed and the wide quarter-deck ladder is in place, and when the inferior extremities are not severely injured or the sufferer does not otherwise require especially tender handling or support. Under these latter circumstances the ordinary "hos- pital cot " has been for years the only means available on Fig. 4063.-Wells's Hammock. horse and mule litters, litieres, cacolets, paniers a dossier, aparejos, and pack-saddles devised for expeditionary ser- vice, and the simpler extemporized stretchers, travaux, travois, or travees, which the emergencies of our military service among the Indians have caused to be constructed. The many varieties of these devices by medical officers of the United States Army have been admirably de- scribed and pictured by the late Major George A. Otis, Surgeon U. S. Army, in his report to the Surgeon-Gen- eral of the Army " On the Transport of the Sick and Wounded by Pack Animals." [Circular No. 9, War De- partment, Surgeon-General's Office, Washington, 1877.] On board ship the necessities and conditions are so uniform that there is no such need for dependence upon temporary expedients. It is possible to devise an appa- ratus to meet the several purposes required, which are board most naval vessels for purposes of transportation, and often, when most quickly needed, this could not be got ready. Even when one was required to be kept con- stantly rigged, it was not unusually occupied by some bed-ridden invalid, -who could not be displaced, and, the necessity arising for another, the carpenter's mate or his assistant had to be summoned to gather the several pieces of the clumsy frame from their place of stowage in some distant corner of the hold, or perhaps under the ham- mocks in the nettings. When found, these would sel- dom fit together, and when fitted, more time was com- Fig. 4064.-The Gorgas Improved Cot. 238 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Transportation, Transportation, sumed in the slow process of lacing a canvas sacking six feet long around the wooden frame, and adjusting the latter thus covered within the cot proper, of which the sides had then also to be laced together ; the whole forming, when all was done, an ill-contrived canvas box, usually too short for the occupant and not easily handled and carried. It was never suitable for lowering a wounded man through a small hatch, the utmost care on the part of four or five assistants being often unable to prevent the patient sliding down to the end of the cot. perhaps upon a fractured leg or thigh, or, especially when helpless or unconscious, from pitching out headlong. Medical Inspector Albert C. Gorgas, U. S. Navy, in 1864, devised an im- provement of the "hospital cot," intended to obviate some of these objections, and his cot has been in use on board many vessels of the United States Navy. Its chief pecu- liarity is a leather-covered double-inclined plane, raised and lowered by a hinged cen- tre and made to catch upon a wooden ratchet attached to each side of the lower half of the cot frame. The thighs and legs being flexed over this plane, its upper surface sustains the weight of the body when the head of the cot is elevated, while a narrow leathern band, passed through two long leathern or canvas loops nailed to the upper cross-piece of the frame, is tied around the chest under the arms, and prevents the tilting forward of the body, which is also partly support- ed by the breast-strap. The lower two- thirds of the body are, however, not con- fined in any way, and notwithstanding the rope handles on the canvas head- and foot-pieces, the apparatus is essentially the same unwieldy hospital cot, not easily handled and not fitted for transport to any distance. Surgeon Henry M. Wells, U. S. Navy, some years ago proposed an ingenious modification of the ordinary ship's ham- mock, by which it may be used in certain cases for the carriage of the sick and injured. Two long strips of canvas were sewed diagonally across the under surface of the hammock, terminating on each side in rope handles by which it could be car- ried, the patient resting on mattress, blankets, and pillow; but even when wooden stretchers were attached to each clew of the hammock this apparatus was at best a makeshift, since it lacked the rigidity which can only be secured by a solid frame, and without which it cannot, with safety or comfort to the patient, be used to swing him over a ship's side into a boat, or to support him during his pass- age on shore. Dr. Wellshimself, recognizing these de- fects, subsequently improved his apparatus by introduc- ing long longitudinal staves through canvas guards run- ning the whole length of the hammock, which he further doubled and stiffened by transverse strips of wood insert- ed between stitched casings in the canvas. Rope handles along the sides of the staff-guards allow the carriage of the patient lying at length as upon an ordinary invalid cot. Notwithstanding these very great improvements, this cot is still unsuitable for the descent or ascent of badly injured men through narrow passages or at very great inclinations. Lieutenant T. B. M. Mason, U. S. Navy, has suggested a method of utilizing the ordinary ship's hammock for ambulance service with landing parties. Eyelet-holes are worked along both leeches of the hammock, as well as across its ends, permitting it to be laced and stretched upon a wooden frame made of two long poles and two transverse stretchers of proper length. While this and the other apparatus described will serve as useful expedients under many circumstances, when other means are lacking, it is important that provision should be made in the outfit of every vessel belonging to the Gov- ernment, and appropri- ately supplied to every passenger and mer- chant vessel, to meet whatever exigency may at any time occur, requiring, as stated at the outset, the safe and comfortable carriage of any sick or wounded individual from aloft, from on deck to sick quarters below, or from below through a small hatch- way to the deck above, the whipping him over the ship's side into a boat in a seaway, and his transportation to the shore and thence to the side of the bed he is to occupy in the hospital, without change of convey- ance from the time he leaves his cot in the ship's hospital or sick-bay. I have proposed to meet all these require- ments by the Ambu- lance Cot bearing my name, which was submitted, by order of the Navy Department, to a board of officers, composed of Captain (now Commodore) Oscar C. Bad- ger, Medical Director (afterward Surgeon-General) F. M. Gunnell, and Passed Assistant Surgeon T. D. Myers, who, on July 5, 1877, reported as follows: "We have carefully examined the Ambulance Cot submitted to us, and have to report that it seems to ac- complish all that was proposed by Medical Inspector Gihon in planning it. It enables a man to be lowered endlong through a hatchway or from a top without fall- Fig. 4065.-Gihon's Naval Ambulance Cot 239 Transportation. Transposition. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ing out, the band around the breast preventing him from falling forward, the bands under the thighs supporting feet long and two and a half feet wide, with the long edges (sides or leeches) and the ends doubled and sewed so as to form casings or sheaths, to receive, those on the sides two staves of tough elastic wood or bamboo, eight feet long, and through the end casings two stretchers' of the same material, two and a half feet in length. The extremities of these longitudinal staves are rounded to form handles, and are passed through metal castings on the ends of the transverse stretchers, the whole forming Fig. 4068.-Swinging the Ambulance Cot over the Ship's Side into a Boat, a springy portable bed or litter. A canvas band, twelve inches wide, securely sewed to the cot bottom, is intended to envelop the chest, and is attached to the sides of the cot by cords passed through eyelets in the canvas. Two narrow straps, attached to the upper edge of this chest- band, pass, one in front of each shoulder, and being also fastened by cords to the opposite side of the cot frame, assist in keeping the chest-band in place. Two canvas femoral bands, seven inches wide, sewed diagonally to the cot bottom, receive and envelop each thigh, and are likewise made fast to the cot frame by terminal cords. These femoral bands sustain the principal part of the weight of the body when the head of the cot is elevated toward the perpendicular. Two narrower bands, five Fig. 4066.-Naval Ambulance Cot. Invalid secured for transportation. his weight. If the legs be injured, there are additional bands to confine them. The cot also permits a man to be swung over a ship's side in a heavy sea-way, and landed in a boat without danger of falling out. He is to remain in the cot in the boat, the elastic side- pieces making a comfortable spring-bed. On shore he can be placed in any kind of wagon, the ends of the side-pieces being placed on any sort of support, and the springing of these side- pieces will prevent jarring. If there is no wagon about, two or four men can take hold of the extremities of the side-pieces and walk away with him to his bedside in a hospital. When not in use the staves and stretchers can be unshipped, placed inside the canvas, and the whole rolled up compactly and placed between the beams overhead." 1 The apparatus con- sists essentially of an oblong piece of stout canvas, about seven Fig. 4069.-Ambulance Cot used as a Hand Litter. inches wide, similarly sewed to the cot, and attached to the frame on each side, receive and confine the legs. A canvas-covered hair pillow, loosely secured to the cot by cords passed through eyelet holes, completes the appara- tus. A sling with a cringle (an iron ring or thimble) placed in the middle, and one on each part near the up- per stretcher, enables the cot to be lowered endwise or to be swung horizontally. The rounded extremities of the side staves may rest on the thwarts of a boat or on blocks in a wagon, protecting the patient's body from pressure underneath, and forming a comfortable bed during his transfer to his destination ; and they may be convenient- ly grasped by a man at each end and the cot carried to the very bedside which is to receive him. The weight Fig. 4067.-Lowering the Ambulance Cot through a Hatchway. 240 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Transportation. Transposition. of the apparatus is less than thirty pounds, and when not in use the stretchers may be unshipped and the cot rolled upon the staves into a bundle eight inches in diameter, which may be readily stowed between the beams over- head, or in some other easily accessible place. While this cot was devised for naval and marine pur- poses, it is equally adapted for field service, when the use of wheeled vehicles is not practicable. Dr. Otis states that under such conditions the ambulance equip- ment must be able to keep up with the troops and not in- terfere with their rapid movements. The lengthening of the side staves, by shaft attachments at the upper end that all the literature of the medical sciences now extant would furnish less than two hundred cases of genuine congenital transposition of viscera, even if cases of the thoracic and of the abdominal viscera occurring sepa- rately, and also those of complete transposition of the organs of both these cavities, be included. Great care is required in cataloguing the bibliography of this subject, on account of the defective and misleading titles given to the articles and reports of many cases. I have found the term, transposition of viscera, employed in cases of mere displacements resulting from tumors, hernias, fluids, or other mechanical causes. To be entirely reliable, such lists should be verified by ex- amining the original of every reference. But for this ne- cessity, and the labor it in- volves, I should have ap- pended to this brief essay the bibliography which I have thus far collected. When the " Index Catalogue of the Library of the Surgeon-General's Office, U. S. Army," shall have reached the term Transposition of Viscera, students of this subject will have but little trouble in find- ing its literature. Definition.-Transposition of viscera is a malforma- tion, or a deviation from the normal type of the animal or- ganization, consisting not merely in a change of location of the organ, or organs, in their relations to others, but also in the relative position of the different parts-in fact, of every part of the transposed organs themselves. In the heart the ventricles, auricles, and vessels are reversed in position ; the same is true of the liver, its lobes, gall-blad- der, and vessels being left-sided instead of right-sided. It is not a mere turning over of the non-symmetrical organs. They are evolved and developed in the embryo right or left, as are the hands and feet, and other parts of the body which possess right and left symmetry. Hence all true cases of transposition are congenital, and not the re- sult of morbid processes. Transposition of a viscus, or of the viscera, cannot be acquired. As above indicated, this anomaly of organization may affect one organ and its appendages, as, for example, the heart and great vessels, with or without change of posi- tion in the heart; the lungs not being transposed. In other cases the transposition is complete, including both the thoracic and the abdominal viscera. Synonyms.-Transposition of the viscera. Lateral transposition of viscera. Transpositio viscerum lateralis. Dislocatio viscerum lateralis. Translocatio viscerum. Transplantatio viscerum. Situs viscerum inversus. Situs inversus mutatus. Situs viscerum transversus. Situs mu- tatus viscerum thoracis et abdominis. Situs perversus. Viscerum corporis inversa. Anomalies of position. Pre- ternatural position of organs. Heterotaxie. Reversed situation of the heart. Right-hearted. Dextrocardia. Dexicardia. Perversio cordis. Inversio cordis. All of the above titles I bave found at the head of re- ports of cases and observations on the subject. Etiology.-It is to embryology that we are to look for the only rational explanation which can be furnished of transposition of viscera. It has been observed that in the early embryo the heart is situated precisely in the median line, and that it gives off two arches which curve to either side and unite below into a single central trunk. These are the two aortae, and the single trunk formed by their union becomes the abdominal aorta. As the septum between the two ventricles makes its appearance, that di- vision of the right aortic arch which constitutes the vas- cular portion of one of the branchial arches becomes ob- literated, disappears, and loses its connection with the abdominal aorta ; a branch, however, persists during the whole of intra-uterine life and constitutes the ductus ar- teriosus, and another branch is permanent, forming the pulmonary artery. During the sixth week, the heart is vertical and situated in the median line, with the aorta arising from the centre of its base. At the end of the second month, it is raised up by the development of the liver, and its apex presents forward. During the fourth Fig. 4070.- Gihon's Ambulance Cot Rolled up for Stowage. and by drag-pieces or low trucks at the other, enables it to be used as a horse-litter, or as a combined hand- and horse-litter, like those devised by Surgeon Charles R. Greenleaf, U. S. Army, and Assistant Surgeon Peter J. A. Cleary, U. S. Army (see Fig. 1182 on p. 142 of Vol. III. of this work). Its lightness and compact stowage permit its ready transport, while the fixed bands and terminal cords allow the safe fastening of the wounded or helpless sick man to the cot, and prevent his falling out, with the least possible disturbance of an injured limb, which is separately and immovably secured. Albert L. Gihon. 1 Hygienic and Medical Reports by Medical Officers of the United States Navy, vol. iv., pp. 1018-19, Bureau of Medicine and Surgery, Navy Department, Washington, D. C., 1879. TRANSPOSITION OF VISCERA. Anomalies of posi- tion in various organs of the human body are occasionally observed during life; but, for the most part, the preter- natural situations of organs are discovered in the course of post-mortem examinations, or in the dissecting-room. Malposition of an organ may result from mechanical causes, as from violence, blows, kicks, etc., or from the pressure of morbid growths, or the accumulation of fluid in natural cavities or adventitious cysts. Thus the heart and lungs may be displaced to the extent of transposition by pleuritic effusion, or by diaphragmatic hernia. Cases of this kind are to be regarded as ac- quired, and belong to morbid anatomy and general pathology. This essay is only concerned with congenital transpositions of one or more organs, and, strictly speak- ing, pertains to the science of teratology. Literature.-The writer was very much surprised, on turning his attention to this subject, to find how little has been written upon it. Encyclopaedic works, such as Ziemssen's and the " Cyclopaedia of Anatomy and Physiology," are entirely silent on this topic. There is no treatise, nor even an extended essay, on transposition of viscera in the English language. The reported cases are extremely rare. A careful search through the seventy volumes of Rankin's " Abstract," and the ninety-six volumes of Braithwaite's "Retrospect," resulted in fail- ure to find a single case. The whole series of thirty-eight volumes of the "Trans- actions of the Pathological Society " of London, contains only a half-dozen cases, and the seventy volumes of " Medico-Chirurgical Transactions" a still smaller num- ber. The same may be said of other extended series of periodical medical literature. The statistics of transposi- tion of the viscera were collected, with much care and labor, by Wenzel Gruber, and published in the year 1865 in Dubois-Reichert's "Archives." Uis list con- tained references to seventy-nine cases. Dr. Scheele added fourteen cases and references in 1875 (Berliner Jclin. Wochenschrift, 1875, No. 30, p. 419). I have found a considerable number of cases which either had been overlooked by these authors, or have been published since the date of their contributions. It is quite probable 241 Transposition. 'Transposition. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. month, it is twisted slightly upon its axis, and the point presents to the left. [" Flint's Human Physiology."] This is the anatomy of man and most of the mammalia. In birds the relative positions of the heart and great vessels are quite different. The situation of the heart is more anterior and mesial than in mammalia, and its axis is al- ways parallel with the axis of the trunk. Its apex is lodged between the lobes of the liver, the diaphragm not being so far developed in birds as to separate the chest from the abdomen. One of the most distinctive characteristics in the ar- terial system of birds from that of mammals is the course of the arch of the aorta over the right instead of the left bronchus to become the descending aorta. It is a very significant and interesting fact, that almost every irregularity hitherto observed in the course and branching of the aorta in the human subject, represents the disposition which that vessel constantly exhibits in some of the inferior animals. This is also true of the anomalies of the human heart. Are not these facts forci- bly suggestive of retrocessive evolution ? It is not easy to explain any of the numerous deviations from the strictly normal or typical laws of organic development which are not infrequently observed to have occurred both in the vegetable and in the animal kingdoms. Cer- tain it is that cultivation in plants, and domestication in animals have produced very marked deviations in their structure ; and while we know the facts, we are ignorant of the modus operandi by which these variations have been wrought. Almost all the malformations which teratologists have described are the result of arrests of development at certain stages of embryonic evolution. We cannot tell what occasioned the arrest, or how the cause operated. A slight perturbing element may have tilted the sensi- tive balance which weighs the non-symmetrical organ, so delicately poised at the time when it occupies the median axis of the body, and have given it the opposite direction from that which it ordinarily takes. And so the heart and great vessels would pass to the right instead of to the left side of the chest ; and the same also with the abdominal viscera. Sinistral, or reversed, varieties of spiral shells have been met with in some of the very common species, like the whelk and garden-snail. Bulimus citrinus is as often sinistral as dextral; and a reversed variety of Fusus an- tiquus was more common than the normal form in the pliocene sea. Other shells are constantly reversed, as Pyrula perversa, many species of Pupa, and the entire genera Clausilia, Cylindrella, Physa, and Triphoris. {Vide Woodward's "Manual of the Mollusca," London, 1856, p. 46.) What tilted the balance of bilateral sym- metry to the left ? Why does it almost invariably tilt to the right ? Why should it not always remain evenly balanced, and thus render all the species bilateral and symmetrical ? Were this last the case there would be no spiral shells. Von Baer offers the following theoretical explanation of transposition, or situs mutatus, of the non-symmetri- cal viscera. "The embryo of a bird during the first thirty-six hours lies with its abdominal surface down- ward ; but in the course of the third day of incubation in the egg of the common fowl a change of position occurs, so that the left side of the embryo comes to be laid on the adjacent surface of the yolk." In rare instances, Von Baer having noticed in the eggs of birds, and in the ovum of the pig, the embryo lying with its right side toward the yolk, he was led to believe this to be the explanation of transpositions of the viscera. Ingenious as this hypothesis is, it is unfortunately wanting in proof, and does not appear to explain the ab- solute reversion, or right and left symmetry, such as we see in the double organs ; as in the hands and feet, hemi- spheres of the brain, and other parts. The law of bilat- eral polarity, by which the symmetrical balancing of parts on the two sides of the median axis of the embryo is produced, would seem to aid us in the solution of this problem. In the case of double monsters, the two indi- viduals are right and left, and the single organs, as the hearts, livers, spleens, stomachs, etc., are relatively placed in bilateral symmetry, by transposition, as much as are the hands and feet in a single body. The original dis- turbing influences which may have acted in the earlier stages of embryonic development, resulting in deviations from the normal type, are so occult in their nature as to defy all our present means of investigation, and hence at this time the genesis of these variations remains obscure and unexplained. Transposition of viscera may be complete, or it'may be limited to the organs of the thorax, or of the abdo- men. A few cases and references will be given under each of the following heads. I. Transposition of the thoracic and the abdominal vis- cera. Case 1.-One of the earliest reported cases of this kind is that of the celebrated anatomist Riolanus, of Paris. This will be found in his Opuscula anatomica raria et nova, 1652, p. 123, under the title " Disquisitio de trans- positione partium naturalium et vitalium in corpore hu- mano." Case 2.-Thomas Bartholinus : " Viscera corporis in- versa." Hist. Anatom. Rariorum, 1654. Cent. II., Hist, xxix., p. 219. In dissecting, at Paris, in 1650, a case of transposition of all the viscera was observed. (It is possible that this may be the same one described by Riolan.) Case 3.-Dr. Sampson, Philosoph. Trans., London, 1674, vol. ix., p. 146, gives a good report of a case of complete transposition of the viscera of both the thorax and abdo- men in a man thirty years of age. Sampson says he was not left-handed. This case is quoted at length by Will- iam Lawrence, in his article on Monsters in " Medico- Chir. Trans.," 1814, vol. v., pp. 178-79. Case 4.-" Sur une transposition des visceres." Sue, Mem. de math, et phys. de. I'Acad. Roy. des Sei., tome i., pp. 292-294. Paris, 1750. Case 5.-" An account of a remarkable transposition of the viscera." Matthew Baillie, in a letter to J. Hunter. Phil. Trans, of the Roy. Soc. of Lond., v. Ixxviii., 1788, Part 2, pp. 350-363. Also in Duncan's " Med. Commenta- ries," December 2d, vol. iii. (vol. xiii. of whole series), pp. 427-429. Man aged forty (in dissecting-room), complete transposition of the thoracic and abdominal viscera. In this case six distinct spleens were found, all supplied with branches of the splenic artery. Case 6.-" Sur une transposition generale des visceres." Beclard. Pull, de la Fac. de Med. du 12 Decembre, 1816. Case 7.-" Transposition of Viscera." Scoutetten. Journ. Univers., Avril, 1823. Also in Edinburgh Med. and Surg. Jr., vol. xix., 1823, p. 652, and in Froriep's Notizen, Bd. vi., No. 8, p. 128. Erfurt, 1824. " I know not," says M. Scoutetten, "whether I have been favored by chance, or whether transpositions are more frequent than we generally imagine ; but it is re- markable that I have met with three examples of the kind in less than a single year." All were in young sol- diers, over twenty years of age. In one the diagnosis was made during life. He was struck with " the extreme precision with which the viscera of the opposite sides oc- cupied the places of one another." Case 8.-" Cas de transposition des visceres recuelli a I'hopital Cochin." Dubled. Arch. (finer. de Med., Ser. I., Ann. 2, tome 6, Paris, 1824, pp. 573-577. Case 9.-Transposition of Viscera. M. Grisolles. Archives Gen., March, 1835. Also, Lancet, II., May 9, 1835, p. 179. Transposition of the principal viscera. The subject was not left-handed. Case 10.-" Report of a case of transposition of the vis- cera." Thomas Chaplin. Lancet, vol. ii., p. 478, 1854. (Am. Ed., vol. i., 1855, p. 138.) Female aged one year and ten months, died July 8, 1854. Heart and aorta on right side. Left lung three lobes, right two. Stomach, spleen, sigmoid flexure, to right. Large lobe of liver to left. In short, complete transposition of the viscera of thorax and abdomen. Case 11.-"Case of transposition of viscera," etc. Al- bert H. Smith. N. Am. Medico-Chir. Rev., vol. iii., p. 242 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Transposition. Transposition. 681, 1859. Man aged thirty-five. The autopsy revealed extensive effusion in the left pleura, heart and aorta on the right side, venae cavae to left. Spleen, stomach, de- scending colon, sigmoid flexure, and rectum all on the right side. The liver, with its largest lobe, on the left. The left lung had three lobes, the right two lobes. Case 12.-"Transposition of the thoracic and abdom- inal viscera." Ibid. Adinell Hewson, of Philadelphia, at the time of the autopsy in the above case (A. H. Smith's), mentioned a similar case that had come under his notice. Case 13.-M. Gachet in La Gazette des Hopitaux (31 Aofit, 1861). Referred to by Dr. Pye-Smith, in report of case 15 of this list. Not left-handed. Case 14.-"Complete transposition of all the thoracic and abdominal viscera." Edward Parker Young. Lancet, June 29, 1861. (Am. Ed., September, 1861, p. 176.) Also, in N. Am. Medico-Chirurg. Rev., vol. v., p. 926, 1861. Lady aged eighty-five. The apex of the heart reached to the lower border of the fourth rib un- der the right mamma. " The venae cavae were situated on the left side, passing into the pulmonary cavity of the heart, which was also on the left side; the aorta sys- temic ventricle to the right; so that not only was the heart reversed in position, but also in formation." The liver was on the left side. The stomach and spleen to the right, as was also the sigmoid flexure of the colon. Case 15.-" Lateral transposition of the viscera." Pye- Smith. Trans. Patholog. Soc. of London, vol. xix., p. 447, 1867-68. "Old woman" at Guy's Hospital. "It affected the whole of the contents of the thorax and ab- domen, all the transposed organs preserving their rela- tive position unchanged." She was not left-handed. Case 16.-" Case of complete transposition of the vis- cera diagnosticated during life." James H. Hutchison. The American Jr. of the Med. Sci., N. S., vol. Ivi., p. 294, July, 1868. Man, aged twenty-eight, in good health ; careful examination proved the heart to be completely on the right side, apex pulsated near right nipple at fifth costal interspace, liver to left side, stomach to right. Rectum ascended to right. Man right-handed. Examined by several. Case 17.-" Malformation of heart ; transposition of auricles and of aorta ; absence of pulmonary artery, etc., with transposition of principal viscera; cyanosis." William Hickman. Trans. Pathol. Soc. of Lond., vol. xx., p. 88, 1868-69. Male, aged six weeks. "The lungs, liver, stomach, and spleen were all completely trans- posed." "The heart, although to all intents and pur- poses transposed, yet actually occupied its usual position and direction in the thorax." Aorta and venae cavae transposed. Case 18.-" Transportation of viscera." William Hick- man (Ibid., p. 93, two plates). Female, aged twenty- eight years. Diagnosis clearly made during life, was confirmed by autopsy. Heart and aorta to right of thorax. Liver to left. Nine little spleens-splenculi (In Dr. Baillie's case, six were found)- and the stomach to the right side. Case 19.-"Complete transposition of the viscera." Thomas Lowne. Descrip. Cat. of the Teratological Series in the Museum of the Royal Coll, of Surgeons of England. London, 1872, p. 4., No. 18. The trunk of a human foe- tus. Mus. Heaviside. Case 20.-(Ibid.) No. 19. An injected and dried preparation of the heart and large vessels, with some of the abdominal viscera, of a human adult, in which all the parts are transposed. Cases 21-24.-" Zur casuistik des situsviscerum muta- tus." Inaug. Diss. George Burgl. 8vo, p. 21. Miincheu, 1876. This dissertation contains reports of four original cases of transposition of all the viscera ; also references to the literature of the subject. Case 25.-"Transposition of the viscera in a living subject." David B. Lees. Trans. Path. Soc. of Lond., 1876-77, vol. xxviii., p. 448. Boy, aged eight years. The diagnosis was clearly made of transposition of thoracic and abdominal viscera. He was right-handed. Cases 26-28.-"Beitrage zum SitusViscerum inversus." Inaug. Diss. Nicolaos G. Potamianos. 8vo, pp. 47. Ber- lin, 1879. This thesis reports three original cases of complete transposition of the thoracic and abdominal viscera. It also contains Gruber's catalogue of references to seventy- four cases. Case 29.-" Ein seltener Fall v. Situs inversus der Un- terleibs-Organe." Inaug. Diss. H. Herberg. Berlin, 1882. Spurious Cases of Transposition of the Viscera. The following cases are entered to show the error of reporting them as transpositions of viscera in the techni- cal sense. I have found a number of this kind in the course of my searches for genuine cases. Case 29*.-"Case of transposition of the abdominal viscera, etc., in a child aged six weeks." Wm. Campbell. Edinburgh Med. and Burg. Jr., vol. xvii., p. 513, 1821. This is a case of diaphragmatic hernia, all the ab- dominal viscera, excepting the liver and kidneys, had entered the left pleural cavity, and pushed the heart and left lung into the right side of the chest. Case 29**.-" A case of transposition of the greater part of the abdominal viscera into the cavity of the thorax." Henry W. Bailey. Trans, of the Obstetrical Soc. of Lon- don, vol. x., 1869, p. 6. " The liver -was drawn to the left side, occupying the situation of the stomach." " The heart was pushed into the right side and placed between the right nipple and axilla." The case was a foetus at full term, which expired a few moments after its birth. As the intestines were found in the thorax, it was a case of congenital diaphragmatic hernia, which drew and pushed the liver and heart into transposition. II. Transposition of the Heart and Great Vessels. Case 30.-" Uncommon transposition of the heart, and distribution of the blood-vessels; together with a very strange, singular formation of the liver." John Aber- nethy. Phil. Tr. Roy. Soc. of Lond., 1793, pp. 59-63. Also in Med. Facts and Obs., London, 1797, vii., 100-106. Case 31.-" Ueber Transposition der Aorta und Arteria pulmonalis in dem Herzen eines neugebornen Mad- chens." B. Beck. Arch. of physiol. Heilk. Stuttgt. 1846, 288-295, 1 Pl. Case 32.-Case of Monopodia (sympodia), in which '' the thoracic viscera exhibit situs mutatus, or trans- position." Specimen presented by J. F. Stedman, 1864. Th. Lowne, Descrip. Cat. of the Teratological Series in the Royal Coll, of Surg. of England. Lond., 1872, No. 234-236, p. 58. Case 33.-(Ibid.) No. 387, p. 89. " Foetal heart and great vessels reversed." Case 34.-"Transposition du coeur a droite." A. Ac- colas. Jr. de Med. et Chir. Prat., Paris, 1875, xlvi., 258- 260. Case 35.-" Zur Geschichte der congenitalen dextro- cardie nebst mittheilung iiber einen diese missbildung vertauschenden krankheitsfall." Inaug. Diss. Arnold Krieger. 8vo, pp. 42. Berlin, 1880. III. Transposition of the Great Vessels, without Change of Position of the Heart. Case36.-"Case of transposition of the aorta, trachea, and oesophagus," etc. Henry Ewen. Guy's Hosp. Re- ports, series I., vol. v., p. 233, 1839. This case is badly reported. Case 37.-"Case of cyanosis depending upon trans- position of the aorta' and pulmonary artery." W. H. Walshe. Trans. Med. Chir. Soc., vol. xxv., pp. 1-4, 1842. Male aged ten months. Aorta arose from right ventricle, pulmony artery from the left. Position of the heart normal. Abdomen not opened. Dr. Walshe, in a note, states that he has only been able to find reports of six other cases. Case 38.-"Caseof transposition of the aorta and pul- monary artery ; with remarks on the causes of communi- cation between the two sides of the heart." T. W. King. Month. Jr. Med. Soc. of Lond. and Edinb., 1844, iv., 32-34. Case 39.-"Cyanosis produced by transposition of the orifices of the aorta and pulmonary artery." Car- ter P. Johnson. Am. Jr. of the Med. Sci., A. S., vol xx., p. 243 Transposition. Trepanning. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 370, October, 1850. Also, Br. and. For. Med. Chir. Rev., vol. vii., p. 260, January, 1851. Mulatto child, lived two months, cyanosis constant. "The pulmonary artery and aorta lay side by side from their origin to the division of the former, the aorta on the right and somewhat in front, the pulmonary on the left a little behind." Case 40.-"Transposition of the aorta and pulmonary artery." O. Ward. Tr. Path. Soc. ofLond., 1850-51, vol. iii., 63-65. Case 41.-"Both auricles opening into the left ven- tricle, and transposition of the aorta and pulmonary artery." T. B. Peacock. Tn. Path. Soc. of Lond., 1855, vi., 117-119, 1 Plate. Case 42.-" A case of transposition of the great vessels of the heart." John Cockle. Medico-Ghir. Trans., vol. xlvi., pp. 193-205, 1 Plate. W. L. died November, 1858, aged two years and four months. Aorta arose from the right ventricle ; pulmonary artery from the left. Intense cyanosis. Dr. Cockle's article (Op. cit.) contains a valuable table of forty-three cases of transposition of the great vessels ; also, citations of twenty-six authorities on the subject. Case 43.-"Transposition of the arteries." J. F. Meigs. Proc. Path. Soc. of Phila., (1860-66), vol. ii., pp. 37-40, 1867. Case 44.-" Malformations of the heart; transposition of the great vessels ; cyanosis." C. Kelly. Trans. Path. Soc. of Lond., 1870-71, vol. xxii., p. 92. Male, aged two months, died November 4, 1870. Heart in normal position. Aorta from right ventricle, pulmonary artery from left. "The venae cavae opened into the right auricle, and the four pulmonary veins into the left auricle. These cavities communicated by means of a patent foramen ovale, large enough to admit a goose quill." No other malformations. Dr. Kelly remarks, " Over forty cases have been at various times recorded of transposition of the great vessels, but in most there has been some other deficiency, either of the heart or in the distribution of the vessels. Four only are narrated in which, with the transposition only, an open foramen ovale has been associated. Cyanosis is nearly always present from soon after birth to the time of death, which occurs in a few days, weeks, or months, and rarely later than the third year." Case 45.-"Transposition of the aorta and pulmonary artery." P. H. Pye-Smith. Trans. Path. Soc. of Lond., 1871-72, vol. xxiii., p. 80. Male, aged fourteen weeks. Died January 28, 1872. Aorta from right ventricle, pulmonary artery from left. The vessels of the auricles were normal in position. Heart and all the abdominal viscera normally located. Cyanosis marked. Case 46.-"Situs transversus der aorta und der lung- enarterie." A Ogston. Oesterr. Jahrb. f. Paediat., Wien, 1873, iv., 169-172. Case 47.-" Case of malformation of the heart, with transposition of the aorta and pulmonary artery." David B. Lees. Trans. Path. Soc. of Lond., 1879-80, vol. xxxi., p. 58. Male, aged seven months. Aorta from right ventricle, pulmonary artery from left. Cyanosis intense. Case 48.-" A case of transposition of the aorta and pulmonary artery in a child of seven months." H. Ash- by. Jr. of Anat, and Physiol., London, 1881-82, xvi., 90-93. Case 49.-"Transposition of aorta and pulmonary artery." Dr. Peacock for Dr. Ashby. Trans. Path. Soc. of Lond., 1881-82, vol. xxxiii., p. 49. Female, died, aged seven months. " The aorta arose from the right ventricle and the pulmonary artery from the left." Dr. Lees has followed the report of his case (see 47) with some very interesting observations concerning the relation of transposition of the great vessels and the usu- al attendant malformations, to cyanosis, which so often accompanies these abnormalities. He maintains that cyanosis is due in all cases to some obstructive condition which results in defective aeration. Mere transposition of the heart and great vessels, unaccompanied by other malformations which could cause obstruction to the flow of blood, would not be attended by cyanosis. The theoretical suggestion of a relation of left-handed- ness to transposition of the viscera, seems to be definitely proven to have no existence. In many of the cases the reporters have stated that the subject was known not to have been left-handed, and in no case is it stated that the subject was not right-handed. The diagnosis during life of transposition of the heart, of the stomach, liver, and sigmoid flexure, would seem not to be difficult. Auscultation, percussion, and palpa- tion, practised with ordinary care and skill, are sufficient to establish a positive diagnosis. The differential diagnosis of transposition from mal- formations, and such as results from displacements by tumors, or fluid accumulations, diaphragmatic hernia, etc., ought to be readily determined by the same methods of exploration. It is a curious fact that three-fourths of the cases have occurred in males. George Jackson Fisher. TRANSUDATIONS. In normal transudations the com- ponents are usually those of the blood-plasma, but the proportion of albumin is always less, while fibrin is gen- erally wholly absent. The aqueous humor is distin- guished by containing a relatively large quantity of urea and a substance reducing Fehling's solution. As referable to the lymph are such fluids as cerebro- spinal, the aqueous, and vitreous humors. The only albuminous matter in the first is soda albuminate. The following table will indicate most of what is known in regard to the chemistry of transudations ; Constituents in 1,000 pabts. Cerebro-spinal fluid of man. (Schtscherbakow.) Cerebro-spinal fluid from the dog. s u □ Aqueous humor of the calf. (Lohmeyer.) Vitreous humor of the eve. (Lohmeyer.) Pericardial fluid of man. (v. Gorup-Besanez.) Synovia of a new- born calf. (Frerichs.) I Synovia of a stalled ox. (Frerichs.) Synovia of a past- ured ox. (Frerichs.) iquor amniL (Scherer.) Tears. (Lerch.) Water Solids ... Fibrin Membranes Mucus-like matters Fats Albumin Extractives Inorganic salts Potassium chloride Sodium chloride Potassium sulphate Sodium phosphate 989.90 10.10 1.85 t 8.14 5.42 988 11 2 9 3 5 2 8 4 4 5 o u 986 13 1 4 7 o 6 • 87 13 22 21 70 11 89 22 986 13 0 1 3 8 0 7 0 ■10 60 fl 36 22 80 61 76 15 955.13 44.87 0.81 21'68 12.69 6.69 965.7 34.3 3.2 0.6 J 19.9 10.6 969 30 'i 0 15 11 9 1 4 6 7 3 948.5 51.5 '5'6 0.7 35.1 9.9 991.04 8.60 0.82 0 60 7.10 982 18 5 13 13 0 0 6 2 c Soda ; Calcium phosphate Magnesium phosphate Lime • 0 6 0 47 "o 0 0 io 03 13 244 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Transposition. Trepanning. To transudations, in the narrower sense, belong such as synovia and pericardial fluid. T. Wesley Mills. TRENCSIN-TEPLITZ is a Spa in Hungary, lying among the foot-hills of the Carpathian Mountains, at an elevation of about 550 feet above the level of the sea. The climate is somewhat raw. There are numerous sulphur springs in the place, one of which, the Briinnlein, is used for drinking, and six for bathing. The follow- ing is the composition of the Briinnlein. Each litre con- tains : Grammes. Sodium chloride 0.174 Sodium sulphate 0.062 Potassium sulphate 0.090 Calcium sulphate 1.177 Calcium carbonate 0.330 Magnesium sulphate 0.575 Organic matters, etc 0.041 Total solids 2.449 Sulphuretted hydrogen gas is present in considerable amount. The Springs are visited by sufferers from gout, rheu- matic affections, tubercular joint diseases, and syphilis. The waters have been used also in the treatment of pul- monary phthisis by Bergeon's method of gaseous rectal injections. Almost the only internal use that is made of the water is in the treatment of those with pulmonary affections, and with gout. T. L. S. TREPANNING ; TREPHINING. By common consent these terms are applied, not merely to the application of that form of circular saw known as the trepan (or diminutive trephine), but to any procedure by which a piece of bone is elevated, or is removed, in order to per- mit the elevation of some adjoining portion. This re- moval may be effected by means of a straight saw, Hey's saw, or the cutting bone-forceps. The opera- tion dates back to the remotest an- tiquity, and seems to have been observ- ed at various times among various peo- ples as a rite or ceremony. Except when performed by sur- geons, it seems to have been done usually with the rudest of imple- ments, and even the instruments used by the previous generation of surgeons were in most respects clumsy and coarse. Indications.-1. Simple fractures, with signs of com- pression. 2. Compound fractures, with depression, even without Fig. 4073.-Galt's Trephine. of this Handbook, where, under the head of " Fractures of the Skull," I have considered these indications in greater detail.) Fig. 4074.-Crown Trephine. 4. Coma, with signs of compression, contusion, or laceration of soft parts, without fracture of the external table. 5. Haemorrhage. The operation is done in this case either to tie a vessel or to remove a clot. This is partially included under heading 4. 6. Abscess of brain. 7. Tumor of the brain or meninges. 8. Bone abscess in the frontal sinus, mas- toid process, etc. 9. Purulent meningitis, the object here being to wash out the suppurat- ing cavity. 10. Acute infectious osteomyelitis of the diploe. 11. Epilepsy or insanity, when any lesion can be local- ized with sufficient definiteness. Fig. 4075.-Hey's Saw. Fig. 4076.-Hey's Saw. Each one of the foregoing conditions is an indication for working through and underneath one or both tables of the skull, in order to effect whatever may be possible be- neath the level of the bone re- moved. The various condi- Fig. 4077.-Rongeur or Bone-gnawing Forceps. tions are discussed in their appropriate places ; we speak here only of that which pertains to the operation proper. Fig. 4071.-The Operation of Trepanning in the Early Part of the Last Century. (From Heister.) Fig. 4078.-Van Buren's Trepanning and Sequestrum Forceps. Dangers.-The South Sea Islanders scrape through each other's skulls with pieces of glass, we are told, and with impunity. Among the Cor- nish miners the operation was re- cently, according to Michel (Amer- ican Journal of the Medical Scien- ces, October, 1879) one of daily occurrence. The Count of Nassau was tre- phined by Chadbourn some twenty-seven times. And all this at a time when, or among a people where, fear of sep- signs of compression, except over the frontal sinus, in adults. 3. Punctured and gunshot fractures, even without symptoms. (The reader is referred to p. 526, Vol. III., Fig. 4072.-Trephine Handle. Fig. 4079.-Liston's Bone Forceps, Curved on the Flat. 245 Trepanning. Trepanning. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. sis has not prevailed. And yet, until very recently, there has been a recognized school of practising surgeons who have uttered sol- emn warnings against even a properly discrim- inating resort to the procedure, and fierce wordy battles have been waged concerning it. But the medical profession is now almost a unit in favor of a diagnostic use of the instru- ment, as it is in favor of an exploratory abdominal sec- danger. Patients frequently die after trephining, but very seldom because of it. This statement cannot be too strongly emphasized. Moreover, the operation is frequently too long delayed. Michel's dictum, " The early trephine is gold, the late tre- phine is lead," should sink deeply into the mind of every- one who may ever be compelled to use the instrument. This obtains especially with regard to fractures of the skull. Much better is it to make a puncture and then find it unnecessary to proceed further, than it is to have it appear later that early operation might have saved a life. The Operation.-Instruments.-Besides the usual scalpel, forceps, periosteum elevator, luemostatic for- ceps and retractors, one needs to be provided with a con- ical trephine, a bone elevator or its equivalent, a Hey's and a metacarpal saw, bone-cutting forceps of one or more patterns, a hammer, and a chisel or gouge. Two forms of trephine are shown in Figs. 4073 and 4074. The straight or crown trephine cuts more quickly, but is more likely to do harm when carelessly used ; with the conical instrument one goes more slowly through the bone, but more safely. Figs. 4075 and 4076 show two different forms of Hey's saw ; an instrument but rarely used, and which can be substituted by bone-cutting for- ceps or by the chisel. Of forceps, those represented in Figs. 4077, 4078, 4079, and 4080, will be found very ser- viceable. The mallet and chisel shown in Figs. 4081 and 4082 will also be found well-nigh indispensable. Everything being prepared as for every aseptic opera- tion, the patient's scalp should be carefully shaved and cleansed. If he be in a condition of coma no anaesthetic will be required ; if he be restless though unconscious, chloroform should be administered. An existing wound may be utilized, for purposes of exploration at least. If there be no external wound, an incision should be made ; and this the writer prefers to make U-shaped, in such a way that, as the patient lies on his back, the wound may drain by virtue of gravity from the cut made by raising this U-shaped flap. A flap of scalp is thus made over an area as large as may seem indicated. Haem- orrhage, which will usually be quite free, must be checked by means of the haj- mostatic forceps. The pericranium is then raised, over a small area if it be merely for the exploratory use of the tre- phine, or from the entire area of the depressed bone which is to be re- moved, if such a measure seem in- dicated. Supposing that we have to deal ■with a compound fracture where the depressed bone is yet not easily removed, the sole object in trephining is to make an opening through which leverage can be exerted and instruments introduced. In order to use it to advan- tage it must therefore be planted on a rigid and unyield- Fig. 4080.-Liston's Bone Forceps, Knee Curve. Fig. 4081.-Lead Mallet. tion. We are now in a position where one may boldly affirm, even in courts of law, that trephining is not, by it- self, a dangerous operation, when properly done, but it must be insisted that the proper performance of the operation includes the most careful attention to antiseptic or asep- tic measures. When these are rigorously carried out the Fig. 4082.-Bone Chisel. Fig. 4083.-1, A Skull Showing Various Examples of Fracture. (After Charles Bell.) A, A triangular portion of the os fron- tis fractured and depressed. B, The three perforations found necessary for its elevation and extraction ; the second and third were rendered necessary by the fact that the edge of the inner table lay under the sound bone. D, a point where the trephine was employed for a fissure of the os frontis represented on its right side; a second perforation was made in the sound bone a little higher up, still the bone could not be extracted ; the trephine was then applied at E, and the bone lifted up. It should have been applied at E in the first place. F, A fracture with depression at the lower angle ; the trephine was placed at G ; it ought to have been a large one, and placed at H, by which a portion of the bone would have been saved and a more favorable form of opening obtained; by perforating at G an acute angle of bone was left between G and F. operation is no more dangerous than the amputation of a finger with the same precautions. The condition which necessitates the operation constitutes the main element of 246 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Trepanning. Trepanning. ing bony surface. The exigencies of the case can alone make it clear just where this spot may be. Unless it be absolutely unavoidable, the trephine should not be ap- plied in the middle line (over the superior longitudinal sinus), nor over the course of any of the large sinuses or vessels, e.g., the middle meningeal. The instrument is provided with a centre-pin which is thrust forward a lit- tle beyond the level of the teeth so as to secure accurate implantation and prevent sliding. A good way to begin "Illustrations of the Great Operations of Surgery" (London, 1821), with their commentary and explanation, will serve to illustrate much better than a long descrip- tion some of the practical points in the operation. This is the classical operation with the trephine. With the removal of the disk of bone the first part, at least, of the operation is ended ; depressed bone may be elevated, pus or blood evacuated, etc. Still it may be found that one such opening is not enough. In this case another suitable position is selected and the manoeuvre is repeated, once, twice, or thrice if need be. By means of openings thus made suffi- cient room may be secured for any further proceeding. Or, after one perforation a saw may be utilized for the removal of a projecting por- tion of bone, or the chisel and mallet can be advantage- ously utilized. Indeed many of the German surgeons pre- fer, as a matter of routine, to do all the perforative work with the point or edge of a chisel. But it usually takes more time to do this, unless one uses the mallet pretty vigorously, and such repeated concussions of the skull, slight though each one may be, seem calculated to injure the patient. Fig. 4088, shows the use of the cutting pliers in removing spurs of bone, and these or the chisel must be used to round off all rough edges and to remove any possible source of dural irritation. Among the few who have it at command, the surgical engine will be found admirably adapted for this kind of work, since after using its circular saws the burr can be inserted and the rough bone margins smoothed down neatly and with ease. When the opening through the skull has been made for exploratory purposes, or when the contour of the cir- cular aperture has not been disturbed, the disk of bone Fig. 4084.-2, The piece of bone removed from A, with its inner table projecting beyond the outer. 4, The button of bone re- moved in order to elevate the fragment represented in 3. Here by careless work the surgeon might have pressed on the de- pressed portion with the trephine, and thus depressed and chafed the dura. 5 and 7, Buttons of bone having inequali- ties on their lower surfaces, showing the necessity for extreme caution during the operation. 6, Another button having con- siderable inner table attached to it, as occurs when the surgeon is obliged to break up the circular portion. is to make a little depression at the point where one de- sires to place the centre-pin, by the point of a chisel and a few light blows with the hammer. The trephine is then applied perpendicularly to the plane of the skull and worked by an alternating motion (pronation and supina- tion of the operator's hand) till its teeth have cut a circu- lar groove. The centre-pin is then withdrawn, and the trephine is again applied with the same motion till it has cut through the outer table. Its entrance upon the diploe will be known by the free flow of venous blood. It should now be handled with extra precaution, and a probe or fine-pointed instrument should be frequently passed around the groove to ascertain if the inner table have yet been perforated at any point; if so the instrument must be made to bear upon the opposite side of the cut. At last, when a locking of the instrument, combined with a definite but indescribable sensation, makes the operator aware that he has nearly perforated the inner table all around the cut, the instrument may be gently rocked, and thus, by a little leverage, the button of bone is sprung loose and either comes out with the instrument, or is left somewhat tilted in its place, attached perhaps by dural adhesions or undivided spiculae of bone. A probe or the point of an elevator will now dislodge it. After removal the best modern practice calls for its speedy deposition in the folds of an antiseptic towel or between two sponges, and temporary preservation in a warm place in case it may be found wise to restore it to its former position before suturing the wound. We have spoken of the diploe ; the reader must remember that children and the aged have no such tissue be- tween the two compact outer and in- ner cranial surfaces, hence he must not look for the sign of its perfora- tion mentioned above, i.e., free ve- nous oozing, nor for the diminished resistance to the hand, nor the altered character of the detritus thrown up by the saw. Moreover, skulls vary in thickness within wide limits. The skull of the colored race is proverbially thick, yet we find just as thick ones in individuals of the white races. The better rule, then, to follow is to act as if each skull were very thin. As every one should know also, its inner surface is liable to be very irregular ; therefore, to cut through every particle of "bone would be to make a serious wound of the dura with the saw teeth. The accompanying illustrations from Charles Bell's Fig. 4085.-2. Sketch of the Fractured Bone ; A, B, C, the three portions of the fractured bone, with depressed edges, which, being sharp, are irritating the dura ; they must therefore be removed. They are, moreover, so separated from their attachments as to have lost their vitality. There being no " purchase " for the elevator, the trephine is applied at D, and the broken pieces ele- vated and picked away. 3. Two disks of bone cut by the trephine, showing the varying thick- ness of the skull. 4. Exfoliation of bone after use of the trephine. 5. Button removed by the trephine, showing the two tables of the skull with diploe between. which was removed, and which should have been kept in a clean, warm, and moist place (ride supra), should be utilized for the closure of the defect; in other words, a species of osteoplasty may be practised. A little notch is cut, for drainage purposes, on the edge, at what will be its inferior margin when the patient is lying on his back ; it is then carefully replaced, the periosteum sutured above it, and over this the scalp, as usual. If the opera- tion has been, as it should be, aseptic, this portion of 247 Trepanning. Trifacial Nerve. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. might be better to use a very fine needle apd fine braided silk. When, however, suture of a sinus wall is impracticable, anti- septic gauze may be packed in, or a piece of absolutely aseptic sponge may be used as a compress and allowed to remain without attempting its subsequent removal. Even should a single sinus become obliterated from such treatment, no apprehension need be felt, as Schelhnann's researches have shown (Ueber ver- Utzung'der Hirnsinus). Injuries to the middle meningeal artery and its large branches are by far the most common of vascular le- sions, and when distinct hemiplegia and signs of compression, even without any external signs of fracture, make it probable that this vessel has been ruptured, it is a legiti- mate and well - recognized iteration to trephine over its course, find, and tie it, and remove any clot that may have formed. Par- ker {Med. Times, 1877, I., 91) trephined a case on one side, there being no external lesion, though coma was profound, and found nothing; he then trephined over the artery on the other side, and found no coagulum outside the dura, but, since the latter had a distended and bluish appearance, he incised it and removed a considerable amount of blood. In three days the patient became conscious, and then quickly re- covered. The middle meningeal is to be found about one and one-fourth to one and one-half inch back of Fig. 4086.-1, A Fractured Skull after the Application of the Trephine and the Removal of the Fragments. (After Charles Bell.) A, B, The flaps of integument; O the cranium ; D, the dura mater exposed. bone should be firmly united with its surroundings in a few days. But if there has been any failure in the pre- cautions such union cannot occur. Those who are un- skilled in such technique had better, perhaps, refrain un- til practice has made them sure. When the dura mater bulges into the wound, or appears very much discolored, one reasonably infers that it does so because distended by blood or pus within its cavity. In this case it is not only proper but indicated to incise it and explore further. If there be fluid blood it should be allowed to escape, and its source should be looked for. If a clot, then it must be gently broken down or dis- lodged with the probe or irrigating stream and washed away. If pus, the dura should be freely incised and its cavity washed out as thoroughly as possible, and subse- quent provision must then be made for drainage. We are discussing here the mechanical features of the op- eration rather than the theoretical and practical applica- tions of the measure, else we should be tempted to en- large upon the more wide-spread application of the same to purulent meningitis, whether traumatic or idiopathic. Bleeding vessels in the dura may be caught with the haemostatic forceps ; if the bleeding is not checked by this forcipressure, a curved nee- dle threaded with a catgut may be carefully passed under the vessels and the gut then tied. So also a wound of a sinus may b e treated, only it Fig. 4088. the external angle of the orbit. It runs sometimes quite- within the bone, sometimes in a groove on its inferior surface, and sometimes quite within or upon the dura. When operating for compound fracture every loose piece should be removed. A considerable area of bone, especially in children, is sometimes depressed without being broken loose. In this case it must be raised to its proper level by a combi- nation of dexterity and force properly ap- plied. So much of the periosteum must be saved as is clean and viable. Any portion which has had dirt or foreign material ground into it must be cut away. The scalp will adhere nicely to bare bone, and the periosteum is not neces- sary, though of advantage, especially over a bony defect. When the brain itself is injured, so Fig. 4087.-The Use of the Gouge and Mallet to Enlarge an Opening in the Skull. (Esmarch.) 248 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Trepanning. Trifacial Nerve. that portions of its substance come through the wound, there is not very much to do save to wash away, with extreme care, with a gentle irrigating stream, so much as will easily come away, and then provide for drainage. All indications having been met, there remains only to properly close and dress the wound. In a serious com- pound fracture with deep laceration, the dura should be sutured over the wound in the brain, leaving room for drainage either of catgut, horse-hair, decal- cified bone or rubber, ac- cording to the exigencies of the case or the prefer- ences of the operator. If it be so decided, the piece of bone may be replaced and the pericranium unit- ed over it in such a way as to hold it in place, still providing whatever out- let may be deemed best for the drains from be- neath. The periosteum is best sewed with catgut, and the union should be made as neat and com- plete as possible. Over this the scalp is united, preferably with catgut; silk or hare-lip pins being used only when considerable tension is expected, and with such attention to drainage outlets as the condition beneath demands, a fresh opening or a counter-opening being made if more direct outflow may thereby be secured. In an absolutely aseptic exploratory operation there will scarcely arise any occasion for drainage, and it will be enough to omit a suture here and there. When discharge of pus or any fluid is expected, it is well to provide for it in the dressing. In this case a piece of protective, perforated opposite the drain outlets, of sensation of the face and head, and, from its being fre- quently the seat of disease, is probably of more interest to the general practitioner than any of the other cranial nerves. It is a homologue of the spinal nerves, having a pos- terior, sensory root, provided with a ganglion-the Gas- serian or semi-lunar ganglion-and an anterior, motor root. The sensory root is by far the larger of the two, corresponding with the function of the nerve, which is preponderatingly sensory. Owing to the fact that its large centres in the medulla are in communication with the centres of many other of the cranial nerves, as well as with other parts of the brain, the reflex relations of the trigeminus are extensive and marked. The sensory root, immediately after emerging from the Gasserian ganglion, divides into three primary divisions, known as : 1. The Ophthalmic Division (d). 2. The Supra-maxillary Division (e). 3. The Infra-maxillary Division (g). The infra-maxillary division is joined just beyond the Gasserian ganglion by the motor root (this is not shown in the figure), so that it becomes a mixed nerve of motion and sensation. 1. The Ophthalmic Division (d) receives vaso-motor nerves from the plexus cavernosus of the sympathetic system, and passes into- the orbit through the superior orbital fissure, dividing into numerous branches which supply sensation to the upper eyelid, the cornea, the con- junctiva, the brow, forehead, temple, and scalp as far back as the vertex, and to the skin covering, and mucous membrane lining, the nose. It also sends a recurrent branch backward to the tentorium cerebelli, supplying it with sensation. This branch is joined by fibres of the sympathetic from the carotid plexus, which supply the tentorium with vaso-motor nerves. It seems probable that the occipital headache which often follows visual strain in those having some ocular defect, may be brought about by circulatory disturbances in the ten- torium, whose effects are carried to the consciousness as a painful sensation through this recurrent branch. True secretory fibres, whose stimulation causes secre- tion, and whose section prevents a reflex excitation of the flow of tears, are said to pass to the lachrymal gland. Reflexly, lachrymal secretion occurs through strong ex- citation of the retina by light (sneezing on looking at the sun is brought about by the tickling of the nose followr- ing the sudden gush of tears into it which excitation of the retina has produced), or from irritation of any of the sensory cranial nerves, but especially of the first and second branches of the trigeminus ramifying in the nasal mucous membrane. Connected with the ophthalmic division is the ciliary ganglion (c), considered by Schwalbe to be rather the spinal-ganglion of the oculo-motor than to belong to the trigeminus. This ganglion lies within the orbit, and has three so-called roots-a short, or motor, from the oculo- motor ; a long, or sensory, from the naso-ciliary branch of the ophthalmic division of the trigeminus (n c); and a Sympathetic (s), derived from the carotid plexus (8g). The short ciliary nerves have been spoken of under Third Nerve. The long ciliary nerves contain three kinds of fibres : 1. Sensory fibres to the cornea and conjunctiva, whose excitation causes reflexly winking and lachrymation; also to the iris, choroid, and sclera. 2. Vaso-motor fibres to the blood-vessels of the iris, choroid, and retina. Those to the iris are mostly from the trigeminus itself, while those to the choroid and retina come largely from the sympathetic. 3. Motor fibres, which dilate the pupil, and are largely derived from the sympathetic, though there are indepen- dent fibres derived from the trigeminus. 4. Trophic fibres-the existence of which has been much disputed. After division of the trigeminus within the skull there occurs in a few days-unless certain precautions to be described presently are taken-panophthalmia, finally Fig. 4089.-Capelline Bandage. Fig. 4090.-Four-tailed Cap for Vertex. Fig. 4091.-Four-tailed for Occi- put. may be laid over the wound, and this may be covered with such absorbent material as the operator prefers. But when no discharge is expected and it is desired to leave the dressings undisturbed till healing has occurred, it will be well to cover the wound with one or more thicknesses of iodoform gauze, and over this to apply in layers a smooth, equably distributed dressing, with some impermeable stuff outside. At all events, the dressing must be used unsparingly, and is better fastened on with a bandage of starched material. Outside of all a reten- tive bandage, like one or other of those here represented, will be found very serviceable. Sometimes an ice-bag applied to the head, or an ice-cap, will be found of ad- vantage, especially if oozing be feared. Many surgeons are fond also of administering an active purgative, which certainly is not without value in some cases. Roswell Park. TRIFACIAL NERVE (Trigeminal Nerve, Fifth Pair. For anatomy see under Cranial Nerves, Brain, Pons Varolii, and Medulla Oblongata) is the principal nerve 249 Trifacial Nerve. Trigger-Finger. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ending in destruction of the eyeball. This was for a long time looked upon as proof of the existence of trophic nerves in the main trunk, until it was shown that the in- flammation was due to the influence of foreign bodies upon the eye. Ordinarily the dust and other particles in the air, which necessarily settle upon the eye, are, in health, constantly removed by winking and the flow of the animal's head in a frame, so that it conld not itself touch its eye with its feet, nor injure it by running about. By this means, and by carefully attending to the hygiene of the eye, they kept the operated animal for months free from ophthalmia. Positive experiments like these are worth any number of negative ones. Just as the " vagus pneumonia" was long thought to arise from trophic changes, but was shown by Traube to be due to traumatism resulting from anaes- thesia of the larynx, so the "ophthalmia neuro-paralytica " has been shown to be an analogous process. "Sympathetic oph- thalmia," or inflam- mation occurring in a healthy eye following operation (especially enucleation) of its fel- low, was also thought to be due to trophic disturbances of reflex origin. But it has been shown that the inflam- mation is really due to pathogenic micro- organisms travelling along the lymph- spaces of the optic nerve, from the dis- eased to the healthy eye. Since the intro- duction of antiseptic surgery " sympathetic ophthalmia" is far less common than for- merly. 2. The Supra-max- illary Division (c) leaves the skull through the foramen rotundum, passes into the orbit through the inferior orbital fissure, emerging upon the face through the infra- orbital canal in the upper jaw. Its terminal branch- es are distributed to the area extending from the lower eyelid to the upper lip, and from the nose to the temple, being its nerves of sensation. The dental branches, three in number, sup- ply the upper teeth, the gum, and the an- trum of Highmore. It has also a recur- rent branch, which, accompanied by vaso- motor fibres from the superior cervical gan- glion, conveys sensa- tion from the area of the middle meningeal artery. (It also, like the recurrent branch of the oph- thalmic division, is probably the seat of headaches.) The supra-maxillary division is intimately connected with the spheno-palatine, or Meckels ganglion (ri), sup- plying its sensory root; the motor root being supplied by the facial nerve (through the large superficial petrosal branch (j). Fig. 4092.-Semt-digrammatic representation of the nerves of the eye-ball (3d, 4th, and 6th), the connections of the Trifacial (5th) and its ganglia, together with the facial (7th), and glosso-pharyngeal (9th) nerves (from Landois's Physiology). (The nerves are designated by their own numbers.) 3, Branch to the inferior oblique muscle from the oculo-motor, with the short root to the ciliary ganglion (c) ; t, ciliary nerves ; I, long root to the ganglion from the naso-ciliary (n, c); s, sympathetic root from plexus («, sy) surrounding the internal carotid arterv (g); d, first or Ophthalmic Division of the Trifacial (5), with the naso-ciliary (n c) and the terminal branches of the lachrymal (a), supra-orbital (b), and frontal (/); e, second or Supra-Maxillary Division ; R, infra orbital; n, spheno palatine, (Meckel's) ganglion with its roots, j, from the facial, and v, from the sympathetic; N, the nasal branches, andpp, the palatine branches of the ganglion; g, third or Infra-Maxillary Division ; A, lingual; i i, chorda tympani ; m, otic ganglion with the roots from the tympanic plexus, the carotid plexus, and from the 3d division, together with its branches to the auriculo-temporal (A) and the chorda tympani (i t) ; L, submaxillary ganglion with its roots from the chorda tympani and lingual (tympano-lingual), and the sympathetic plexus of the external maxillary artery (?). 7, Facial nerve; j, its great superficial petrosal branch; a, ganglion geniculatum ; (3, branch to the tympanic plexus; y, branch to the stapedius; 3, anastomotic twig to the auricular branch of the vagus. 8, stylo-mastoid foramen. 9, Glosso-pharyngeal nerve, A its tympanic branch; tt and e, connections with the facial; N, terminations of its gustatory fibres in the circumvallate papillae of the tongue; Sy, the sympathetic, with Gg, s. the superior cervical ganglion. I, II, III, IV, the four first cervical nerves ; P, parotid gland ; M, submaxillary gland. tears. When, however, the eye is deprived of sensation these automatic preservative acts no longer take place at all, or but irregularly and insufficiently, and inflammation results. Snellen was able to postpone the inflammation following section of the fifth nerve, by shielding the ani- mal's (rabbit's) eye by fixing its ear in front of it. Senft- leben and Cohnheim constructed an apparatus which held 250 Trifacial Nerve, Trigger-Finger. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The sensory fibres of the ganglion-joined by new fibres from the ganglion cells, probably vaso-motor in function-convey sensation from the roof, lateral walls, and septum of the nose, from the hard and soft palate, and from the tonsils. 3. The Infra-maxillary Division (^) is a mixed nerve in function. Its sensory branches convey sensation from the lower teeth and gum, and from the lower lip and skin covering the lower jaw, and mucous membrane lining the cheek. (These are not shown in the figure.) By its auriculo-temporal branches, part of the skin of the temple, the anterior wall of the external auditory meatus, the tympanic membrane, and the anterior por- tion of the pinna are supplied. The lingual branch (n), as proved by section, is the nerve of sensation of the anterior two-thirds of the tongue, of the anterior palatine arch, and of the floor of the mouth. Stimulation causes reflex salivary secretion. (The chorda tympani (i i), which accompanies the lin- gual, is a branch of the facial nerve.) The motor branches are derived from the motor root. They supply the muscles of mastication, namely, the masseter, the internal and external pterygoid, the tem- poral, and also the mylo-hyoid and anterior belly of the digastric, some fibres going also to the triangularis menti and platysma myoides. (These are not shown in the figure.) Through the otic ganglion (m), which derives its motor root from this division of the nerve, motor fibres are sup- plied to the tensor tympani and tensor palati. The functions of the trigeminus having been sufficient- ly alluded to, it remains to discuss the various pathologi- cal disturbances which may affect this nerve. (See Neu- ralgia, Tic Douloureux.) Trismus is a tonic spasm of the muscles of mastication, causing clenching of the teeth. It is usually one of the earliest indications of beginning tetanus. Showing itself at first simply as a stiffness and discomfort in opening the jaws, it may finally become so violent as to break the teeth by the force of the muscular contractions. It arises from irritation of the motor centres ; the most common causes being the action of the infectious poison which causes tetanus, and the effects of strychnine poisoning. In children a mild form of trismus, shown by grinding the teeth in sleep, often arises reflexly from intestinal irri- tation caused by worms, indigestible food, etc. Chattering of the teeth is a clonic spasm, arising re- flexly from cold, rigor preceding fever, and from fear and other emotions. Paralysis of the trigeminus nerve is not of common occurrence. When complete there is anaesthesia of the affected parts, and loss of motion of the masticatory muscles on the side affected. As a secondary result of the anaesthesia, as already alluded to, various inflamma- tory troubles of the eye, nose, and mouth occur. Bibliography. Landois: Manual of Human Physiology. Philadelphia, 1885. Cohnheim: Allgemeine Pathologie. Berlin, 1882. Schwalbe: Neurologie. Erlangen, 1881. Walter Mendelson. TRIGGER-FINGER. Synonyms: Spring-finger; Fr. Doigt a Ressort; Itai., Dita a Scatto ; Sp., Dedo de Re- sorte; Ger., Schnellender Finger, Federnder Finger. This peculiar affection was first described by Notta in a memoir published in 1850, and was named, five years later, doigt d ressort by Nelaton. Since that time, but more particularly during the past ten or fifteen years, instances of the affection have been reported by various observers, the number of recorded cases up to the present time (May, 1888) being seventy-two. The condition is one of impeded motion to the finger. It is characterized by resistance to flexion of the digit beyond a certain point, which is variable in the different cases, but constant in each, up to which point, however, the motion is normal. When flexion has proceeded thus far it is suddenly and sharply arrested, but if the effort to bend the finger is continued (sometimes the assistance of the other hand is necessary) the obstruction is over- come, a sharp pain is felt, often a slight click is heard, and complete flexion ensues. The sudden yielding of the finger, accompanied by the faint snap, resembles the closing of the blade of a penknife, or the fall of a trig- ger, whence the name, spring-, or trigger-finger. Subse- quent extension of the finger is arrested in the same manner, and the forcing of the barrier (which in most cases can be accomplished only with the aid of the other hand) occurs with like suddenness, and is accompanied by the same painful click. Any one, or several, of the fingers may be thus affected, but more commonly only one, and this the thumb or ring-finger. The middle-finger is also frequently the seat of the trouble. Sometimes both hands are symmet- rically affected, the impediment existing in the two thumbs, or in one or more of the other fingers of both hands. In a case communicated to Schmit by Notta, all the fingers of both hands were affected. Konig and Solaroli have each reported a case in which a similar condition was noted in the great toe. The degree of impediment to motion varies consider- ably in the different cases. Sometimes it is so slight that the patient scarcely notices it, and the physician can de- tect it only by palpation of the finger during flexion. In other cases it may be so great that the patient is unable to overcome it by muscular effort alone, and is obliged to employ the other hand, or even, as in a case reported by Blum, to sit upon the finger before it can be forced be- yond the barrier. It is almost always more easy to flex the digit than to extend it. This is probably due simply to the fact that the flexor muscles are stronger, and work at a greater advantage, than the extensors. Yet, in some cases the arrest of motion is noticed only in exten- sion, the act of flexion being apparently perfectly free. In a case of Eulenburg lateral motion of the ring-finger toward the little finger was accompanied by the same phenomenon. The pain is also variable, amounting at times merely to a slight discomfort, felt only at the moment that the obstacle is passed, at other times being almost unbear- able and excited by any movement of the finger, but always most intense at the moment of resistance to flex- ion. It is referred usually to the metacarpo-phalangeal articulation, but in the severer cases extends to all parts of the finger, and even into the hand. Sometimes, even when the impediment is most marked, there is no pain at all, but there is almost always tenderness on pressure on the volar aspect of the finger near the metacarpo-phalan- geal joint. In several instances various paraesthesia*, a burning sensation, formication, etc., have been noted. The click is usually very perceptible, but may be en- tirely absent. In the case reported by Solaroli, in which the great toe was affected, the noise resembled the snap- ping of a whip, and was so loud that it could be heard by persons in another room, or even on another floor of the house. The arrest of movement occurs in the same patient in- variably at the same point, but in different individuals there may be great variety in the amount of free motion possible. In some patients, for example, the click may occur almost at the beginning of motion, while in others the second phalanx may be bent nearly at a right angle to the first before any impediment is noticed. In rare instances there is a double click, and two halts are made before the finger can be fully flexed or extended. Two cases of this sort have been reported. In one case, two little jerks were noticed during extension of the finger; in another, in which the middle-finger of the left hand was affected, one click occurred when the second pha- lanx was bent on the first, and another during flexion of the third phalanx on the second. Women are much more frequently affected than men. In sixty-eight of the reported cases the sex was noted, and of these forty-one were women and twenty-seven men. This disproportion is explained, by those who favor the mechanical theory of the production of spring-finger, by the fact that women use their fingers for fine work, in sewing, knitting, etc., much more than do men. All ages are liable to the affection, but the period of active adult 251 Trigger-Finger. Troches. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. life is that in which it occurs with the greatest frequency. Thus, of fifty-eight patients in whom the age was noted, six were under twenty years of age, forty-one were be- tween twenty and sixty years, and eleven were over sixty years of age. One case, reported by Berger, was in a child between five and six years of age, and Waterman's patient was ninety years old. In almost all the cases there is to be felt, near the digito-palmar fold, a small kernel on the flexor tendon. This nodosity is usually in the palm, but may be in the fold, or on the volar aspect of the finger. In a case noted by Perroud it was situated on the index-finger near the joint between the second and third phalanges. Some- times, however, this little swelling is absent. In a case reported by Herraez, in which the middle- and index- fingers were affected, it was present in the flexor tendon of the middle-finger, but could not be found, after the most careful search, on that of the index. Busch failed to discover it in two cases, and Jacoby has noted its absence in one instance. In a case of Leisrink it was found only when the finger was strongly flexed. Mar- cano maintains that the swelling is always present, and that, when it is not found, the fault lies in the in- ability of the examiner to detect it. But as its presence is necessary in order to bear out his theory of the pro- duction of trigger-finger, this assertion loses much of its force, and the reputation for accuracy and careful ob- servation, borne by those who have asserted its absence in certain cases, precludes the possibility of error on their part. The nature and mode of origin of this nodosity, and the part played by it in the production of the essential phenomenon of this affection, have been matters of dis- pute from the time that the first cases were noted. In Notta's cases the swelling was referred to dropsy of the synovial cul-de-sac of the flexor tendons, and the interfer- ence with flexion of the finger was attributed to the en- gagement of the synovial swelling against the interdigital edge of the palmar fascia. Nelaton, who was the author of this theory, seems later to have rejected it, and to have adopted that of the presence of small bodies in the sheath of the tendon, similar to floating bodies in the joints. Pitha believed that the symptoms were best explained by assuming the presence of floating bodies in the joint itself rather than in the tendon sheath. Blum supposed the nodosity to be due to a circumscribed enlargement of the flexor tendon, possibly from a plastic tenosynovitis. Despres referred the swelling to rupture of a vessel, with hoemorrhage into the tendon and resulting induration. But in whatever way the localized enlargement of the tendon was produced, most of the more recent writers, excepting, of course, those who found no nodosity, have attributed the impediment in motion to this cause. Menzel determined experimentally upon the cadaver that the symptom could be produced by winding a fine thread around the tendon, so as to increase its thickness at a certain point, at the same time constricting the sheath slightly close to the enlargement. He believed, conse- quently, that a constriction of the tendon sheath was as necessary to the production of the phenomenon in ques- tion as was circumscribed swelling of the tendon. Mar- cano regarded the tendinous enlargement as the only es- sential factor, and thought that the arrest of movement was caused by this tumor engaging against the edge of the fibro-osseous canal at the root of the finger. This theory would seem to be more satisfactory and simpler than any other to account for those cases in which a nodosity on the flexor tendon is present. But, naturally, it does not afford any explanation of the ressort in the cases, like those of Busch and Jacoby, in which nothing abnormal could be detected in the joint or on the tendon. Such cases might possibly be produced in the way sug- gested by Steinthal. lie had amputated a finger for ap- parent anchylosis of the two interphalangeal joints fol- lowing a panaritium, and found that the trouble lay wholly in the flexor tendon, and that, after this was di- vided, the phalanges could be extended without any difficulty. He foufid, however, that, after one segment of the finger was bent a short distance, it suddenly flew into complete flexion, the same jerk occurring in exten- sion. On searching for the cause he found it in an ab- normal position of the lateral ligaments of the joint, which were inserted too far toward the palmar aspect of the base of the second phalanx. When the joint was slowly flexed the posterior fibres of the lateral ligaments were seen to be put tightly on the stretch, until the maximum was reached, at about 45°, when extreme flexion occurred with a sudden snap. In extension of the finger the an- terior fibres were made taut. Kbnig also reports a case of similar nature. It was one of trigger-toe, and he had amputated the affected digit. On examination, he found a small outgrowth from the articular cartilage which caused a slight sepa- ration of the joint surfaces in partial flexion. At this point the lateral ligaments were put on the stretch, but a little further movement to one side or the other brought the joint surfaces again in close contact, and with this sudden relief of tension on the ligaments the jerk took place. These cases would seem to disprove the necessity of a tendinous node for the production of the phenomenon, and Steinthal's theory of changes in the ligaments may account for some of these cases. He attributed the change, in the case reported, to the chronic inflammatory process excited by the panaritium, and believed that a much less severe grade of inflammatory action would suffice for its production. Most writers look upon rheumatism as the underlying cause of spring-finger, but some cases have been caused by penetrating wounds in the neighborhood of the meta- carpo-phalangeal articulation of the affected digit, and others would seem undoubtedly to be due to traumatic influences. Schmit, indeed, regards traumatism as the main, if not the sole, factor in the production of the primary affection. He instances four cases, reported by Astegiano, of trigger-finger occurring in young cadets who had spent many hours a day in the practice of fenc- ing, and he endeavors to show that the majority of pa- tients are those whose occupation calls for the over-use of certain fingers, such as seamstresses, brush-makers, flutists, and the like. The etiology, though not the nat- ure, of trigger-finger is, therefore, according to his view, similar to that of writers' cramp, with this difference, however, that in the latter certain fingers are used with precision but with little force, while in the former force is the main characteristic rather than precision. It is, perhaps, worthy of note that in two cases reported by Bernhardt, and in one by Charpentier, there was also contraction, more or less marked, of the palmar aponeu- rosis ; but in only one did the contraction bear upon the affected finger. The prognosis of spring-finger is usually good. Many cases recover without any treatment other than rest for the affected digits, and under appropriate treatment im- provement is generally noticed within a few weeks or months, though occasionally the affection continues with- out material change indefinitely, even for years. The treatment of trigger-finger, like that of most affec- tions, gives usually better results the earlier it is begun. The most important therapeutic measure, and one, in- deed, that is almost indispensable to success, is rest; and in order to be effectual this should be absolute. It is not sufficient to caution the patient against the use of the fin- ger, but the member should be immobilized by means of a light splint. In many cases this alone, or combined with the application of tincture of iodine, will suffice for a cure. In other cases massage will be useful, warm moist compresses being applied in the intervals of active treatment. Electricity in the form of galvanism, and elastic compression, have been advised, and have been of undoubted benefit in certain cases. As a last resort re- course may be had to surgical measures. Leisrink has reported a case in which, other measures having been tried without avail, he cut down upon the tendon at the point where the tumor could be felt. He found it to be caused by a fold in the tendon, which seemed to be too long. This was excised and the divided ends of the ten- don were then united by suture. Union occurred by 252 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Trigger-Finger. Troches. first intention. Of course, any attempt to excise the nodosity should be made only under the strictest anti- septic precautions. Litebatuke. Notta, A. : Archives G6n6rales de Medecine, vol. xxiv., p. 142, 1850. Feneriy (Nelaton): Gazette des Hopitaux, vol. xxviii., p. 129, 1855. Notta, A.: Union Medicale, vol. iv., p. 631, 1859. Nelaton (Fourchy): Pathologic Chirurgicale, vol. v. Paris, 1859. Arrachart: Bulletin Medical du Nord, pp. 159-166, 1861. Busch : Lehrbuch der Topographischen Chirurgie, vol. ii. Berlin, 1864. Busch : Verhandlungen der Nat. Ver. d. Preuss. Rheinl. und Westphal., vol. xxii. Bonn, 1865. Annandale: Malformations, Diseases, and Injuries of the Fingers and Toes. Philadelphia, 1866. Pitha and Billroth : Handbuch der Allgemeinen Chirurgie. vol. iv., Part II. Vienna, 1868. Dumarest: Lyon M6dical, December 8, 1872, and Revue d'Hayem, vol. i., p. 690, 1873. Iluguier : Archives Generales de Medecine, 1873. Hahn : Allgemeine Medicinische Centralzeitung, February 11, 1874. Menzel: Centralblatt fur Chirurgie, August 29, 1874 ; also translations in the Rivista Clinica di Bologna, 1874, and the Boston Medical and Surgical Journal, 1874. Roser: Handbuch der Anatomischen Chirurgie, Tubingen, 1874, and ibid., 1883. Berger: Deutsche Zeitschrift fur Praktische Medicin, Nos. 7 and 8,1875, and Schmidt's Jahrbiicher, vol. clxvii., p. 154, 1875. Fieber: Wiener Medizinische Wochenschrift, February 15, 1879. Fieber: Wiener Med. Blatter, Nos. 14, 16, and 17, 1880, and Canstatt's Jahresbericht, vol. ii., p. 352, 1880. Vogt: Die Chirurgischen Krankheiten der Oberen Extremitaten, in Deutsche Chirurgie. Stuttgart, 1881. Felicki: Thesis of Greifswald, 1881. Blum : Chirurgie de la Main. Paris, 1882. Blum : Archives G6n6rales de Medecine, May, 1882. Berger: Art. Schnellender Finger, in Eulenburg's Real-Encyclopiidie, 1st edition, vol. xii. Vienna, 1882. Herraez: La Cronica M^dica, December 20, 1882, and La Revista de Medicina y Cirurgia Practicas, February 7, 1883. Marcano: La France Medicale, No. 15, 18S4. Marcano: Le Progres Medical, Nos. 16, 17, and 19, 1884. Rehn : Centralblatt fur Chirurgie, 1884. Leisrink: Centralblatt fiir Chirurgie, 1884, and Semaine Medicale, 1884. Polaillon : Article Doigt, Dechambre's Dictionnaire Encyclopedique des Sciences Medicales, vol. xxx., p. 256. Paris, 1884. Bernhardt: Revue de Medecine, 1884. Charpentier: L'Union Medicale, August 31, 1884. Romei: Gazzetta degli Ospitali, October 20. 1884. Rusconi : Gazzetta degli Ospitali, No. 78, 1884. Notta, M.: L'Union Medicale, 1884' Despres: N61aton's Pathologie Chirurgicale, 2d edition, vol. vi. Paris, 1884. Largeau : Archives Generales de Medecine, 1885. Solaroli: Il Raccoglitore Medico, February 20. 1885. Valerani: Gazzetta delle Cliniche di Torino, No. 13, 1885. Kunz: Centralblatt fiir Chirurgie, February 7, 1886. Jacoby: New York Medical Journal, June 19, 1886. Meyer: New York Medical Journal, June 19, 1886. Steinthal: Centralblatt fiir Chirurgie, July 17, 1886. Astegiano : Giornale Medico del Reggio Esercito e della Reggia Marina, September, 1886. Eulenburg: Deutsche Medicinische Wochenschrift, January 6, 1887. Schmit: Bulletin General de Therapeutique, Nos. 4, 5, and 6, 1887. Romei: Gazzetta degli Ospitali, April 24, 1887. Konig: Lehrbuch fiir Chirurgie, 4th edition. 1887. Thomas L. Stedman. TRILLO is one of the most celebrated of the Spanish health resorts. It is situated on the banks of the Tagus, not far from Guadalajara, at an elevation of about 2,300 feet above the level of the sea. There are many thermal springs here, the waters of which, issuing at a tempera- ture of from 77° to 86° F., contain about three and a half parts per thousand of solid constituents, the chief of which are ferrous carbonate and calcium and magne- sium sulphates. The waters are prescribed internally and in baths for those suffering from the malarial cachex- ia, constipation, dyspepsia, chlorosis, syphilis, and rheu- matism. The season extends from the middle of June to the middle of September. T. L. S. TRIMETHYLAMINE, N(CH3)3. Trimethylamine is a tertiary monamine, found native in various plants and also in various animal fluids, notably in herring-brine, whose strong, rank odor is due to this ingredient. Prior to the researches on the amines by Hofmann, native trimethyl- amine was thought to be the isomeric body, propylamine, NHa(C,H,), and considerable confusion still exists in medical understanding on the subject, through the mis- application of the term propylamine to what is, in truth, trimethylamine. As a matter of fact, propylamine, prop- erly so-called, is not, and never has been, used as a med- icine, and all medical preparations passing under that name are preparations of trimethylamine. Trimethyl- amine is a mobile, colorless liquid of the specific gravity 0.673 at 0° C. (32° F.), and boiling point between 9° and 10° C. (48.2° and 50° F.). It is very soluble in water, which fluid also eagerly absorbs and dissolves the vapor of trimethylamine. It is combustible, and so, too, is its concentrated aqueous solution. Trimethylamine has a powerful and very searching ammoniacal and fishy odor. For medical purposes an impure solution in water, pre- pared from herring-pickle, was first employed. This so- lution contained also ammonia and various undetermined ammoniacal compounds, and probably other organic matters. Its proportion of trimethylamine was variable, in accordance with the varying constitution of the sam- ples of herring-pickle of different years' make. Hence, of later years, the definite salt trimethylamine hydrochlo- ride, N(CH3)3 HC1, was proposed. This salt occurs in white, very deliquescent crystals, freely soluble in water, and is the best form of trimethylamine for medical ad- ministration. Trimethylamine is a powerful irritant, its concentrated solution being even mildly caustic. Taken internally, large doses-such as in excess of 2.00 Gm. (about thirty grains), produce decided symptoms of gastro-intestinal irritation with burning in the throat and stomach. After absorption the medicine evinces a tendency to depress the force and frequency of the pulse, the body-temperature, and the excretion of urea. Trimethylamine was at one time used for the treatment of rheumatism and gout, but of late years has been so completely superseded by the salicylates as to have be- come almost obsolete as a medicine. The drug is best administered in the form of an aqueous solution of the hydrochloride, aromatized to cover the rank, fishy taste. The dose of the hydrochloride will range between 0.25 and 0.50 Gm. (between four and eight grains, about), sev- eral times a day. Edward Curtis. TROCHES [Trochisci; Lozenges]. These are small, solid tablets, made of some sweet preparation and con- taining a drug meant for the medication of the parts with which it will come in contact when the lozenges are dis- solved. They are used in various disorders of the buccal cavity and pharynx, and their effect is obtained by allow- ing them to dissolve slowly in the mouth. They are gen- erally made with fruit-paste, an officinal article, the most commonly employed variety of which is composed of the black currant. When used for the constitutional effect of the contained remedy there is no objection to the hard consistence of the officinal lozenge. Most troches contain from seventy to eighty per cent, of fruit-paste in each, one to two per cent, of powdered tragacanth, four per cent, of sugar, and a varying quan- tity of the medicament, according to the formulae given. This method of medication is of doubtful value, and should never be used when the ingredients of the lozenge are of such a character as to disorder the digestion of the patient or introduce into the stomach an irritating drug. They have steadily declined in popularity in this country by reason of their intrinsic defects, and within the past few years they have been practically superseded by a new device, the invention of Dr. Robert A. Fuller, of New York. This is the so-called tablet triturate, a small disk about one-fourth of an inch in diameter, and com- posed of sugar of milk as a menstruum for the contained medicament, the whole being held together by means of a special solution. Tablet Triturates.-The use of these little disks has become general, their value and merit having been quickly recognized, so that even now they are used ex- tensively in the United States and are being adopted in Europe. The manufacture of tablet triturates is the combination of a process and result which presents the medicine in an acceptable form to the patient, and includes methods which inspire confidence in their preparation. Pills are made by the addition to the powdered med- icines of an adhesive and plastic material, to bind the parts together, and this material often performs its part 253 Troches. Trusses. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. so well that all the forces of solution and digestion in the body cannot separate them. Compressed pills or powders are made by pressing the particles of the drug together so forcibly and firmly that only that part of the tablet next to the solvent is under its influence. A tablet triturate is bound together by a process of re- crystallization. The liquid with which the triturated compound is made into a mass dissolves the right proportion of the sugar of milk used in dividing the medicament, and this saturated solution of milk-sugar recrystallizes through the whole of the moulded tablet, binding it together suf- ficiently to preserve its form when bottled and dispensed. This solution, or the liquid with which it is made, plays an important part in the formation of the tablet. The powder for each tablet triturate absorbs about one- half a minim of liquid, to make a mass of the right con- sistence to press into the moulds. The liquid permeates the entire tablet, and the dried product is of exactly the same size as the freshly moulded, moist tablet. The dried tablet of plain sugar of milk weighs one and two-fifths grain ; so that about one-third of the space was originally occupied by the liquid which has evapo- rated and left a dry spongy disk, the pores of which at- tract and absorb the liquid presented to it for solution. The manufacture of tablet triturates involves three distinct processes : 1, Perfect comminution and tritura- tion of the drug ; 2, the addition of the liquid to bind the sugar and drug together into the required form ; and, 3, the perfect drying of the tablet for the right length of time. Trituration requires powdering, mixing, and rubbing. The vegetable drugs are composed- of cells which are too small to be easily seen when the plant is fresh, and when the plant is dried are only from one-tenth to one-fifth of their original size. The dried cell has a hard, tough coat which no amount of rubbing with a pestle in the hands of an apothecary's assistant will be certain to break ; it requires a pressure of two hundred pounds or more in the powdering machine, and the presence of a heavy weight in the machine which does the triturating and mixing. The liquids for forming the mass are always alcohol and water, and the experience of the manufacturers of tablet triturates has shown that, if the quantities of the two liquids be correctly apportioned, no other means is necessary to bind the particles together. Heat was the first means used for drying the tablets, but it was found to dry them too quickly, and in some cases to injure the drugs. A rapid circulation of dried air is now used, with perfect success. The perfected tablet triturate furnishes a uniformly divided, exact, soluble, and elegant method of dispensing and administering such medicines as, from their character and the size of the dose required, admit of this form of manufacture. Moreover, the tablet may be administered either in its original form, as a pill ; or, by simply crushing it, as a powder ; or, by dissolving it in water, as a solution. It is easily portable and, when kept in well-corked bottles, readily preserved. The variety of drugs which can be put up in this way is very extensive, and the tablets can be used for either general or local effect. Compared with the troche they are in every respect superior, and there is little question but that their popularity has been definitely and permanently established. D. Bryson Delavan. TRUSSES. A truss is an appliance consisting of a spring or band encircling the body, to which is attached a pad, to prevent the protrusion of a hernia. Trusses, or bandages for hernial retention, are of very ancient usage. As early as the first century Celsus recommends the employment of a bandage and com- press, and says that in young children cures often fol- lowed their use. Galen repeats the doctrine of Celsus, and Theodorus Aetius, in the sixth century, employed a soft compress retained in position by a bandage, thus fol- lowing the practice of his illustrious predecessors. Pads of wood and iron attached to a soft girdle, were used in Italy in the thirteenth century. Gordon, in the four- teenth, and Gatenaria, in the fifteenth century, recom- mended an iron girdle. These soon fell into disuse and gave place to the hard pads and soft bands which had previously been used. In the commencement of the sev- enteenth century, Fabricius Hildanus employed trusses made of very soft and flexible iron, which could be moulded to fit the form. In 1665 Mathias Major is said to have first employed an elastic steel spring. The same material was afterward adopted by M. Blegny, and by his recommendation brought into general use. Although the adoption of the elastic spring was a great advancement toward the perfec- tion of the truss, still the trusses of this period were very rude and primitive in their construction. Arnaud say.s that "when he was appointed truss-maker to the military hospitals of Paris, the store-houses belonging to those hospitals were filled with trusses which it was impossible tp use, because they were of only three different sizes, and contrived for only one kind of rupture." The most reliable statistics which can be obtained in- dicate that one out of every twenty individuals is the subject of hernia. There are, therefore, but few disa- bilities for which the ordinary physician will be more frequently called upon to prescribe than for this. Until some operation for the radical cure of hernia more uniformly successful than those hitherto practised has been discovered, it is safe to say that in the majority of cases a truss will be recommended. On the skill and judgment displayed by the physician in the selection and adaptation of the truss, a great amount of comfort or suffering on the part of his patients affected with hernia will depend. No opportunity, by study or experience, should be neglected which will enable the surgeon to choose and apply properly the best instrument for each individual case. Trusses have been made of almost every conceivable material, and in endless variety. Some of them are marvels of mechanical ingenuity and complication. For that reason they should be avoided, as those of simple construction are less likely to get out of order, and are usually much more effective in retaining the hernia. For convenience of description they may be divided into two classes, viz.: belt trusses-those whose efficiency in preventing the descent of the hernia depends upon the tightening of a belt around the body ; and spring trusses -which give pressure upon the hernial opening by means of a steel spring. Until within a few years, with the exception of the Moe-Main truss, which was used to a considerable extent in England, the belt truss had fallen into disuse. But during the last fifteen years the elastic, and various forms of non-elastic, belt trusses have been extensively adver- tised, and though not receiving the sanction of any rec- ognized authority, a large number are being sold. Belt trusses should not be used, except for umbilical or ventral hernia, or for night use. For inguinal or femoral hernia they are unreliable, whether the belt is made of elastic or non-elastic material. They are not only unsafe, but they give a false sense of security, en- couraging the wearer to take exercise and make exer- tions, which he would not do if he did not suppose him- self adequately protected. If a band is buckled around the pelvis on a line with the inguinal region, it will be found that the pressure is not brought upon the inguinal canal, but upon the prominent edges of the ilia. To exert any pressure over the hernial opening, a very thick, clumsy pad must be used, and this must be held down by a perineal strap, drawn so tightly as to occasion more or less discomfort. In the act of stooping the belt and strap loosen, and do not follow the body as a spring does. The same objection holds against a malleable metal band, which is sometimes substituted for a steel spring. It is a revival of that which was tried and dis- carded in the seventeenth century, as the use of the belt truss is a return to the practice of the early centuries. Another objection to this form of truss is that, when the hernia is at all difficult to hold, the belt is drawn so 254 Troches. Trusses. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tightly as to cause absorption of the tissues beneath it, and a crease, often half an inch deep and the width of the band, will be cut into the flesh all around the body. This is especially troublesome if it is wished afterward to use a spring truss, as the spring will invariably slip into this crease, and cannot be raised to its proper place upon the back. The first and most important part-the basis and foundation-of a truss is a well-tempered elastic steel spring. It should be of such a temper as to admit of some manipulation and shaping, but not so soft as to lose its shape as well as strength from the strain brought upon it during vigorous physical exertion, or that inci- dent to putting it on or off. The spring should be so shaped as to tit the body perfectly. Unless it is so adapted the truss will not be sure to retain the rupture, nor will it be worn with comfort. A great variety of shapes, as well as sizes, will be re- quired to fit the different forms which are met with in daily practice. A large proportion of the springs in the trusses ordinarily sold are made by mechanics who have no knowledge of the anatomical formation of the body, no clear idea of the location of a hernia, or of the rela- tion which the truss sustains to it, nor the direction in which its force should be applied. It is in this respect that I find it necessary to exercise the most vigilant over- sight of my workmen, in order to secure Springs not only of proper form, but of sufficient variety. That I have not insisted too strongly upon this matter of the adaptation of the spring to the form of the body, will be shown by the accompanying diagrams (Fig. 4093), which contrast the section of the pelvis of a rotund appendage should always be used as a protection in case of violent efforts. Next to the spring, the pad of a truss is of most im- portance. Indeed some authorities give it the first place. Pads have been made of many substances and in many shapes. Metal, ivory, glass, wood, hard rubber, cellu- loid, cork, sponge, felt, blanket, wool, hair, air, and water, have been used in their construction. Some twenty-five years ago it was the practice of many sur- geons to recommend some form of hard pad, either of wood, ivory, or hard rubber, for two reasons: First, because of their cleanliness, they being impervious to the perspiration of the body ; second, because of their supposed effect in promoting a cure of the hernia. The theory of cure was that the irritation of the solid pad caused adhesive inflammation, which agglutinated the skin, cellular tissue, superficial fascia, and tendons into one common mass of condensed tissue, so as to close the inguinal canal and rings. I believe this theory of cure to be entirely erroneous, and that such changes of adhesion and condensation do take place as the results of the pressure, I am not prepared to admit. My obser- vation and experience with hard pads has been that they promote absorption of the tissues upon which they press, causing them to become thinner and weaker, instead of stronger. I have no doubt that many children whom I fitted with solid pads and failed of a cure, might have to-day been sound and well, had I used soft elastic pads instead of hard ones. The mode, then, in which trusses effect a radical cure- is by their mechanical influence in producing perfect re- tention of the bowels, preventing the hernial descent for a sufficient time to allow nature to effect the contraction of the aperture in the aponeurotic and muscular portions of the walls of the abdomen, and not by exciting adhe- sion in the parts which they compress, nor even by in- ducing contraction or closure of the sac, which is often the result of their use. Elastic pads of soft rubber, filled with air, have been in use in Paris for many years, being first brought to the notice of the profession by M. Cres- son. These pads were very successful in preventing the descent of herniae most difficult to retain, and the press- ure exercised could be borne with great ease. A serious defect was found in them, however, as after a short time the air gradually escaped and the pad would flatten, al- lowing the hernia to protrude. Their merits were too great to allow them to fall into entire disuse, and Mal- gaigne relates a very obstinate case of direct inguinal hernia which he was able to control with an air-pad, while the pressure of other kinds of pads was unsup- portable on account of the extreme prominence of the spine of the pubes. The ideal pad is the water-pad. It was suggested to me, many years ago, by Dr. Samuel Cabot, of Boston. The results of a thorough experi- mental trial proved so satisfactory that they are now recommended by many of our best surgeons. The press- ure exercised by them will be better borne than that by any other pad, and yet they are firm enough to retain the most difficult hernia. The water does not escape through the rubber as air does, and the pad, if properly made, will retain its firmness and shape until the rubber begins to soften. If made of the finest Para rubber, as they always should be, they have an average life of two years. Next to the water-pad may be placed those of felt or hair. To have them effective, great care should be exer- cised in their construction. They should possess a cer- tain amount of elasticity ; yet if mad6 too soft and yield- ing they will not only lose their shape, but fail to retain the hernia. The shape of the pad is of importance as well as the material of which it is composed, and every variety in shape and pattern has had its advocate. The limits of this article will not admit of a description of them all, nor of a discussion of their merits or demerits. I can only lay down a few general principles drawn from a some- what extended experience to guide in determining the proper form of pad. For inguinal hernia the oval, the pear-shaped, or the tri- Fig. 4093.-A, Section of large and round pelvis ; B, section of thin and flat pelvis; C, outline of spring with narrow bow ; D, outline of spring with large bow. individual with that of one thin and flat. Two shapes of springs are also shown. The absurdity of expecting comfort or efficiency by applying the spring C to pelvis A, is apparent at a glance ; and yet just such misappli- cation of trusses is being made daily. As many varying degrees of strength are required as of size and shape. It is very evident that the meagre assortment of trusses kept by the ordinary druggist will furnish the physician a most inadequate range of selection to enable him to properly lit his various patients. Another point of some importance in regard to a truss spring is its length. Some surgeons have adopted a length which embraces a little more than half the cir- cumference of the body-the end of the spring extending but a little beyond the spine toward the unaffected side. Such a length of spring not only fails to retain its posi- tion upon the body securely, but it is likely to cause discomfort by the end of the spring pressing into the flesh, unless it is protected by an extra pad. To give the greatest amount'of comfort and security the spring should extend beyond and clasp the iliac wing of the unaffected side. When the spring is constructed of this length, well fitted to the curves of the pelvis, and is properly tempered, it will so clasp the body as to be capable of maintaining its proper position under ordinary exertions without the aid of a connecting strap, although such an 255 Trusses. Trusses. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. angular form of pad may all be used, and each has its ad- vantages in certain cases. The selection will have to be made from a study of the figure of the patient. The in- ner surface of the pad should be sufficiently convex to allow pressure upon the whole length of the inguinal canal and to completely close the internal and external rings. It should be large enough to extend some half an inch beyond the canal in all directions, so that a slight move- ment of the truss may not dislodge the pad and leave the ring unprotected. Too small and convex a pad concen- trates the entire pressure upon the canal, having a ten- dency to weaken and force apart the aponeurotic tissues. Flat pads, which by some prominent surgeons have been strongly recommended, I consider unreliable and delusive. Except in rare cases, the upper edge of the pad will rest against the abdominal wall above, also upon Poupart's ligament below, and the pubes in front; and while if easily held, the hernia may be prevented from escaping at the external ring, the intestine is allowed to pocket itself at the internal ring and distend the upper portion of the canal. For femoral hernia, an ovoid or triangular-shaped pad should be used. It should be of small size, and with a quite convex surface, that it may concentrate its pressure as much as possible and completely close the saphenous opening. If too large and flat, it will rest upon Pou- part's ligament, the sartorius, and the adductor muscles, thus preventing the closure of the crural canal. It will also cause discomfort by pressing unduly upon the thighs in sitting. Finger-pads, rings, pads with corrugated surfaces, with projecting knobs to press around the ring, " for a baby six months of age." (This may be thought a travesty and a needless caution, yet I personally know it to be a fact that such orders are frequently received from intelligent physicians. It is the result of hurry and Fig. 4095.-Single Water-pad Truss. thoughtlessness, for a moment's reflection would show the absurdity of the request.) For a case of slight inguinal hernia in a person of quiet habits, a light French truss (Fig. 4094), or a water-pad truss (Fig. 4095), will prove a very comfortable and sat- isfactory instrument. Especially in the case of females, these will so conform to the shape of the body that they Fig. 4096.-Ratchet Truss. with grooves cut in the surface to prevent pressure upon the spermatic cord, are all fanciful devices without special merit. Soft pads should be covered with kid or buckskin, these materials being so pliable as not to interfere with the elasticity of the pad. The cover of the spring of the truss serves as a protection to the flesh from the pressure of the bare metal, and also as a belt to retain the instru- ment in place. The best material for the cover is calf- skin, and if the belt is to be cushioned, the inner lining should be of kid. In the selection of a truss for any individual case, first of all, choose one that will most surely retain the hernia under all circumstances. The next care should be to se- lect one that will give the patient as little discomfort as possible. There is no form of truss that is applicable to all cases. There are many considerations to be taken into account in the proper selection : Whether the patient be round and fleshy, or thin and spare ; his habits : whether he be a laboring man, subject to violent exer- tions, such as lifting and straining, or a sedentary person leading a quiet life ; the character of the hernia : if large and difficult to hold, or small and easily retained. All these are factors in the guidance to a choice. If the phy- sician does not have an assortment to make a personal se- lection from, he should, in ordering from the maker, give all the above information, in addition to stating the kind of hernia, the size of the patient, and the side affected. This will enable the manufacturer to select a truss that will be likely to meet the requirements of the case. Do not give an order in such indefinite terms as-" Send me a truss for a man five feet eleven inches high ; " or Fig. 4094.-Light French Truss. may be worn with greater ease and more comfort than any other style. For laboring men who have heavy bur- dens to lift and large hernise, difficult to retain, a ratchet truss (Fig 4096), will be found most satisfactory. This is an old variety of truss, and one which has been exten- sively used in this country, particularly in New England. The firm but elastic spring is attached by screws to a Fig. 4097.-Single Dutch Truss. brass neck on which the mechanism of the ratchet is ar- ranged. To the arm which carries the lever-spring of the ratchet, the pad is attached by a screw. A series of holes in the plate of the pad allows it to be placed more 256 Trusses, Trusses, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. or less obliquely on the body, which, with the movement of the ratchet, permits of a considerable variety of adjust- ment. With the oval-shaped water-pad adapted to this truss, it leaves nothing to be desired by the class of cases to which it is suited. In the case of a fleshy person with pendulous abdo- men, or of an elderly person with lax tissues, the Dutch truss, Fig. 4097, with its broad, easy pad, will prove to be a most excellent one. The ball-and-socket truss, Fig. 4098, as it is known in this country, is a modified form early part of the century, but was soon superseded by the modifications of Drs. Hood and Chase. Hood's truss had a very convex, small wooden pad, and exerted its entire pressure over the external ring, which it had a tendency to distend rather than close, and it soon fell into disuse. It has since been modified as represented in Fig. 4101, and its use revived. The truss of Dr. Heber Chase was a famous one in its day, a long report in its favor being made, in 1837, by a committee of the Philadelphia Medical Society. It was of an old style invented by Salmon and Ody, of London, nearly a century ago. Its original form is well repre- sented in Fig. 4099. To one end of a semi-elliptical spring is attached a broad back-pad, which rests upon the sacrum. The other end of the spring, which crosses the body in front, is connected with the front pad by a ball-and-socket joint placed in one of the foci of the ellipse of the pad. This permits freedom of motion in all directions, and if the pad is placed over the inguinal ring, with the ball-and-socket joint at its lower part, it will give an upward and out- ward pressure that is often quite effective in retaining the hernia. The swivel move- ment allows it to conform to every movement of the body, and makes it very comfort- able to wear. Some persons object, however, to the press- ure of the pad upon the sa- crum. It is a useful truss in cases where the antero-poste- rior diameter of the pelvis is equal to the lateral, as it is difficult to get a spring of the ordinary kind with a bow sufficiently large to fit such cases. The Moc-Main truss, Fig. 4100, is an old English in- strument invented by Mr. Evans. It consists of a pad- ded leather belt to encircle the body and buckle to an oval pad in front. The external surface of the pad has a groove running across the centre. In this groove lies a steel spring which projects at the lower end. At the upper end of the pad is hinged a brass lever with a knob Fig. 4098.-Improved Ball-and-Socket Truss. Fig. 4101 -Hood's Truss. an improvement on those which had preceded it, as the pad was larger and better adapted to the anatomical con- formation of the parts. It was a wooden-pad truss, however, and subject to the objections urged against any truss with pads of hard material. It is illustrated in Fig. 4102. To come to later times, we have the hard-rubber truss, Fig. 4103, consisting of a steel spring coated with hard rubber or vulcanite, with pads of the same material. It has the merit of being cleanly and durable, and is not affected by perspiration. The objections to it are, that Fig. 4099.-Original Salmon and Ody Truss Applied. Fig. 4102.- Dr. Chase's Truss. it is more likely to slip upon the body than a padded truss, and thus to allow the descent of the intestine. It is not worn with a great degree of comfort, except in cases where the body is well cushioned with muscular and adipose tissue. It also has the hard pads, which have, as already explained, a tendency to cause absorp- tion of the tissues, weakening instead of making the ring stronger. Dr. John Wood, of London, devised a truss for in- guinal hernia with a pad shaped somewhat like a horse- shoe. He recommends it as a retentive appliance in Fig. 4100.-Moc-Main Truss. at its extremity. When this lever is drawn down firmly by the peri- neal band, which is attached to the knob, it bears upon the spring, and the lower portion of the pad can be made to press quite firmly against the body. If properly made, it is one of the best of the belt trusses. Stagner's truss, with a wooden block, grooved upon its abdominal surface so that by its pressure adhesive in- flammation might be caused, was much vaunted in the place of an ordinary truss, and also to be worn after his operation for radical cure to prevent a return of the hernia. He thus describes it: " The pad for oblique in- guinal hernia is made with a flat surface, rounded off smoothly at the borders, and of the shape of an oblique horseshoe, with the outer or inferior limb shorter than the inner or superior. A cleft about three-fourths of an inch long and half an inch wide, intervenes between the ends of the horseshoe, Fig. 4104. This is for the lodg- Fig. 4103.-Hard Rubber Truss. 257 Trusses. Trusses. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ment of the spermatic cord as it lies upon the groove of the outer pillar of the superficial ring, external to the pubic spine, which is also placed, when the truss is properly fitted, in the cleft or groove. " The mobility of the healthy spermatic cord is so great that, when the pad is placed upon the inguinal canal so that the cleft is opposite to the pubic spine, looking downward and inward toward the testicle, the cord slips into its proper place under pressure of the ends of the pad, -while the upper rounded border presses upon and prevents protrusion through the deep or internal abdom- inal ring. The spring is fixed • by a screw upon the geometric / centre of the oval pad, so as bear equally in its pressure Jr upon the deep and superficial rings. It is held by a screw, which, when slackened, al truss with a single spring and a pad mounted upon each end. This form of double truss is very objectionable. It is almost impossible to fit it so that it can be worn with comfort. The whole force of the spring is exerted upon the pads, pressing them together in front, so as to either impinge upon the spines of the pubis, or to press upon the spermatic cord. If a shorter spring is selected, which will not reach to the pubis, it will then press un- comfortably upon the alae of the ilium, unless the person be very fleshy. Many surgeons recommend the use of a double truss in all cases of single hernia. They argue that a double LEACH & GREENE, Boston. SECTION Fig. 4100.-Double French Truss. Fig. 4104.-Horse-shoe Pad. truss can be worn as easily as a single one ; that it re- tains its position upon the body more surely, and that the existence of a hernia indicates a tendency to weak- ness of the rings. By supporting the sound side, the patient is assured against a second hernia, and it enables the use of a lighter pressure than would otherwise be necessary. The reasoning is sound and the practice sen- sible. The utmost that can be urged against it is, that it is an excess of caution. For femoral hernia, an entirely different style of truss is required. The spring should be light and very elastic, clasping the body closely without great pressure. The bow of the spring should be short enough not to carry the pad so far forward as to press upon the ramus of the pubis, as such pressure soon becomes intolerable. The pad should be small and quite convex. A water-pad is preferable to all others, as its pressure will be better lows the rotation of the pad until the proper obliquity and right bearing upon the inguinal canal are obtained, when it can be fixed by tightening the screw with a small screw-driver. The studs on the ends of the horseshoe are for the attachment of an understrap when this is needed." I experimented quite extensively with this horseshoe pad some years ago, when Dr. Wood's operation was first introduced into this country, and while it answered a very good purpose in some mild cases, I failed to dis- cover any especial advantage over the other forms of pads already in use; and in many cases it utterly failed to hold the hernia before and after the operation for rad- ical cure. The use of the ring pad for direct inguinal hernia, Fig. 4105, I must dissent from entirely. If the hernia is at all difficult to retain, there must be pressure Fig. 4105.-Ring Pad. Fig. 4107.-Double Water-pad Truss. brought to bear upon the spermatic cord and pubic spine, which would be excessively uncomfortable as well as in- jurious. Double trusses, whether for inguinal or femoral rupt- ure, should be made with two springs. These may be attached by screws to a well-cushioned back pad, or, as in the case of the light double French truss (Fig. 4106), or the double water-pad truss (Fig. 4107), the posterior portion nf the springs may be broadened and well padded so as to rest easily upon the back. Being connected by a leather strap and buckles, the truss can at wrill be readily made smaller or larger. By having holes in the springs, a similar change can be made in those attaching to a back pad. The back pad should be stuffed the fullest at either end, so that the greatest amount of pressure may be brought upon either side of the spine. A back pad should always be flexible and never made of a stiff plate of metal. When the springs are screwed to such a pad, it is practically one contin- uous spring. Some manufacturers make the double borne in this sensitive region. A perineal strap is indis- pensable. See Fig. 4113. A great diversity of opinion exists among surgeons as to the form of truss to be used for umbilical hernia. Some recommend a single spring encircling three-fourths of the body, with an oval-shaped pad upon the end, cov- ering the umbilicus. Others use two springs, attached by hinges to the front pad, the end of each spring termi- nating in a small pad resting upon the back on either side of the spine. The truss is held in place by a con- necting strap. Various forms of belts are used-from a simple elastic webbing to a full abdominal bandage with a pad inside, to give support over the umbilicus. Great diversity exists also in the forms of pad to be employed. Some insist upon a simple flat surface ; others make it slightly convex. A pad, w ith a central projection to fill the umbilical cavity and press upon the ring, is claimed by the ma- jority to be essential. The minority advocate the 258 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Trusses. Trusses. opposite view, insisting that the projecting centre tends to press into and open the ring, and that the proper pad is one shaped like a ring, pressing around the umbilical opening and not into it. It does not seem to me that this theory of the minority is well founded. In some few cases, with a navel without depression, and on a level with the surface of the abdomen, the simplest support will suffice to retain the hernia ; but where there is a deep umbilical cavity, an open ring, and an easily protruding intestine, a ring-pad, pressing around the umbilical ring, will not close it. On the contrary, it will allow the intestine to enter the ring and act like a wedge to distend it. An oval plate, sufficiently large to extend some dis- tance outside the ring, with a central projection large enough to completely fill the umbilical cavity and cover the opening, without pressing into it, will best fill the in- dications for either a retentive or a curative apparatus. A large majority of umbilical herniae are in females. In adults, especially those who are fleshy, it will be found exceedingly difficult to keep a spring truss in position. It is extremely liable to displacement, result- ing in the escape of the intestine. After an extended trial for many years of various forms of trusses which have been devised, I have found nothing which gives so much satisfaction as the belt truss shown in Fig. 4108. It retains the hernia much attached to the back of the supporter. By this means, any desired pressure may be made upon the hernia, while general support is given the abdomen. The same principles hold good in the treatment of um- bilical hernia in children. The spring truss, with its tendency to displacement, is being very generally dis- carded, and I have found nothing better than the soft buckskin-lined elastic belt shown in Fig. 4109. It is more comfortable for the child, easier to ap- ply, and the degree of pressure required can lie regulated to a nicety by the side buckles. The constant tendency of the belt to slip down in infants, arising from their form, can be over- come by pinning the webbing tag on the front pad to the waist or underclothing. Oc- casionally a case will be met where, from some peculiarity of the form or unusual restlessness of the child, a broader belt will retain its place better. This can be made of silk or cotton elastic, or of jean or coutil, with elastic webbing bands in the back and an umbilical pad in front. A permanent cure may be confidently looked for in the great majority of cases where this belt, or any other which completely retains the hernia, is care- fully applied and faithfully worn for a few years. A like favorable result, as regards permanent cure, may be hoped for in inguinal hernia of children, provided a proper truss is applied which never allows the descent of the intestine. As before stated, a hard pad should not be used on account of its tendency to cause absorption of the tissues. With this proviso it matters but little what truss is used, so long as the retention of the hernia is constant and complete. The simplest and most efficient that I have found is the child's French truss, illustrated Fig. -1109.-Child's Umbilical Truss. Fig. 4108.-Umbilical Belt Truss. better, is less likely to slip up, and can be worn with greater comfort than any other. It consists of a belt of heavy webbing, lined with buckskin, with elastic bands in the back separated by a spring which prevents them from drawing together. This belt is attached by buckles to a front pad, with a felt or water-filled projection in the centre. This projection should be of sufficient promi- nence to fill the umbilical cavity, and press upon the ring with force enough to retain the hernia. The proper adaptation and adjustment of this central projection to the individual case, is of vital importance to its success- ful treatment. Cases are frequently found in which a truss has been worn for years, but with a projection of insufficient depth to perfectly close the ring, with the result of allowing the escape of a mass of intestine and omentum spreading over the abdomen, dissecting up the adipose tissue, and forming a large flattened tumor, which in many instances has become adherent and irreducible. Another troublesome class of cases is that in which the hernia has existed for years, and no effort has been made either to reduce or to retain it. In the majority of these cases the tumor is largely omental, and is very apt to have become adherent. The proper treatment of these difficult cases will be described under the head of irreducible her- nia. In some peculiar forms the use of the perineal straps, to prevent the belt from slipping up, will be re- quired. These can be made of firm canton flannel, and a sufficient supply should be made for change or washing. In some cases the abdomen is so heavy and pendul- ous that it requires support as well as the hernia. Such cases can be treated with a firm linen belt, made to accurately fit the form, or a silk elastic belt. Inside of the belt a proper pad is adjusted over the navel. To this pad, outside of the belt, is attached a light semi-ellip- tical spring, the ends of which buckle to elastic bands Fig. 4110.-Child's French Truss. in Fig. 4110. The style for double inguinal hernia is shown in Fig. 4111. Water-pads, or those stuffed with hair, are best. Owing to the ceaseless activity of children, and the numberless positions they assume, a perineal strap should always be used. In applying a truss to infants, care should be taken not to allow the pad to press unduly on the spermatic cord. If this precaution be not observed, irritation of the cord and oedema of the scrotum may ensue. Ventral hernia may be best treated by some form of belt and a pad adapted to the case. Each case has its pe- culiarities of location and form, which will tax the in- ventive genius of the surgeon. At the present time, when laparotomy is so common, the increase in ventral hernia has assumed alarming proportions. Much of this 259 Tnbercnlar Disease. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. might be prevented by proper precautions. A surgeon who will allow his patients to go about, after an incision of the abdominal walls, without proper support, is guilty of gross carelessness. Nor is it enough to direct them to apply the ordinary abdominal supporters of the shops. The supporter should be made of proper material, fitted with the utmost accuracy, and, as the one thing indis- pensable, should have a pad over the line of the in- cision. This pad ought to be from two to two and one- half inches wide, and should be a little thicker at its most dependent portion. Having been called to treat so many of these cases of late, I feel that I should be derelict in my duty if I did not call special attention to this matter. Irreducible herniae are almost invariably the result of neglect. They are largely omental, and are most fre- quently found in the femoral and umbilical varieties, al- though not infrequently in the inguinal region. These cases, until within a few years, have been generally con- sidered amenable only to palliative treatment. Dr. J. Collins Warren, of Boston, has, however, re- cently demonstrated that a large proportion of supposed irreducible herniae, even those of many years' standing, may be reduced if the patient will submit to confine- ment and the requisite pressure for a sufficient time. The time will vary from ten days to as many weeks, ac- cording to the severity of the case. His method is to put low-pad truss (Fig. 4112). In children, if the testicle can be brought through the external ring, so that a truss can be applied to retain the intestine, and not press upon the testicle, it should be done. The cord will usually elongate and the testicle gradually de- scend to its place in the scrotum. I have been called to treat but three cases of perineal hernia, and was able to retain them by the use of a conical hard rubber pad, held in position by straps buckling to a pelvic belt. A few suggestions in regard to the method of applying a truss may be of value to those who have had but slight experience. Having taken the measure of the pa- tient-which should always be around the body on a line with the hernia-and selected the truss, place the patient on his back upon a lounge, if the hernia is one that descends without exertion when stand- ing. A majority of herniae will slip back unaided in a few moments after the patient has assumed the recumbent posture. Should the hernia be obstinate and not yield to very gentle pressure, grasp the mass of the tumor with the right hand, pressing it gently, yet forcibly, toward the ring, at the same time applying the fingers of the left hand to the constricted end of the sac, where it en- ters the ring. With these fingers of the left hand around the aperture of the sac, the intestine can be directed into the ring, care being taken to prevent its pressing over the upper edge of the ring, or into the cellular tissue on either side. While pressure is being exerted upon the main body of the tumor, its neck can be compressed by a kneading pressure of the fingers of the left hand. In most cases it will yield in a few moments and slip back into the abdomen. If the patient is nervous and excited over the thought of a painful operation, holding his breath and resisting the efforts at reduction by the ten- sion of the abdominal muscles, he should be left alone for ten or fifteen minutes, and allowed to rest quietly upon his back. Upon renewing the effort the reduction will often be easily accomplished. If the hernia is not sensitive nor the pressure painful, it may be continued for some time and with considerable force. Sometimes a bag of ice-water or pounded ice may be applied for twenty minutes with advantage. The head should be placed as low, or a little lower than the hips ; the knees raised with the soles of the feet flat upon the lounge. The thigh of the affected side should be rolled inward so as to relax the fascia of the limb and aponeurosis of the external oblique muscle. When the hernia is reduced, pass the spring of the truss under the hips of the patient, making sure with one hand that there is no protrusion of intestine ; with the other place the pad over the ring, so that it will press upon the whole length of the inguinal canal, with its lower edge slightly lapping the bone and Poupart's liga- ment, that, in making exertions, there may be no unpro- tected space between the pad and bone to allow the rupt- ure to escape. Grasping the free end of the spring, it should be drawn tightly so as to fit closely to the body all around. The strap, or belt, should now be fastened with a sufficient degree of tightness to hold the truss in its position, but not to occasion discomfort. The pa- tient may now be allowed to rise, and before permitting him to test the truss, it should be carefully examined to see if it is properly adjusted in all respects. The pad should rest evenly upon the body, pressing a little more at its lower margin than at the upper. The spring should rest upon the affected side about midway between the trochanter and the anterior superior spine, passing across the back slightly above the swell of the nates, with the free end resting just below the crest of the ilium. If the pelvis is broader at the trochanters than at the iliac crests, and the abdomen is flat, a peri- neal strap will be required to prevent the truss from slipping up. In elderly persons, with wasted glutei muscles, a suspender may be required to prevent the Fig. 4112. - Hollow Pad. Fig. 4111.-Child's Double French Truss. the patients upon their back, raising the foot of the bed from eight to twelve inches. Continuous pressure is then put upon the hernial tumor by means of water-pads, sand-bags, and elastic bandaging. In cases of large scrotal hernia, he has used a " rubber water-bag, externally inelastic, but containing an elastic lining inclosing a space to which air or water could be admitted by a tube." This bag was placed over the tu- mor and held securely in place by a T-bandage, which formed part of the apparatus. When firmly buckled in position, any escape around the mouth of the bag was prevented by pressing it down upon the pillars of the ring with blocks arranged for that purpose. Any desired pressure upon the hernia could now be made by forcing in water to the internal compartment. In several cases, after some weeks of preparatory pressure, the hernia yielded to this unique method of applying force, and was driven through the ring. In umbilical herniae, unless very intolerant of pressure, much less time will be required for this reduction. From three days to three weeks will usually be sufficient. If the patient is not willing to submit to this method of treatment, then a truss with a hollow cup-shaped pad should be used. In umbilical hernia such a belt and pad are easily arranged, and, if the tumor is not too large, are worn with much comfort. I have seen many cases of omental femoral hernia where, after the use of a hollow pad truss for some months, the omental tissue became so lax and flabby that, by a slight effort at taxis, I was en- abled to reduce it and apply an ordinary truss. For scrotal irreducible hernia a firm bag-truss should be employed. Occasionally the physician will find an un- descended testicle lying in the inguinal canal, with the intestine following it through the internal ring. In adults, these cases are best treated by the use of a hol- 260 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. J^rlular Disease. truss from slipping down. The truss having been ad- justed satisfactorily, the patient may be allowed to test its retentive qualities. This may be done by coughing, stooping, lifting, and reaching above the head. If the truss stands the test, remaining in position, retaining the hernia, and not causing discomfort by improper pressure, the patient may be dismissed with the injunction to avoid all violent exertions, or efforts to force the hernia past the truss. Some patients seem possessed with the incli- nation to be constantly trying their truss to see if it will hold, when they should favor it all they can after they have commenced wearing it. In adjusting a truss for femoral hernia, care should be taken to select a very light elastic spring, one that will clasp the body firmly with strength enough to hold the hernia, but not to press upon the nerves and arteries so as to cause discomfort. The bow of the spring should be much shorter than for inguinal hernia, to prevent the carrying of the pad so far forward as to press upon the ramus of the pubis. Such pressure, although it may be slight, will soon become intolerable. The free end of the spring should be long enough and so shaped as to reach over and clasp the opposite hip, thus preventing the liability of displacement. The pad should be small, ovoid, or triangular in shape, quite convex, soft and elas- tic, yet firm enough to retain its form. It should be so adjusted as to bed itself in Scarpa's triangle ; its upper edge pressing firmly against Poupart's ligament. The ovoid form of water-pad will be found the best for the larger proportion of cases. A perineal strap fallacious character of this expectation and the reasons for rejecting this theory of cure. The truss which most completely prevents the entrance of the intestine into the canal, without causing absorp- tion of the tissues by too unyielding pressure, is the best truss, and the one most likely to result in a permanent cure. Instead of adhesive inflammation ot the parts subjected to pressure, the deposit of lymph in the canal, and the agglutination of the tissues, the real anatomical change which wre may seek and expect in the treatment, with a truss, for the permanent cure of hernia, is the contraction of the muscular and tendinous structures of Fig. 4114.-Cross-body Radical Cure Truss. the hernial apertures. To accomplish this object, the perfect retention of the hernia within the abdomen for a considerable length of time is necessary. As it is therefore on the retentive pow'er of the truss that the surgeon must depend, he should direct his best efforts to obtaining for each individual case the most complete and perfect adaptation of a truss possible. If, with all his effort and care, he still fails of a radical cure, he will at least have the satisfaction of knowing that he has adopted the best palliative course of treat- ment for the disease, even in those cases where there is scarcely a remote possibility of a permanent cure being effected. In inguinal and umbilical herniae of children, the great majority might be permanently cured by the use of a truss, if sufficient care w'ere taken to secure perfect and continuous retention of the hernia. Many parents lack sufficient intelligence to properly care for their children, or are too careless to appreciate the necessity for a more vigilant oversight to secure the desired result of a per- manent cure. They should see that the truss is properly applied, worn continuously, and renewed whenever it becomes weak and used up. Under such conditions, cures would be the rule and not the exception. After twenty years of age the chances for a cure are very much lessened, and the physician should be exceedingly guarded in his prognosis. While a considerable number of cures do occur in the healthy and vigorous in youth and middle age, sometimes even after the dead line of fifty has been passed, still these are comparatively fewr. To secure the most favorable conditions for a cure, the patient should have three trusses : one for day use, a belt truss to sleep in, and a truss to bathe in. With these provisions for all emergencies the hernia should never be allowed to protrude. Nathaniel Greene. TUBERCULAR AND SYPHILITIC DISEASE OF THE KIDNEY. I. Tubercular Disease.- Tuber- cular disease of the kidney has been described under two forms : the miliary tubercle and the large solitary or in- filtrated tubercle. The miliary tubercle, as ordinarily seen, is merely one of the features of general tuberculosis, and probably rarely gives rise to symptoms which can with certainty be recognized ; it is merely a post-mortem feature in cases of pulmonary or abdominal tuberculosis. In the other form, the lesion usually presents itself in large masses which occupy a greater or less portion of one kidney, though both may be affected, and should not w'ith justice be described as tubercle any more than we would speak of a cheesy mass in the lung due to ca tarrhal pneumonia as a tubercular mass. Whether it may happen that these large masses in the kidney can be produced by miliary tubercle originating Fig. 4113.-Femoral Water-pad Truss Applied. should always be used. Fig. 4113 represents such a truss applied. Various trusses have been devised for the radical cure of hernia, and many such are still advertised in the news- papers and journals. They are generally the product of enthusiasts or charlatans-largely the latter. By hold- ing out the hope of a permanent cure, enormous sums are obtained for them. A cure is guaranteed (?), with no other basis than the verbal assurance of the vender, the money always being secured in advance. An occasional closure of the ring in an exceptional case-which may be obtained with any truss-is heralded far and wide, and secures fresh victims. Though differing in details, they all act upon the same principle. A small oval projection of wood, ivory, or hard rubber is usually placed in the centre of a soft pad, as represented in Fig. 4114. This is placed so as to press into the external ring very forci- bly, with the hope of exciting adhesive inflammation, and closing the canal. I have already pointed out the 261 Tubercular DUeaZe' REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. in the kidney itself or in the urinary passages, just as we see large masses originating in the lungs as the result of primary miliary tubercle, is a question hard to settle. Cases are comparatively so rare that a judgment of the matter is difficult to form. The probabilities seem to point the other way, namely, that they do not owe their origin to miliary tubercle ; but, on the other hand, they may, as such masses do in the lung, give rise to second- ary miliary infection either of the kidney and the urinary passages, or of the general system. Miliary tubercle, as seen in the kidney, gives rise to very little alteration in the general appearance of these organs. They are, as I have said, found there as one of the phenomena of the post-mortem examination of a case of general or local miliary tuberculosis ; the kidneys are not found enlarged in size or otherwise altered, except directly at the seat of the tubercle ; here there is a zone of congestion. The tubercles rarely exceed in size a small pea or cherry-stone, and may be so small as to be invisible to the naked eye, and are only to be discovered in a section under the microscope. A single tubercle is usually rounded, and when tuber- cles present other shapes than this it is due to their aggregation in clusters. These aggregations may be very irregular in shape, and even present themselves as streaks or striae. The larger- sized tubercles are masses produced by aggregation of several, and may present conditions of softening, but a single tubercle is rarely otherwise than firm, even at its centre. The tubercles are found mostly in the cortical portion, but no part may escape their deposit. They are probably more numerous at the surface, showing well through the capsule of the kidney. Here they are found jutting above the surface as little rounded masses of a white color, and in this situation the surrounding zone of congestion is usually more marked than when they are placed in the deeper layers. Tlie capsule is always adherent over them, even while in the other portions it may be separated with greater ease than normal. In the kidney where any miliary tubercles are dis- coverable by the naked eye, very many more may be found by the microscope. The appearance of the younger tubercles is, of course, very little characteristic. They consist of aggregations of the usual indefinite cellu- lar elements found in the intertubular connective tissue. As these cellular elements increase in number their first effect seems to be to press upon the capillaries around which they are seated, resulting in a more or less complete obstruction to the flow of blood. Beyond the limits of these cellular aggregations the capillaries show dila- tations, resulting from the damming up of the blood unable to And its way through the area of infiltration. The next effect of the cellular elements thus aggrega- ted is on the epithelium of the renal tubules. These epithelial cells show swelling and granular changes, and the basement membrane of the tubule becomes thickened. Later the tubule becomes dis- torted and is lost in the increasing number of new cellular elements. Occasionally a tubule will remain, presenting appearances not unlike the giant cell ; how- ever, at this early stage the remains of the tubule can be distinguished from a giant cell by the traces of the base- ment membrane. Usually the epithelial cells perish before the basement membrane wholly vanishes. In other cases, where the aggregation of cellular elements is very rapid, the tubules in the way of the newly forming tubercle undergo rapid granular and fatty degeneration, giving evidence of their presence by debris not unlike the cheesy appearances presented by older tubercles. At this stage evidences of reactive inflammation in or around the tubercle, such as are seen in gummata or in morbid growths, are wholly wanting; the original struct- ure of the part usually breaks down rapidly. By this feature one ought to be able to differentiate tubercle from other formations even in this early and uncharac- teristic stage of their formation. Still later the tubercle, when it has increased to a size which renders it visible to the naked eye, presentsappearances under the microscope wholly similar to those found in tubercles of other organs or tissues ; the debris of the original tissue has vanished ; the capillaries have disappeared ; they grow by extending peripherally, and they undergo the same central degeneration, while the peripheral parts show evidences of active growth and accretion. In the ma- jority of cases which have fallen under my observation the central softening or degeneration has not advanced far, and the changes that we subsequently find tubercles undergoing in other organs or tissues do not seem to take place ; death, through the general effects of the miliary deposits going on in the other organs of the body, arrives before the kidney tubercles have become far advanced. As I have said, the tubercles, while not solitary, are usually isolated ; but where an aggregation takes place, when several tubercles closely placed unite at their bor- ders and form what looks to the naked eye like a large tubercle, the central softening becomes more apparent, and is further advanced than is usually the case. It is very rare, however, to find actual fluidity of these central portions, much less to have a cavity forming. The deposit of miliary tubercles in the kidney probably adds very little or nothing to the symptomatology. Though many cases in which miliary tubercles are found, at the post mortem, show albumin in the urine, the clinical history shows that they invariably have a high temperature; it, therefore, becomes impossible to decide whether the albumin is the result of the high tem- perature, as we see it in other febrile diseases, or is due to the deposit of tubercle. There are, however, cases w-hich I have observed where it is possible to assert that at least a portion of the albumin results from the forma- tion of miliary tubercle. These are cases in which there has been the temporary appearance of blood in the urine. Now, the explanation of the presence of the blood is readily accounted for by a comparison of the microscopic appearances of the kid- ney. It is undoubtedly due to the over-distention or dilatation of the capillaries at the periphery of the tuber- cle. This dilatation is almost invariably present at some stage or other of the formation of the miliary de- posit, and, in consequence of this over-distention, the blood-pressure in the capillaries gives rise to the exuda- tion of blood-corpuscles, which find their way into the renal tubules, and thence make their appearance in the urine. Although the number of blood-corpuscles escaping into the tubules under these circumstances is never sufficient to give the appearance of smoky urine, yet in many cases where a suspicion of miliary deposits in the kidney has arisen, a careful search has shown me the presence of a few blood-corpuscles. It is not an unfair inference, therefore, that at least a portion of the albumin is due to the exudation of blood serum thus resulting. Its amount in these cases is never great ; and, according to my experience, it would be fair to conclude that a large amount of albumin indicated some other form of kidney disease than that due to the formation of miliary tubercles. I have never been able to find tube-casts, nor even blood-casts, in the urine of any case which did not show post mortem other renal changes than those of miliary- tubercle. In all cases, therefore, the existence of mili- ary tubercle in the kidney can be predicated only with great uncertainty, and the cases must be even more rare in which the presence of these miliary deposits can give rise to symptoms connected with the disabled condition of the kidney, or in which they do in any way contribute to the fatal result. The so-called diffuse or solitary tubercles of the kid- ney require careful and minute study, not merely in re- gard to their mode of origin and formation, but more especially in reference to their symptomatology. As I have said, the miliary tubercle, as it occurs in the kid- ney, is to be looked upon as merely a local manifestation of a general constitutional disease in which the kidney is affected along with the other organs of the body ; while 262 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. J^ereular the diffuse or solitary tubercles of the kidney, often called strumous pyelitis or scrofulous nephritis, or the inflammatory form of tubercular disease of the kidney, seems to me a purely local disease. It may, however, lead to a general systemic infection, as we see scrofulous or inflammatory deposits in other portions of the body doing the same. The kidneys in this form of so-called tuber- culosis invariably present great alterations, are manifestly much changed, and, to a greater or less degree, disabled, and the general symptoms which the patient presents are in connection with these organs. Not only do we And the kidney itself altered, but the urinary conducting apparatus is also involved. The or- gan as a whole is enlarged, usually irregular in outline, and the surrounding connective tissue shows evidences of change. On section of the kidney it is principally the pyramids which are affected, and with these the pelvis of the kidney and the ureter are greatly altered. The con- dition of these tissues, and the degree of their alteration or involvement, varies in almost every case. The condition is almost invariably a prolonged chronic disease. The statements made by various authors concerning this af- fection are, however, very various and contradictory. These contradictions are largely due to the varying views on the pathology of tubercle in general which are held by these authors. The statistics as to the age, dura- tion, and the character of the symptoms, as wTell as their features are, in the same way and from the same cause, useless. On no one point do writers so frequently contra- dict each other as in speaking of the frequency with which one or both organs are involved. In speaking of the symptoms there is also constant confusion made by writers in regard to the two forms of tubercular disease of these organs. This form of tubercular disease of the kidney has been known from early times. Morgagni gave a good descrip- tion of it, but Bayle was the first to furnish the particulars of how the alteration was brought about. He described the changes in the kidney, the ureters, the bladder, the prostate gland, the testicles, and the vesiculae seminales. Later, very many authors have furnished good descrip- tions of the disease: Howship, Marechal, Duchapt, Craigie, Pasquet, Bayer, and especially Lacorche and Henry Morris-the latter in relation to the surgical as- pects of the question. These authors differ greatly as to the period of life at which tubercular diseases are found with the greatest frequency. Those who consider the two forms of tuber- cle under the same head make the statement that tuber- cular disease of the kidney is more common in children than in adults ; and doubtless this statement is true, since it is especially true that general miliary tuberculosis is more frequent in childhood than in adults, and in gen- eral miliary tuberculosis the kidneys are as likely to be affected as any other organ of the body ; but diffuse tu- bercle, or strumous pyelitis, is undoubtedly much more common in adults than in children, and more frequent in men than in women. The reason for this will be re- ferred to later. In speaking of the causes no definite statement is made by the majority of authors. As we have already said, the cause of miliary tubercle in the kidney is the same as the cause of the general tubercu- losis, whatever that may be ; but the cause for the pro- duction of the diffuse form in the kidney I believe can be traced invariably to morbid conditions of the parts sur- rounding, or connected with, the kidney ; in other words, the alterations in the kidney are not primary, but the organ is affected secondarily. That the general condition known as struma underlies, in all probability, all the cases in which tubercular dis- ease of the kidney develops, is probably true. In other words, it is unlikely that any patient would develop this form of inflammation in the renal organs unless the con- dition of struma was present. An inflammation devel- oped in the kidney by the same cause would, in the strumous case, lead to tubercular disease, while, in a pa- tient not strumous it would, in all probability, give rise to simple suppuration or abscess. The causes, therefore, of tubercular disease in the kidney are numerous, and their action begins in very different parts of the urinary excreting apparatus. The one essential feature which these causes must pos- sess in common is the power to propagate the inflamma- tory condition to the kidney, usually directly through the ureter as the last step in their line of march, and, secondly, they must bring about such obstruction to the outflow of the urine, as well as of the inflammatory prod- ucts forming in the pelvis of the kidney, that the func- tion of the organ ceases and the inflammatory products are retained. Without this retention the highest form of development of tubercular kidney cannot be brought about. Whether the various causes, if acting in the manner above described, can produce the so-called tuber- cular kidney in a non-strumous individual, is doubtful. It would seem, however, from some of the reported cases, that struma is not an essential factor. The doubt arises principally from the indefiniteness concerning what is to be called struma. When wTe study the cause of dif- fused tubercle of the kidney from this point of view, we can point to many conditions which may give rise to it. Tubercular disease is very constantly spoken of as commencing at the renal papillae and extending thence deeply into the kidney, as well as to the pelvis, and down- ward through the ureter to the bladder; but from the examination of a large number of carefully reported cases I have failed to find the evidence on which to base the conjecture that the initial step in the disease is in the kidney; in fact, I have failed to find a single case in which there was a reasonable probability of such an ori- gin. . . Many cases are published' in which the statement is made that such was the initial point of the lesion ; but in all cases where the clinical history of the patient is fur- nished, there is invariably evidence to be found that the patient had suffered, at a period sometimes quite remote from death, from disease affecting the urinary conduct- ing apparatus somewhere in its course. And further, it will be found that the disease was excited by some one of the various causes capable of producing an inflamma- tion, anti at the same time of obstructing to a greater or less degree the outflow of urine. These causes may be looked for in such conditions as an exceedingly tight phimosis in the young child, a stricture of the urethra, or the cystitis which results from it, or which results di- rectly from the gonorrhoeal inflammation which produces the stricture ; or again, wre may have an irregularly en- larged prostate gland which obstructs the outlet of one of the ureters ; or w*e may have one of those mysteriously caused strumous inflammations of the testicle, or of the vesiculae seminales ; or in women we see the affection ex- cited by some one of the inflammations occurring in the pelvic cellular tissue, at points where the inflammatory products may press upon and obstruct the ureter ; or it may be by so simple a cause as a uterine or ovarian tumor, wfliich acts in the same manner. Of course, cystitis in the female may produce the same result as in the male. It is in the different relations of the urinary conducting apparatus in men and women that we find the reason for a greater number of cases in men than in women. Let us trace out how these causes act. An inflammation seated in the mucous membrane of the urinary conducting apparatus is the first and es- sential feature. No amount of obstruction alone and by itself can be looked upon as a sufficient cause for the production of the tubercular disease of the kidney ; there- fore we should expect that the causes among those be- fore mentioned which have as their essential feature an inflammatory element, would be the ones most likely to lead to such an affection ; for example, a gonorrhoeal in- flammation of the bladder is a hundredfold more likely to lead to kidney disease than is simple pressure on the ureter by a uterine fibroid. Uterine fibroid is very potent for obstruction, and it may cause inflammation ; a gonor- rhoeal inflammation passes readily to one or both ureters and thence to the kidney, and can easily be conceived to be so violent in degree, and accompanied by so much swelling, that the ureter may become obstructed. In either of these instances we see the groundwork 263 Tubercular Dim"*. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. laid down for the production of tubercular destruction of the kidney. A simple obstruction of the ureter is probably never sufficient for the production of the dis- ease, since the mere retention of the urine is not sufficient of itself to excite inflammation. The pressure of the re- tained urine causes the secretion to cease, and the kidney, so far from becoming inflamed, may become anaemic through internal pressure of its retained secretion. The occurrence of inflammation in the pelvis or sub- stance of the kidney, or in the ureter, produced by a cal- culus in any of these situations, without a simultane- ous obstruction to the flow of urine toward the bladder, leads not to tubercular disease, but to ordinary suppura- tion with pus formation. The retention and subsequent inspissation of the inflammatory products, whatever may be the cause of the inflammation, must be viewed as an essential factor in the production of the complete picture of tubercular disease of the kidney. Let us trace the course of the inflammation, for ex- ample, in a case of cystitis. Suppose gonorrhoea to be the cause of the cystitis (there are very many such cases on record), then the tubercular disease of the kidney may result promptly, long before the production of a stricture of the urethra; the inflammation of the mucous mem- brane of the bladder, especially if it be of a virulent character, extends to the ureter ; a sufficient degree of swelling occurs at the orifice of the ureter to cause its closure, but the inflammation continues to extend toward the pelvis of the kidney. The retention of the inflammatory products tends to make the inflammation continuous. As soon as the ob- struction of the orifice of the ureter is complete, the re- tention of the urine thereby effected causes the cessation of the renal function so soon as the pressure of the re- tained fluid equals the blood-pressure within the capil- laries ; but the inflammation does not cease. The calyces and the apices of the pyramids are bathed with the re- tained inflammatory materials. The inflammation ex- tends directly through the conducting tubes of the pyramids, or indirectly to the kidney substance at their base. In not a few specimens we find the inflammatory changes pursuing this mode of extension, death result- ing before the kidney is involved to any great degree. In the later stages of the process, however, all the tubes of the pyramid become involved, and their lumina become filled with the inflammatory products, which rapidly undergo degenerative changes. The kidney examined at this stage of the disease shows a considerable degree of swelling, one or more of the pyramids are seen on section to be so markedly swollen as to have lost their usual conical form, and to have become more nearly circular or spherical. Their tissue is more or less hard according to the degree of the de- generative changes. Their color is pale; they seem devoid of blood at their periphery, and in the cortical portions connected with the obstructed pyramids there are distinct evidences of reactive inflammation or of con- gestion. The other pyramids of the kidney to which the inflammatory process has been slow to extend, and whose tubes have not become obstructed, show a high degree of redness. The kidney as a whole, under these circumstances, has a very irregular outline, presenting protuberances of the surface at parts corresponding to the obstructed pyra- mids, while the other portions, retaining their usual level, appear sunken. At a more advanced stage all the pyramids become involved, provided the closure of the ureter remains perfect, and then we find all the pyramids passing through the stages of inflammation and obstruction which have just been described. Later, softening, more or less com- plete, occurs in the pyramidal areas thus involved, and with this softening the size of the kidney becomes much augmented, its outline is very irregular, and its surface is beset with regular rounded protuberances correspond- ing to each pyramid. The color of the surface of the kidney varies according to the nearness with which the cheesy softened masses approach it. In some instances the masses have actually reached the surface, probably by way of the straight tubes of the pyramids of Ferrein. In these cases the surface shows a greater or less number of yellowish spots irregularly distributed over it. In other instances it is uniform in color and usually pale, except perhaps in the furrows between the lobules of the kidney. The large veins of the capsule are usually distinctly to be seen over this otherwise anaemic surface. If the softening is far advanced the most protuberant portion can be felt to fluctuate under the finger. On section of such kidneys we find the areas corresponding to the pyramids presenting a varied appearance ; in some the consistence is very firm, in others the tissue breaks down under pressure like a soft, dry, cheesy material; while in others, again, the structure has been entirely lost, the whitish or yellowish material flowing out like thick cream, and leaving a cavity with irregular sides. In all portions of the cut surface in cases of tubercle, the softened central areas are seen to be surrounded by the remains of the cortical substance reduced to varying degrees of thinness, according to the degree of extension of the central softening. In some cases it has seemed to me that the cortical portion was considerably thickened, and probably swollen, as the result of reactive inflam- mation. This is true only of the largest-sized specimens. The pelvis and ureter have greatly thickened walls, and their mucous membrane is rough and irregular, and covered with adherent cheesy material which fills their lumina. The pelvis usually looks small in size compared with the greatly enlarged kidney. The ureter, however, has a greater diameter than normal, often two or three times, and feels hard, almost solid like a cord. Its lumen is increased, but the major portion of the increase is due to a thickening of its walls. Very commonly the lymphatic glands in the hilum of the kidney, on the ureter, or at the base of the bladder, are enlarged and sometimes cheesy. The statement is often made by authors that the tuber- cular disease of the kidney is quite as frequently bi- lateral as unilateral. Much confusion exists in these statements, and is to be explained in part by the confusion of nomenclature which fails to make a distinction between the miliary variety and the scrofulous kidney. The former is undoubtedly more likely to affect both kidneys, on account of the general dissemination of the tubercles in all the organs of the body in such cases. I have, however, seen instances where the miliary tubercle was confined to one kidney, although the general systemic dissemination was marked. In regard to the scrofulous kidney the matter is quite different, and it must be considered on another basis. To find, post mortem, typical scrofulous changes in both kidneys is manifestly not to be expected, since death would undoubtedly arrive long before the typical condi- tion could be developed in both organs. That a partial condition of scrofulous change may be found in both organs is very true ; it is rare, however, to find it equally advanced in both. According to my experience, it is exceptional to find more than one kidney affected with a genuine scrofulous or disseminated tubercular change. In fact, if the tu- bercular disease is at all advanced it is the rule to find the kidney of the opposite side enlarged, to make up for the deficiency of the other kidney. It is almost impos- sible to suppose that the cause which leads to the pro- duction of scrofulous kidney, namely, inflammation, with the simultaneous obstruction of the ureter, could be active on both sides without resulting in death almost immediately from suppression of urine. It is probable that, if both kidneys are affected, the causes have acted intermittently, first on one ureter and kidney and then on the other ; this would also agree with the conditions which most authors speak of, namely, that the disease is more advanced on one side than on the other when both organs are affected. The kidney which seems to be most commonly affected is the left, but no reason has been assigned why this one should be selected in prefer- ence to the other. Symptoms.-In the early stages the symptoms are not 264 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Jubercul'aJ DiZeasl' marked, are little characteristic, and not infrequently fail to direct our thoughts to kidney disease. Not infre- quently the symptoms are so slight as not to attract the patient's attention. The development is often so slow and so insidious that nothing.characteristic is present until the very latest stages. There is no certain sign by which we can recog- nize the presence or progress of the disease in the kid- ney. This uncertainty is what might be expected from what has been pointed out in relation to the mode of production, especially the obstruction of the ureter. This partial or complete occlusion to a great degree shuts us off from all knowledge of the state of the kid- ney. The symptoms which may attend the gradual closure of the ureter become confused with those de- pendent on the changes in the bladder or in the external urinary conducting apparatus. The urine may, under these circumstances, not be altered in quantity or quality. This is due to the fact that the other kidney almost in- variably remains unaffected. In other cases the urine is markedly altered in many of its characteristics, owing to the fact that the disease which leads to the kidney trouble commences in the bladder or in the urethra, and the altered qualities of the urine are dependent on the bladder affection rather than on the kidney changes. At all events, with the disease of the bladder present we are unable to recognize with certainty any changes in this fluid dependent upon kidney disease. In the majority of cases it is the closure of the ureter which prevents our gaining a knowledge of the state of the kidney. In cer- tain cases, in the early stage, the quantity of urine seems undoubtedly increased, or, at all events, this is a frequent complaint of patients. This feature is probably due to the irritation in general of the urinary apparatus. The urine is described as albuminous and alkaline ; this is due undoubtedly to the inflammation of the bladder it- self. In other cases it is said to be bloody or to contain pus, and this is probably due to the ulcerations of the bladder which are not infrequent in these cases. In not a few cases, however, the urine is found clear, acid, and otherwise of normal appearance. In those cases in which minute cheesy masses or debris of tissue, which can be recognized as of renal origin, are seen, the disease has undoubtedly approached a later stage, where softening has taken place and the retained cheesy matter is moving out through the ureter, which is no longer oc- cluded. Thus we have two groups of cases, the one in which the bladder is unaffected and the urine is normal, the other in which the bladder is affected and the urine presents the appearances usually seen in cystitis. In both groups of cases we may finally have urine con- taining matters characteristic of the tubercular disease of the kidney. It may also happen, in cases where the kidneys are af- fected in succession, that more or less complete suppres- sion of urine occurs, and is attended with uraemic condi- tions leading to death. Vesical irritation and frequent micturition are not infrequent symptoms even in the ab- sence of cystitis. Pain is not an habitual phenomenon. Apparently pain may occur as the initial symptom, attending probably the closure of the ureter, and then cease. The so-called tubercular matter or strumous deposits may, after their formation, remain temporarily quiescent, and even become permanently so, the cheesy or putty- like mass shrinking and becoming thickly encapsulated. In other cases augmentation of the size of the kidney re- sults through the continuance of the inflammatory con- ditions. In such cases the kidney, after a time, may be discovered as a more or less voluminous tumor in the flank, often non-sensitive, or at most giving rise to a sense of dragging or other discomfort resulting from the dis- placement of neighboring organs. The increase in the size of the diseased kidney is ap- parently due to the reactive inflammation which takes place in the organ or in the surrounding parts and this inflammatory condition is commonly accompanied with the softening and liquefaction of the cheesy material, add- ing to its increase in bulk. This process is commonly attended with great dis- comfort, and the symptoms due to it are often of a very marked character. They are such as usually attend the softening of such deposits-high temperature, sweating, and rapid emaciation. In other cases these cheesy masses in the kidney lead to a general systemic infection, and miliary tubercles result secondarily which are deposited throughout the system. Sometimes, how'ever, these de- posits are local, commencing more markedly around the affected kidney or spreading to the general peritoneum, and infecting the organs of the abdomen in general. Such localizations seem to result from the obstruction of the lymph-channels ascending directly from the kidney and its surrounding parts. In other cases, the lymph communication remaining unobstructed, the lungs become the seat of very abun- dant and rapidly formed nodules of miliary tubercle. In such cases the symptoms are so rapidly developed, owing to the abundance of the miliary nodules scattered in these organs, that death comes as if from a sudden congestion of the lungs or from pneumonia. The meninges of the brain do not escape the deposits of miliary tubercle. Instead of the rapid tuberculariza- tion of the lungs or of the peritoneum, with the abdominal organs, we may see cases of very slow development of disease in both of these situations, probably much more commonly in the lungs. Cases have been described in which, undoubtedly as the result of a scrofulous kidney, chronic pulmonary dis- ease has occurred. In such the first symptoms which have attracted attention are those dependent on changes in the lungs rather than in the kidney, in which, instead of innumerable miliary nodules forming in the lung, the few and often localized formations have led on to chronic catarrhal pneumonia with subsequent formations of pul- monary cavities. In these cases urinary symptoms have not been devel- oped until later, when through the general failure of nu- trition the renal deposits have become softened and are discharged, accompanied with characteristic urinary changes. I have seen cases in which the tubercular disease ex- isted in one kidney, where interstitial nephritis subse- quently developed in the other kidney. This was at- tended with the usual phenomena of this disease. The patient suffered from occasional periods of scanty urine, which was smoky and albuminous, and after a short course he died of uraemia. The tubercular kidney in this case was shrunken in size, and the other kidney showed but few of the charac- teristic appearances which the symptoms had led me to anticipate. It is doubtful if the changes occurring in the kidney last affected are truly to be regarded as those of interstitial nephritis or contracting kidney. They probably result from the kidney failing to enlarge and to become truly hypertrophied, and from the great congestion excited by the demand made upon the renal activity. The following cases, with their histories, seem to me to give the chief features of the disease ; and the drawings illustrate the gross and microscopic alterations which this organ undergoes in the two forms of the malady. Case I.-Large Tubercular Kidney.-The cut (Fig. 4115) shows the left kidney taken from a man aged twenty-three. He had suffered from gonorrhoea fol- lowed* by cystitis about a year previous to death. After a short time he had recovered from the cystitis, and the urinary apparatus apparently returned to its normal condition. He seemed well, attended to his business and made no complaint during this time, but later said that he had felt a weight or pain in the abdomen. A few weeks prior to death there was general malaise, gastric disturbance, and, later, symptoms like those of conges- tion of the lungs or of pneumonia, with high temperature, leading to death. There was pain in the region of the bladder, but no abdominal tenderness; frequent micturi- tion, often hourly ; the urine was not changed in amount, but, though some months previously it had been normal, it was found after the development of these symptoms to 265 Tubercular Disease* REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. contain catarrhal products, a little pus and albumin, but no tube-casts or other abnormal products. (No tumor was felt in the abdomen ; but, of course, none was sus- pected.) The family had no hereditary taint. At the autopsy the abdominal walls were found thick with muscle and adipose tissue, and there was no marked emaciation. Death had occurred from apncea. The brain was not examined (objected to). The serous mem- branes of the great cavities were thickly set with miliary tubercles, as well as the subserous connective tissue of the abdomen, but these membranes showed no recent inflammatory changes. The lungs were filled with fine miliary tubercles and deeply congested, but no solid areas, old or recent, were found. The right kidney was enlarged (compensatory hypertrophy) and much con- gested, but otherwise not altered. The right pelvis and ureter were normal. The left kidney was tightly adher- ent, and the tissue around it especially was thickly set with large, whitish, firm tubercles; it was greatly en- larged, measuring ten inches by six ; its outline was pretty well preserved ; its surface showed irregular prominences corresponding to the lobules of the organ ; the more prominent of these lobules fluctuated slightly, but the kidney was in general rather firmly elastic. On section, there were found large blocks, as it were, of yellowush- white cheesy matter, somewhat quadrilateral in outline, occupying the areas of all the pyramids ; these masses were breaking dowm, though not fluid, and the cheesy matter dropped from some places, leaving irregular cavi- ties. The cut, taken from a photograph, shows this kidney laid open, exposing the irregular cavities, the pelvis partly filled with the cheesy matter, and the upper portion of the ureter dilated and filled with this same material. The figure shows very distinctly at several not seem to be thus affected. The cheesy matter showed nothing distinctly, merely the debris of the tissue and fatty and granular particles. (A longtime afterward this cheesy matter was examined for tubercle bacilli, but none were present, although other organisms were found ; of course, the urine was not examined for those bacilli, as the case occurred before the time of their discovery.) The left ureter in all its course was enlarged and quite firm, feeling like an unevenly twisted rope. Near its en- trance into the bladder was an enlarged lymphatic gland which compressed it. The orifice of the ureter within the bladder was prominent, but was closed by the swell- ing of the mucous membrane ; a little softened cheesy matter could be squeezed from it, and a probe could be passed, but only as far as the seat of the lymph-gland. The bladder walls were thick, and the mucous membrane congested, but no tubercles or ulcers were seen. There was a small amount of cloudy urine with Hakes of cheesy matter present. The lymphatics at the hilum of this kidney were enlarged, but there were no other glandular enlargements or cheesy deposits discovered. Case II.-Tubercular Disease of the Kidney, Ureter, and Bladder.-The accompanying figure (Fig. 4116) shows the right kidney of a man, aged thirty-eight, who was under observation for only five days before his death. There was no inherited taint, but he had probably had both syphi- lis and gonorrhoea. Five Fig. 4116. months previously he had had a severe cough and profuse haemoptysis, followed by other haemorrhages, a continu- ous cough, and progressive emaciation. Physical exami- nation was incomplete because of delirium during four days; the bowels were regular, the temperature was con- tinuously subnormal, the pulse was 90 to 110, and the respirations averaged 26. Micturition was exceedingly frequent and urgent. The urine was cloudy, of light amber color, acid, specific gravity 1.010, albumin about one-eighth of its volume, containing pus-corpuscles, blad- der epithelium, and mucus. Autopsy : Double pleurisy with abundant exudation on the left and old adhesions on both sides. Both lungs were compressed and studded throughout with fine miliary tubercles ; two or three old cheesy spots of small size were found in each lung. The bronchial lymphatic glands were pigmented, a little swol- len, but not cheesy. The liver and the spleen showed numerous tubercles. The left kidney was large, weigh- ing six ounces, and appeared swollen ; numerous small tubercles were visible on the surface, raising up the cap- sule which was adherent to them, and half a dozen nod- ules of similar character were seen on the surface of the principal section of the organ ; they were of a whitish color and firm consistence. The pelvis and ureter of this kidney were normal. The right kidney was considerably enlarged, the increase being principally in thickness ; its upper extremity fluctuated indistinctly, and its lower half was firm and of a dense white color. On section, an abundance of whitish creamy matter containing lumps of Fig. 4115. points the preservation of the cortex, while the pyramid of the same lobule has been completely destroyed. A microscopic examination of the cortical portions thus preserved enabled one to recognize the tissues of which it is normally composed, such as the Malpighian bodies and convoluted tubes ; they were, of course, much com- pressed and undergoing atrophy, and showed evidences of reactive inflammation, being in parts surrounded by small-celled infiltration. At places in the cortex the po- sition of the tubes or pyramids of Ferrein could be distin- guished, showing intratubular destructive changes ; this result was the effect of an extension of the inflammation from the area of the pyramid ; but the convoluted tubes did 266 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Disease' firm cheesy material was found in the pelvis and the cav- ities in the upper half of the organ ; these cavities occu- pied the seat of the pyramidal cones, were of irregular, ragged outline, but did not invade the cortex ; the lower half of this kidney showed scarcely a trace of normal tissue, and, although the cortical areas could be outlined, the cortex was thinned out over the very-much-distended swollen cones ; the latter had assumed an almost globu- lar shape, and one of them showed slight softening in its centre, but this half of the organ was firm and elastic. While the renal pelvis contained a creamy fluid, the soft- ening process had not extended to the cheesy matter fill- ing the ureter, and this part, up to the point of contact with the bladder, was most firm, and measured fully an inch in diameter ; to the ureter adhered considerable hyperplastic tissue and several swollen lymphatics, one of which is shown in the illustration. The bladder was not much thickened; its mucous surface was injected and uneven ; several shallow ulcers and numerous small, hard tubercles were seen. The right ureter could be felt through the wall, and, although the orifice was not di- lated, it could be stretched back and distended so as to show the cheesy material filling the tube. The middle lobe of the prostate gland was enlarged, and on section there were seen whitish areas, which were, however, not softened. The testicles were not diseased. The lym- phatics, from the femoral ring to the diaphragm on the right side, were enlarged, and some of them around the kidney were cheesy. The figure shows the upper half of the kidney occupied with the cavities from which the creamy, cheesy material escaped when the section was made; the renal pelvis shows the distention to which it has been subjected, while the lower half has a nearly uniform aspect. The ureter, even in the picture, looks firm and rod-like, and shows the attached tissue and the lymph-gland. The enlarged middle lobe of the prostate projects from the under sur- face of the bladder. Case III. Tubercular Disease of Kidney, with a Patu- lous Ureter.-Fig. 4117 shows a kidney taken from a man who suffered from well-marked symptoms of tuber- cular inflammation of that organ. The clinical details I am unable to furnish ; there had been disease of the tes- ticle, which was removed by operation, and the phenom- ena of cystitis. The patient died of the exhaustion con- sequent on the latter ; there resulted no general tubercu- losis. The figure shows the left kidney cut in median section, and from under the edge, in the line of the cut, projects the divided end of the ureter. The renal pelvis in the central part of the cut is shown very much reduced in size, and it is oc- cupied by new tissue; the opening to the ureter can be traced by a fine probe. On either half, near the outer margin, can be seen the pouches having, more or less accurately, shapes like the py- ramidal cones whose former position they occupy. These cavities are walled around with the remains of the cortical tissue, now con- verted into fibrous tissue ; the cavities communicate at their apices by small openings with the renal pelvis. The ureter all the way to the bladder was of normal size; it was of very firm consistence, and on section its increase in size was seen to be owing almost wholly to the thick- ened wall, and only the finest probe could be inserted into its lumen. This kidney, probably without any doubt, had passed through the same phases as the organs shown in Figs. 4115 and 4116, had been swollen, with cheesy blocks filling the areas of the cones, and with its ureter closed from the effects of the cystitis. Subsequent to this condition, when softening took place the occlu- sion of the ureter was removed, and the cheesy matter flowed out, leaving a collapsed and empty kidney. (This kidney measured in the fresh state about two inches in length, but it was photographed on a larger scale proportionately to the others; the other kidneys have shrunken, post mortem, more than this organ, owing to the escape of the contents.) Case IV. Miliary Tubercle of the Kidney, Early Stage.-The cut (Fig. 4118) is a copy (made by hand) of a photo micrograph, taken with a half-inch objective, camera drawn out. The microscopic section was made from the kidney of a man, aged twenty-seven ; his family history was without taint, and he had been free from previous disease except rheumatism. During three months, after a severe exposure to cold, he had suffered several rigors, most of the time fever, but no sweating; much dyspnoea and abundant muco-purulent expectora- tion, but no haemorrhages ; physical examination showed no evident consolidation at any part of the lungs, but the percussion note was less clear, and the fremitus increased slightly toward the left apex, with a variety of coarse rales. No tubercle bacilli were present in the sputum. The urine had a specific gravity of 1.010 ; no casts, blood- corpuscles, or albumin. The autopsy showed dissemi- nated miliary tubercles in both lungs, and a few small spots of softening, not cavities, in the upper portion of Fig. 4118. the left lung. Both the spleen and kidneys showed numerous fine white tubercles. The photograph was taken from a tubercle in its earli- est stage of development, before it was visible to the naked eye, before it had become white, or fatty and ex- sanguine. This tubercle indicated its presence on the surface of the capsule by a spot of congestion the size of a pin-head (not an ecchymosis for the blood-spot could be displaced by pressure with the finger, showing that the blood was in the vessel and not in the tissue), while on the cut surface scarcely anything was visible. This was in truth a microscopic tubercle, although its size was sufficient to render it visible had it been opaque. At the top of the section one may see the capsule, of normal thickness, attached to the renal tissue ; immediately below, the tissue presents a confused appearance, and through it are seen darkly-shaded linear patches ; these darker areas are the intertubular capillaries much dilated (the one-fourth objective shows the blood-corpuscles fill- ing all these capillaries). The convoluted tubes, in this upper central part, can be distinguished with the higher powers, but the nuclei of their epithelial cells stain very poorly compared with those of other parts of the section ; to the left, above and below, and to the right side below, the convoluted tubes are easily seen, as are also the in- tertubular capillaries, but they are less full of corpuscles than those in the central parts ; below, about one-fourth way from the bottom and a little to the right of the median line of the figure, is seen a Malpighian body, deeply shaded, for the blood had clotted in its vessels ; and again, below is seen a tube cut transversely; the cleft Fig. 4117. 267 Tubercular DiZeaZZ* REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. to the far right is a rent made by the needle in handling the specimen. In the immediate central portion can be seen a number of dark-shaded capillaries, only moder- ately distended. Capillaries were found in the normal parts of this kidney carrying two red corpuscles abreast; in this central part-the area of the newly-formed tuber- cle-the corpuscles are three abreast; while in the periph- ery the distended capillaries, especially above as they approach the tubercle, are seen filled with six red cor- puscles abreast. Between these central capillaries the convoluted tubes have faded out, disappeared, and their place is taken by the corpuscles or nuclei which go to form the tubercle. In size, these new nuclei are a very little larger than the nuclei of the epithelium of the tubes. The outline of the tubercle is pretty sharply limited-to its left side it is seen pressing upon, and deflecting out- ward, a group of straight conducting tubes. These new nuclei all stain brightly with carmine, and the color is equal and uniform, as no degeneration has commenced in the centre of the tubercle area. The characteristic feature of the tubercle, at this early stage, is the destruc- tion which it works in the pre-existing elements at the seat of its deposit, or growth-a destruction or degenera- tion not due to deficient blood-supply, for it is not until a later stage that the capillaries become occluded. It is interesting to note that tubercle bacilli are not to be found in these very young tubercles, although in the same kidney the older tubercles show the bacilli in numbers ; apparently this micro-organism does not make its appearance until the stage of degeneration. This is a very important feature in connection with the etiologi- cal relations of this organism. Case V. Miliary Tubercle of the Kidney, Later Stage and Fully Developed.-The microscopic section, repre- sented in the accompanying figure (Fig. 4119), was taken capillaries are seen. The spots close to the centre, darkly shaded, just above the central Malpighian body, are more conspicuous photographically than microscopically, and they look like spots of degeneration, perhaps com- posed of the epithelium of a convoluted tube which has re- sisted until this late stage, but it is impossible to say that they are not blood-corpuscles in one of those dilated capillaries, breaking down. The new corpuscular ele- ments or nuclei, composing the tubercle, are much more abundant and closely set than in the previous section from the earlier stage, and they stain fairly well; but pervading the whole area, they confuse the picture, re- move the former appearance, and leave not a hint of the former structures of the kidney. It is plain to see that the central portions of the tubercle, now cutoff from the direct blood-supply by the closure of the capillaries, are losing vitality and already commencing to degenerate ; they even now stain less well than the peripheral por- tions. This feature, it seems to me, is one of the most important characteristics of a tubercle-this and the early complete destruction of the pre-existing histological ele- ments are its chief and diagnostic features. To attempt to distinguish it from similarly shaped and sized morbid deposits by measuring the cells or nuclei and describing the intercellular or basis substance, is quite futile, for the nuclei, or indifferent cells composing it, vary in size in different tubercles and even in the same tubercle, and they may measure quite the same in a miliary abscess or young gumma, the two deposits for which a tubercle may be mistaken. In the miliary abscess, while the indifferent cell or nucleus may measure the same as in the others, and its cells are usually more abundant in the earlier stage, the abscess-nuclei do not efface the pre-existing structures so promptly ; it is not until later that this destruction is completed, when the abscess-area has be- come fluid-and the tubercle never becomes completely liquefied. In the miliary gumma, the cells of the new deposit, also not varying pronouncedly from the others, seem not incompatible with the entire preservation of the former tissue, especially the capillaries of the part, which may continue to carry blood through the gummatous de- posit ; and with respect to degeneration, the miliary gum- ma practically never undergoes a process of degeneration similar to that of tubercle (a large gumma may exhibit central cheesy changes, but the small gumma never); the gumma tends to organization, and the round nuclei are replaced by spindle-shaped elements, and finally fibrous tissue, tending to cicatricial contraction. In respect to the intercellular or basis substance, it varies in all cases with the tissue or organ in which the deposits take place, and is in none of them truly characteristic. It is by their life-history, mode of growth or deposit, and the subse- quent transformations, that the differential diagnosis of these three morbid products is to be made, and not by measuring the cells and describing the arrangement of them in the tissue ; otherwise it were possible to scrape or squeeze a little juice from the one and the other, and by the use of the micrometer to distinguish one as tuber- cle, the other as gumma or abscess. (It may be asked why I give these signs and regard them as of more value in forming a diagnosis than the search for the micro- organisms. I have already shown that the tubercle ba- cillus is positively absent from these young tubercles ; syphilitic gumma has no recognized organism, and no evidence can, therefore, be furnished by its absence ; the various forms of staphylococci, as well as other organ- isms, are common to pysemic abscess and several other different diseases, so that they furnish a very uncertain basis for differentiation. How would it be possible, for example, to say whether the morbid changes in a small area of the kidney were due in one specimen to pysemic abscess, and in the other to an embolus from a rheumatic endocarditis of so-called malignant character, when both specimens of kidney furnish one or two varieties of cocci ?) Case VI. Miliary Tubercle of the Kidney Becoming Cheesy.-The accompanying cut (Fig. 4120), taken from a photo micrograph, shows a vertical section through a tubercular deposit at the surface of the cortex ; the cap- Fig. 4119. froin the same kidney as that represented in Fig. 4118. It represents one of those white nodules projecting on the capsular surface, and so often seen surrounded by a halo of congestion. The drawing shows at the top the straight line of the capsule, which is of normal thickness ; the tubercle extends from near the surface on the left side downward obliquely to the right, surround- ing and extending slightly beyond the conspicuous Mal- pighian body in the lower part of the field. Around the tubercle can be seen the convoluted tubes, one or two Malpighian bodies, and numerous intertubular capillaries; in the area of the tubercle itself nearly all the capillaries have disappeared, and it is only above, near the surface, and also between the Malpighian body at the left border and the prominent body in the centre, that any distended 268 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tubercular DUeaZe*. sule is seen slightly swollen and, over the summit of the tubercle, shows inflammatory changes (the capsule in this stage is usually slightly adherent locally, and on removal tears the kidney, or more likely, is itself torn); the section contains two miliary tubercles, one seated immediate- ly under the capsule, the other surrounding the dark- shaded Malpighian body, and the two are almost con- tinuous, only one or two capillaries which carry blood being seen passing between them, as shown by the dark shading. Outside the areas of the tubercles the tubes and capillaries are distinctly visible, and the open circle is where a Malpighian body has dropped from the sec- tion. The surface tubercle is farther advanced in degen- eration than the lower one, but unfortunately the shad- ing of it is not quite dark enough to represent the differ- ence accurately ; of the area of the tubercle in this later stage no particular description can be given and none is needed, for its elements have become cheesy, and they are now as devoid of characteristics as the cheesy mate- rial from other sources-one might examine equally well the material from a milk-cheese. The tubercles in this stage generally show the bacilli when stained, but it is not every section that is found to contain them. The periphery of these tubercles, in contact with the still the urine of some cases, or at certain stages of miliary tubercle of the kidney. The figure, made by hand from a photo-micrograph taken with a fourth-inch lens, camera not drawn out, shows the centre of a tubercle in its very earliest stage of development. The changes in the kid- ney-tissue are so slight that it is difficult, without most careful observation, to define the limits of the deposit, and only one or two places in this area exhibit marked altera- tions ; no peripheral zone of congestion, and no obstruc- tion of the capillaries are observed. In the right centre of the cut one sees a circular body, with a dark border, and its interior filled with small cellular elements ; above it and extending obliquely farther to the right is a lighter- shaded, partly cleared cleft, which represents the curv- ing margin of the capsule of Bowman, belonging to a Malpighian body which reaches to the convoluted tube seen on the left margin of the capsule ; the diameter of the Malpighian body measures in the section about an inch ; the limits of the tubercle can be appreciated some- what by the distinctness with which the tubes are visible. The whole area appears swollen and overrun with nuclei, but the tubes have not yet disappeared. The most con- spicuous change is in the Malpighian body and the greatly swollen tube shown just below it; both of these Fig. 4120. Fig. 4121. patulous capillaries, shows the cellular elements well stained, and new cells, extending into the intertubular con- nective tissue, are here seen ; but such tubercles seem to exert very little pressure on the surrounding parts, ex cept that caused by their obstruction of the blood-current in the capillaries. Case VII. Tubercle of the Kidney. - The specimen shown in Fig. 4121 was taken from the kidney of a man, aged thirty-eight, who was under observation a month before death ; he was seized fifteen days previously, while exposed at sea, with a rigor followed by high fever ; he also had diarrhoea ; he had a cough, which later increased very much, but with little expectoration ; fine dry rales were heard, and later some moist ones; the urine contained a small amount of albumin, no casts, specific gravity 1.020; toward the last there were attacks of dyspnoea. At first the appearances were those of typhoid fever, and it was difficult to distinguish the acute miliary tuberculosis; the expectoration contained no tubercle bacilli. The lungs were found to be very emphysema- tous, full of miliary tubercles, with many spots of soften- ing, not cavities ; numerous small tubercles were found in the liver and kidneys, and a few small deposits on the intestine with shallow tubercular ulcerations. The illustration is intended as an aid in the explana- tion of the mechanism of the production of albumin in structures exhibit most active proliferation of their tis- sues. I know of nothing with which to compare the condition of the Malpighian body other than the appear- ance in glomerulo-nephritis, and the tube seems to have participated in similar changes. Diagnosis.-The diagnosis of the tubercular kidney, in the early stages, depends on the accidental anomalies of the urine, and is difficult or impossible except under exceptional circumstances. In attempting to arrive at a conclusion the general characters of the patient, as regards a strumous taint or otherwise, are to be regarded. In the presence of symp- toms which may be considered as indicative of inflam- mation, the character of the patient may help us to dis- tinguish the disease from other forms of kidney inflam- mation. I am utterly unable to give any rules by which an or- dinary pyelitis can be distinguished with certainty from the form of inflammation which leads to the scrofulous or tubercular deposits of the kidney. Ordinary pyelitis is usually due to other causes than the tubercular, and it usually commences in or about the kidney ; whereas tu- bercular trouble commonly starts in parts remote from this organ. The former is rarely attended with obstruction of the ureter, and the ureter remains patulous throughout the 269 Tubercular Disease". REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. continuance of the disease. The tubercular disease com- mences with an obstruction of the ureter, and it remains occluded until softening occurs. Pyelitis is rarely at- tended with any haemorrhage, and then usually only in the early stages ; it is slight in amount, scarcely amount- ing to more than a smokiness. The scrofulous disease, on the other hand, if attended with haematuria, exhibits it usually only at the terminal stage, and the blood comes intermittingly, accompanying or streaking the discharged cheesy masses. Pyelitis due to renal calculus shows fre- quent haematuria, usually alternating with intermittent pyuria. Enlargement of the kidney due to morbid growths, which may imitate a tubercular kidney in some of its symptoms, is more commonly attended by haema- turia, usually of considerable amount and more or less constant. Sometimes the conditions which lead to the tubercular deposits in the kidney, by reason of the thickness and induration of the ureter, may be recognized from an ex- amination of this canal. The absence of a tumor does not contraindicate scrofulous kidney. A large kidney, which can be differentiated from a morbid growth of the organ, is very likely to be of this character. The occur- rence of the general symptoms of tubercular disease, in connection with local signs of kidney trouble, tends greatly to confirm the diagnosis. The factor which most frequently obscures the diagnosis of the kidney con- dition is the very frequently accompanying bladder trouble. The prognosis is most unfavorable. The duration of life depends on the escape of one kidney from involve- ment. Death usually comes with rapidity through soft- ening of the kidney deposits or through general sys- temic infection. The cases in which the deposits in the kidney remain quiescent are rare. Some authors speak of alterations in the kidneys found post mortem in patients who have presented symptoms of former disease of the urinary passages from which recovery has taken place, but the nature of such cases is exceedingly uncertain. Safety apparently can only be afforded by the removal of the kidney. Treatment.-In the main it is the same as that for gen- eral tubercular or scrofulus conditions. Nevertheless, specific treatment is, as a rule, hopeless, since the devel- opment of the disease depends almost entirely upon a local condition, namely, the occlusion of the ureter. Any treatment, to be effective, must be directed to the prevention of this condition. But, as has been shown, we are almost wholly cut off from the recognition of this anatomical condition by the circumstances of the cases. Recently, suggestions have been made for catheterizing the ureters. The treatment of vesical disease becomes most impor- tant, since it happens that so large a number of cases result from cystitis, etc., as their antecedent condition. In the progress of the cases the alleviation of pain de- mands very constant attention. This often can be ef- fected by the external application of anodynes to the lumbar region or to the loins. Employment of anodynes internally is to be avoided, if possible, since they inter- fere so much with general nutrition. The improvement of the general health, which is so constantly and markedly affected, is generally the most important indication in the treatment, and for this pur- pose such measures as are employed when the same con- ditions exist in other parts of the body are to be made of use. The removal of the affected kidney seems to offer the only chance for eradicating the disease. Whether the operative procedure is to consist of the removal of the kidney as a whole, or whether simple incision and evacu- ation of the cheesy matter is to be pursued, must depend on the circumstances of the individual cases. It is prob- able that success will not attend operative procedures, if the bladder is involved in an active inflammatory pro- cess. Professor Gross {American Journal of the Medical Sci- ences, July, 1885) has shown that the operation is at- tended with success in a very considerable proportion of cases, especially so in operations undertaken at an early stage and where the general condition of the patient is favorable. It is not improbable that a simple incision, in the early stage of the disease, may serve to check the advance by preventing an accumulation of the inflammatory pro- ducts in the pelvis and ureter. It seems probable also that in some cases an incision of the ureter near the bladder, with subsequent drainage, would be effective in preventing the advance of the dis- ease ; but in all cases in which the bladder, prostate gland, and testicles are involved, operative procedures are likely to be followed by a promptly fatal result. In the advanced cases lumbar nephrectomy is probably to be preferred to nephrotomy and drainage. It must be remembered that drainage in these cases, on account of the firm cheesy character of the accumulated inflamma- tory products, is not likely to serve its purpose, and the exhaustion connected with the drainage of such a mor- bid condition, in persons with a strumous tendency, is likely to be more exhausting than their bodily force is able to stand. II. Syphilitic Disease.- Syphilis of the kidney shows itself under three pretty distinct forms, although one or more of these forms may be found combined in the same organ. First come circumscribed nodules (gummata). These may occur in an organ which is other- wise normal, or in one in which a considerable degree of interstitial hyperplasia exists ; occasionally the nodules are found in organs affected with tubercular nephritis. Secondly, syphilis shows itself in the kidney by the production of irregular cicatricial depressions on the sur- face, or similar contractions in the deeper parts. Thirdly, diffuse inflammatory changes are found in those who are markedly syphilitic, which may be fairly ascribed to this disease. With all these forms we may find lardaceous degener- ation of the vessels, a condition so frequently dependent on syphilitic disease. Rayer seems to have been the first who described a syphilitic disease of the kidney. He described all the forms which are now recognized, but he, as well as many other authors since then, ascribed to syphilis a more important role in the production of renal alterations than was probably justified. The recognition of the gummatous formations is a matter of great ease, and can be effected with entire cer- tainty, but that of the other two forms presents greater difficulties. The irregular cicatricial depressions are often accom- panied by fresh gummatous deposits which afford an easy means for the recognition of their character; but the changes present in the third form, the diffuse inflam- matory conditions, remain in a large number of cases uncertain in their character, as neither the coarse nor the microscopic appearances afford complete certainty as to their character. The changes presented by the kidney affected with syphilis differ very considerably according to their du- ration and the varying intensity of the process, and finally, also, great variations are often presented in differ- ent parts of the same organ. Syphilis of the kidney, looked at from the clinical aspect solely, is a question much more difficult of settle- ment, and the diagnosis of this condition too often must remain doubtful until confirmed by the post-mortem ex- amination. The cases clinically distinguish themselves by the symptoms, which correspond very well with the anatomi- cal groups above mentioned. We can distinguish symptoms connected with the kid- ney which are produced by the localized syphilitic change in these organs. The symptoms, however, of these cases do not differ from those produced by other small circumscribed alterations of these organs ; hence the difficulty of their recognition as syphilitic. The other group of cases usually present themselves at the terminal stage of severe constitutional syphilis. In these cases we are always in grave doubt whether the renal symptoms are due to the distinct syphilitic process 270 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. «i*ea*e' in the kidney, or to the degeneration of tissue resulting from the generalized syphilitic process. Clinically, also, we may speak of the purely amyloid orlardaceous affections of the kidney resulting from syphilis, when in truth the kidneys have escaped from all localized or diffuse syphilitic disease. On the w'hole, we may say that, apart from the general difficulty of the recognition of local syphilitic changes in the kidney, by far the larger number of cases suffering from syphilis are due not to the localized disease, but to processes which are not themselves strictly syphilitic. Gumma of the Kidney.-The gumma can be pretty readily recognized in the kidney by careful attention to certain points which distinguish it from tubercle or from certain other morbid growths in the earlier stages. Sometimes it becomes necessary to differentiate the tu- mors from infarction-areas, or from the beginning cyst- formations in contracting kidney. Gummata are never very large; on cross-section they rarely exceed the size of a split marrowfat pea. They are very regular in outline, whitish in color, and, in the early stages, of firm consistence, appearing like rounded masses inserted in the tissue and to a certain extent dis- placing the normal parts. They fade off into the surrounding tissue, never pre- senting any appearances of incapsulation, and rarely showing any'peripheral zone of injection; on the con- trary, the surrounding parts are often anaemic, as though compressed by the newly inserted mass. When seen on the surface of the organ they usually present slight pro- tuberances raising up the cortical tissue in the centre of the prominence, showing as a w'hite speck. A.gumma rarely show's any considerable portion wholly projecting from the surface, as miliary tubercles so commonly do. The veins of the capsule are often seen displayed over the surface, and these veins sometimes show an engorged zone in the periphery of the prominence. Gummata have their seat apparently quite indiffer- ently either in the cortex or in the medulla. The seat of the newly forming gumma may often be suspected by the appearances of congestion, a very small local- ized spot in which the deposit is not yet sufficiently abundant to become w'hitish, as it does later. Such areas can be recognized by the microscope, and the vessel can be seen loaded with blood-corpuscles. In this early stage, microscopically examined, the most conspicuous feature at the seat of the newly forming gumma is the great en- largement of the capillary vessels of the part. With this there is seen (it can be best examined in the cortical portions) a swelling or expansion of the intertubular areas. The intertubular connective tissue is partly tilled with small round indefinite cells or nuclei without spe- cial characteristics. There appears to be a very distinct swelling of the intertubular connective tissue, a swelling probably of a fluid character. The widening of these spaces cannot be due solely to the newly deposited cells, since these are insufficient in number to account for it. The capillary engorgement is produced by the swelling and pressure exercised by the newly deposited cells. This engorgement is very irregular in its extent, and often occupies an area greater than that which is likely to be taken up by the future gumma. Very many such areas can be found in every kidney in which fresh gum- matous deposits are visible, and they are often very dif- fusely scattered through the organ. I have never been able to make out that they affect one lobule more than another, or that they follow in particu- lar the course of any branch of the renal artery. In the later stage, the intertubular spaces at the seat of the newly forming gumma become filled with small cells, and the capillaries through such parts become completely closed by the pressure. The whole area, however, does not become cut off in this manner from its blood-supply. It is often the case that the free capillary blood-track may be found passing directly though a small-sized gum- ma. The periphery of the gumma is, at this stage, never a well-circumscribed area; the new deposit of cells is found reaching out into the surrounding tissue quite irreg- ularly, corresponding to the appearances presented to the naked eye. The renal tubules in the area of the gumma become compressed, and probably gradually close, the epithelium undergoing a more or less rapid fatty degen- eration. The basement membrane of the tubules swells and gradually disappears. Thus the whole area of the gummatous deposit be- comes tilled with moderately closely placed, newly formed cells or nuclei which, very evenly from centre to periphery, stain brightly and equally with carmine. At no time during the formation of the gumma, until it has reached a comparatively large size, does it show degen- eration of its elements. Any fatty detritus which may be discovered in its area is probably due to the remains of the epithelial cells of the renal tubules. If in any case fatty degeneration of the newly deposited cells is discovered, it may be set down to the great size and very rapid formation of the gumma, a deposit so rapid that organization or transformation of the new cells has not kept pace with the increase in size of the deposit. Usually, however, organization or transformation of the new cells commences very early, the areas originally occupied by the round cells ox' nuclei beginning to show elongated, flattened, or spindle-shaped formations. This transformation may apparently take place at the periph- ery almost as soon as at the centre of the deposit, and it may commence so early that the pressure exercised by the abundant small-cell deposit may lessen with sufficient rapidity to allow7 of the preservation, almost in their en- tirety, of one or more of the renal tubules within the area of the gumma. Very constantly do we find several of the capillaries remaining patulous and carrying blood ; small arterioles, especially near the Malpighian tufts, re- main with their calibre unaffected, although their walls show considerable alterations or may entirely lose their characteristic features. A gumma may commence to form, having apparently its centre in one of the Malpighian tufts, and then this structure rapidly loses its characteristic features and dis- appears in the subsequent changes taking place in the gumma ; but in other cases where the gumma forms in the neighborhood of the tuft, it simply suffers compres- sion without w'holly disappearing, and is subsequently converted into a fibrous area remaining like an island in the surrounding gumma, the tuft apparently, from its more ample vascular supply, resisting invasion, or per- haps tending to remove the new cells which invade its area. The compression and displacement of the renal tubules is well seen at the periphery of a newly forming gumma. The absence of the zone of engorgement is well illus- trated, for the capillaries suffer compression and displace- ment along with the renal tubules. This crowding to one side and the insertion, as it were, of the gumma are especially well seen among the straight tubes of the renal pyramids. Case I. A Minute Gumma of the Kidney.-The spec- imen from which the accompanying figure (Fig. 4122) wras copied, was taken from a man aged forty-five, who had probably acquired syphilis twenty years previously, and had suffered during that time from irregular seizures, called epileptic, at long intervals ; he had never been para- lyzed until the present attack, when he fell while walk- ing, became unconscious temporarily, was unable to ar- ticulate, and remained paralyzed on the left side of the trunk and extremities ; he died a fortnight later without further developments. A gumma the size of a pigeon's egg was found in the right corpus striatum, and a num- ber of places of thickening at various situations on the meninges; the kidneys showed many cicatrices of ir- regular shape on the surface, and a number of firm, white nodules of small size superficially as well as in the depth of the cortex, and also tw'o in one of the pyra- mids. The illustration (Fig. 4122) shows one of these gummata in the pyramid, and a portion of the other one is seen at the margin of the picture. The photograph was taken with a one-inch objective, and it was selected for representation on account of the clearness of the camera picture ; the appearances of the cortical gummata, 271 rSbeJcula^ DiZeise* REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. microscopically, were essentially the same, and varied only by the difference in their respective situations. The gummatous formation shows at a glance its character- istic ; it appears, contrasted with the tubercle, as a nodule thrust into the midst of the straight tubes of the cone, midst of this are seen many spindle-shaped cells ; many of these cellular elements are the remains of the pre- existing tissues, which have been displaced by the new formation. These cells are not placed hap-hazard, but are arranged somewhat in concentric whorls, or else fol- low waving courses of short extent. It suggests the de- velopment of the gumma from several points, the growths from which coalesce to form a single deposit, and it re- minds one strongly of the mode of growth of a fibroma, but the actual centres of growth seen in the latter are wanting in the gumma ; in the gumma the cells of round and spindle forms are distributed impartially over the whole, and not, as in the fibroma, with the young round elements in the centres of growth and the firm fibres and spindle-cells at the periphery. All features of degenera- tion are absent in the gummatous formation, and this contrasts it most characteristically with the tubercle. In the second form of syphilitic kidney, namely, the cicatricial depressions, the kidneys in their general ap- pearance and symptoms present otherwise a normal aspect. In other cases the kidney is often markedly altered, through fatty changes, through contractions due to interstitial nephritis, or again through changes due apparently to a generalized renal syphilitic process. That some one or other of these general kidney altera- tions, except the last, is due to other processes than syphilis, is evident from the fact that one kidney alone presents the cicatricial depressions, while the other kid- ney, free from cicatricial depressions, shows general alter- ations due to another process than syphilis. A kidney affected with syphilitic cicatrices alone is of the normal size, save at the points where cicatrices are present. These depressions differ from those due to em- bolism in the stage of contraction in having an irregular surface. The capsule, which in other places may be removed with normal ease, is over the seat of the cicatrix tightly adherent. The outer surface of the capsule at this part is often shaggy from increase of the perinephritic con- nective tissue. On removal of the capsule it rarely tears the tissue over the cicatrix, as in the simple contracted kidney, so firm is the kidney substance. The outline of the area of the syphilitic cicatrix is much less regular and well-defined than that of the embolic area, and the syphilitic cicatrix never proceeds to the same high de- gree of contraction as does the embolic area. The depressed area in syphilis does not show the same crater-like depression as does that of embolism in its last stages, so that at no stage of one or the other process could they be mistaken for each other. On section, too, they present equal differences of ap- pearance. It is a very small embolic area in the kidney which does not, throughout all its stages, present a well- marked wedge-shaped appearance, and the small embolic area is very unlikely to be mistaken for a syphilitic cicatrix. A section through a syphilitic cicatrix shows that it is almost entirely the surface of the cortex which has suffered, the deeper part often failing to be affected ; wrhen the deeper portions are also affected the area be- neath the cicatrix is usually very irregular in its outline. The embolic area, on section, may show a cheesy nodule, which later becomes purely fibrous, or else thoroughly incapsuled, and on microscopic examination all the normal histological appearances have vanished. In the syphilitic area not infrequently are there to be found well-preserved tissues within the area which is de- stroyed, or we may find scattered here and there a few Malpighian tufts or their remains, and occasionally a normal renal tubule may be seen coursing through it. The microscopic appearance of the syphilitic cicatrix is unlike that of the gumma at any of the stages of the latter. It never presents the same uniformity ; there are often present in it large amounts of fatty detritus ; the small-cell growth is rarely seen, and regular areas of the spindle-cell tissue, so constant in the gumma, are never prominent. The firm fibrous tissue of the embolic area is absent, and the universal fatty degeneration of tubercle is never seen. Great assistance is frequently afforded in the recogni- Fig. 4122. pushing them aside and destroying them by pressure, maintaining, meanwhile, its own integrity. A tubercle, under the same conditions, seems not so much to overrun the tissue by crowding, but to lead to degeneration of the tissues among which it comes, itself also promptly degenerating. Even with this low power several tubes, evidenced by the darker, shaded streaks at the upper and lower portions, can be seen in the midst of the gumma. Fig. 4123 is taken from the same gumma, photo- graphed with the quarter-inch objective, near its right Fig. 4123. lower border ; on that side of the picture are seen several of the tubes, compressed and pushed aside, but maintain- ing their integrity. The structure, which can be made out with ease, is composed of comparatively scanty small, rounded nuclei, placed in a nearly clear hyaline basis sub- stance of indistinctly fibrillar connective tissue ; in the 272 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. J"bercu!ar Disease' tion of cicatricial syphilis by the presence in the kidney- substance or in the cicatrices of newly-formed gumma. These shine out, perhaps not with the distinctness, if in the latter situation, which they present when occurring in the midst of normal kidney-tissue, but they are suffi- ciently distinct usually to lead us to recognize the char- acter of the cicatrix. These cicatrices present another feature which is highly characteristic of them. They differ from embolic areas in having a redder color, in fact often appearing hypersemic, whereas the embolic area in its stage of contraction is strikingly anaemic. The surface of the cicatrix is quite uneven and irregular, and may by this means, if such distinction w7ere ever necessary, be distinguished from the regular, coarse or fine, granulations of the surface of a contracting kidney. The contracting kidney very constantly shows the small islets of yellowish spots of fatty degeneration regularly interspersed through it, not only on the surface but in the depth of the cortex. Such spots are never to be found in the syphilitic cicatrix, and this difference serves to point out, even in the same kidney, the parts affected by the syphilitic cicatrization and those involved in the usual granular process of interstitial nephritis. Fig. 4124, taken from the kidney of the same case as the preceding (half-inch objective), shows a portion of from interstitial nephritis. Other portions of this kid- ney appeared normal, except where affected by recent gummata or by cicatrices, there being several of each of these present. The third form of syphilis of the kidney presents many difficulties in its recognition, except in well-marked typ- ical specimens, or in cases occurring with universally dif- fused syphilitic changes in other organs of the body. These kidneys, and usually both are involved to an equal degree, show a very marked degree of enlargement in all their dimensions. They appear swollen, and the swelling is of a firm character. Their color is usually pale, often bluish or grayish, though sometimes pinkish, and there is described a degree of translucency, though this is not highly marked. The capsule is easily separated from the surface, which is left smooth, and the stellate veins on it are often markedly injected. Very constantly are seen very small- sized yellowish spots or streaks scattered through it, con- fined to the cortex and never appearing in the pyramids. The organs are firm, tough, and almost hard, but not like the uniform hardness of the kidney accompanying valvu- lar heart disease. On section, although the kidney is spoken of as appearing swollen, it does not show the bulging surface at the cut which is the characteristic feature of the swelling in tubular nephritis. The cortex is broader than normal, but is usually pale, the fulness of the veins not appearing here as on the capsular surface : the color is a more uniform pale pinkish or grayish, and the scattered specks are seen here as on the surface. The Malpighian tufts are often conspicuous, and the pyra- mids of Ferrein are equally so. The pyramids appear large, and are redder in color than the cortex. On microscopic examination the most important change is in the intertubular connective tissue, which is always considerably increased in amount. This portion appears swollen as though infiltrated with serum ; it often con- tains very numerous, though scattered, nuclei. The capil- lary blood-vessels show no evidence, either general or local, of compression. Dilatation and engorgement, as seen in the periphery of gummata, do not appear. In the interstitial spaces, irregularly scattered through the firm connective tissue, are found heaps of granular de- tritus in which often the fatty changes are very pro- nounced. The convoluted tubes do not show marked evidences of compression. The epithelial cells in the parts are often found very fatty, but the cells do not appear distended, rather in fact atrophied, and the tube at this portion ap- pears fallen in as the result of the fatty degeneration of the cells. The Malpighian bodies are often somewhat enlarged, or appear so in comparison with the surround- ings. Their capsules are frequently not changed, or at the most appear swollen. The vessels are seen very constantly to have undergone amyloid or lardaceous degeneration, and this lardaceous change is pretty universally exhibited in all parts of the kidney. The tubules of the pyramids appear very little altered ; the calibre of these tubes is constantly found filled with the granular or fatty debris, or with casts of the same character. The factor which is conspicuous in such kidneys is the exudation and the metamorphosis of the intertubular connective tissue, as well as, to some extent, the new7 formation in this part-a change pretty evenly diffused through the cortex. There is a failure of the new forma- tion to organize or to undergo cicatricial contraction, and a very constant tendency to fatty degeneration, more marked in the intertubular tissue than in the epithelium of the tubules; this fatty degeneration is uneven in its distribution, and thereby produces the fine specks or streaks seen by the naked eye. These changes in themselves are not distinctly charac- teristic of syphilis ; perhaps it would be more correct to designate them as a nephritis of syphilitic origin rather than to speak of the process as genuinely syphilitic. That such kidneys, taken alone, can with certainty be described as syphilitic is doubtful; but taken in connec- Fig. 4124. the cortex immediately beneath the surface-depression of a syphilitic cicatrix. In the upper part of the picture is seen the notch of the cicatrix, and over this surface the capsule is increased to many times its normal thickness ; the capsular tissue, while showing some increase of its coarse fibres, is mostly composed of pale-stained nuclei imbedded in a faintly fibrillar tissue. The appearances represent to one's mind a falling in of the capsule rather than the forcible drawing-in such as occurs in intersti- tial nephritis, or after the organization of an embolic in- farct. The depression represents the seat of the inner half of the gumma, while the other half of the gumma originally projected above the level of the cortex. The cortical tissue, under the depression, has apparently suf- fered mostly from the reactive inflammatory changes which alw7ays take place in the surroundings of gum- mata, although here the actual presence of gummatous formation and its subsequent alterations cannot be ex- cluded. Four Malpighian bodies are seen close to the notch, which have become converted into fibrous areas with their capsules much thickened. The uniform part, to the left of the median line, closely resembles the little areas of subacute inflammation in a contracting kidney 273 TubZ^cnllr DiXst. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tion with undoubted syphilitic alterations in other organs of the body, and especially in connection with lardaceous changes in the blood-vessels, not only of the kidney but of other organs of the body (no other causes of the amy- loid disease appearing), they lead us to conclude with great certainty on the syphilitic origin and basis of these changes. It is just this amyloid degeneration of the walls of the blood-vessels, as well as similar infiltrations of the kidney- tissue, that, in part, leads us to doubt whether the gen- eral process in the kidney is genuinely syphilitic. May it not be that the interstitial changes, as well as the fatty degenefation, here conspicuous, are but a part of the amyloid changes ? In those organs which show chiefly the intertubular connective-tissue changes and the fatty degeneration, the doubt as to their nature becomes considerable ; w'hile in those which are conspicuous for their intertubular new formations, or aggregations of round cells, or their trans- formation into a spindle-cell growth, but without ten- dency to contraction, the syphilitic character, as distin- guished from the simple amyloid origin, can be more safely concluded. The increase in the thickness of the cortex and the ab- sence of evidences of contraction point toward a syphi- litic origin, and to a new formation, rather than to an in- flammatory process. The appearance of the Malpighian bodies points in the same direction ; the general consist- ence and size of the organ are unlike what wre find in interstitial nephritis. For the complete recognition of such organs as syphilitic in character, indubitable syphi- litic changes in other organs must be found. Rayer, who was inclined to regard many conditions of the kidney as syphilitic which were doubtfully of such nature, speaks, in connection with the kidneys here de- scribed, of their presenting an appearance which is char- acteristic of their syphilitic origin. He intimates that dark-red streaks are seen on their surface by which their character can be recognized, and he compares this to an exanthem, similar to that occurring on the'skin, both re- sulting from the syphilis. In this opinion he has found no supporters, and if such conditions do present them- selves they are probably due to an irregular injection of the vessels of the capsule. Morris Longstreth. TUBERCULAR DISEASE OF GLANDS , SCROFULA. (German, Skrofeln, Scrofulosis; French, Scrofule.) Definition.-In the present state of science it seems almost impossible to give a definition of scrofula beyond saying that it is a clinical term, which is applied to a col- lection of symptoms, whose essence is, apparently, a vul- nerability of the system and a predisposition to chronic inflammations in certain parts. In looking through the history of the subject one cannot fail to be struck with the fact that in the beginning the term -was used for many diseases of which, at the present time very few, perhaps none, are knowm to be due to scrofula. If we glance at some of the definitions given, it will be seen how the subject has been narrowed down until the exist- ence of scrofula, per se, is denied absolutely. Brissaud (we begin with the French because dyscrasia, idiosyn- crasy, temperament, etc., still play a very important role in their etiology) says (1882): " Scrofula is a modality of the constitution predisposing rather to affections of pe- culiar form than to a real malady ; in other words, it is a peculiar condition of the organism due to a general dis- turbance of the functions of nutrition, followed in its turn by various well-defined processes, foremost of which are the scrofules (tumefaction in the neck and enlargement of its glands) of the old writers." Frankel (1878) defines scrofula as follows : " By scrofulosis is meant a disease of the constitution which manifests itself especially dur- ing the course of inflammatory affections." He adds to this the qualification of Virchow of increased vulnera- bility of the parts and greater pertinacity of lesions, and liability to recurrence of inflammation, and states that the characteristic stamp of scrofula is to be found in the sym- pathy of the lymphatic system, and the fact that disease in it, although the original cause is removed, still persists. Finally, he admits that scrofula is a clinical term which can have its physiology, but not its pathological anatomy, clearly defined. Treves (1883) defines scrofula as a ten- dency to inflammations of a peculiar type, and then de- scribes the peculiarity of the inflammation, to all of which attention will be called hereafter. It is unnecessary here to insist on the difference between the scrofula of the older and that of the modern writers, beginning with Kor- tum (1789) and Hufeland. The former author compares the two views by a quotation from Plink and by his own theory. Plink's view is "induratio unius aut plurium glandularum colli vel axillarium scrofula vocatur his own, " Rectius itaque definiuntur scrofula? per glandula- rum, praecipue conglobatarum, indurationes ac intumes- centias chronicas, ex singular! lympha? systematisque lymphatici vitio pulullantes et peculiari ut plurimum corporis habitu externo comitatus." As will be seen from these definitions, taken from various sources, representa- tive in their nature, there is a certain vagueness, common to all, which has caused great mental dissatisfaction from the standpoint of abstract science, but which in all instances reduces the term to a clinical one. In discus- sing the pathology of the affection it w'ill be seen whether or no we are justified in adhering to even this view', or whether the whole subject, as an entity, has to be dis- carded. Derivation of the Term Scrofula.-The name comes to us from the Greek through the Latin. The Greek authors called those tumors of the neck, which they supposed to be characteristic, xotpdSes from xoipas (%oipds), a pig. The explanations that are given for this choice of name are various; the tumors, it is said, give to the human neck the appearance of a hog's neck ; the tumors are as numerous as the litter of a sow'; the tumors resemble maritime rocks which were called xoipdSes irerpas, etc. (Kortum). Of these the first certainly seems the most reasonable, and is borne out by the Latin translation scrofa, a pig. The older Latin w riters preferred the term struma, and it is not until we come to the Barbaro-latins that we find scrofula, which is supposed to be a dimin- utive of scrofa. On account of this derivation from the Latin, scrofula should be spelt "scrofula" and not " scrophula." History.-This can be divided conveniently into two periods. In 1749 the Royal Academy of Paris offered a prize for the best essay " Pour determiner les caractSres des tumeurs scrofuleuses, leurs signes, leur cure." (To determine the character of scrofulous tumors, their symp- toms, and their treatment.) Before that time a great many things were confounded with what we call scrofula, and the most fantastic views were expressed regarding the cause and nature of the affection ; for instance, Wharton thought the affection due to retained sperma. In look- ing over the older writers very fine distinctions will be found between struma and scrofula; discussions were held whether or no goitres were scrofula, and many other things of the like nature. It will be remembered that Hippocrates, Galen, and their pupils, referred only to the tumors of the neck, xojpdSey, and not to any general affec- tion. The discovery of the lymphatic system by Asseli gave a new impetus to the study of scrofula, which found a climax in those essays accepted for the Academy prize referred to above (Faure, Charmetton, and Bordeu), and marks the beginning of the second period (1757). In Germany we find Kortum and Hufeland (1795); in Eng- land, White (1774), Phillips, and a great many others. To the waiters of this century, however, the term scrofula has meant something more definite than to those above mentioned. It may be added that in France the disease was called " le mal du roi," and in England " the king's evil," for the touch of royalty was supposed to be suffi- cient to cure it. Dr. Johnson, when he was a child of thirty months, was touched by Queen Anne for the troub- le. In the present century Henle was the first to show how much the term scrofula has been abused-" it is the basket into which are thrown all the maladies which attack children under fourteen, the causes for which are unknown"-and to Virchow is due the credit of having placed the subject upon a scientific basis. From that 274 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tii^^ular J^ease^ time to a comparatively recent date, little has been done to advance our knowledge of the subject. For several reasons, clinical as well as pathological, the identity of scrofulosis and tuberculosis has been the source of never- ending discussion. It is but just to say that both sides of the question have been well put, and in favor of both views, the identity and the non-identity, good arguments have been advanced. The foremost workers for non- identity have been Schiippel and the late Friedlander ; for identity, Cornil, although he has recently had reason to modify his opinion. The discussion, when carried on by pathologists, after all, hinged upon the deflnition of a tubercle; and as this seemed impossible from a purely histological view, it would have been kept up indefinitely if it had not been interrupted by the discovery of the bacillus of tuberculosis. We are now in a position to state which body is a tubercle and which is not, and it is merely a question of time, if the subject of scrofula is not yet entirely cleared up, when it will be solved. It is remarkable that the brilliant work of Friedlander upon local tuberculosis, and the thorough investigations of Cor- nil on the lymphatics, should already seem historical and so far removed from the present time. It certainly, fur- thermore, speaks well for the new methods, that so careful an observer as Cornil is willing to give up all that he could deduce from his former investigations, and accept results diametrically opposed to what he conceived them to be. Etiology and Pathology.-Scrofula follows the same etiological laws that are followed by tuberculosis. It can, therefore, either be hereditary or acquired. The statistics that have been gathered upon the subject of scrofula are of little value at the present day, for, mani- festly, several things have been thrown together under the heading of scrofula. It seems to be an established fact to-day, that scrofula and tuberculosis are produced by the same poison. Cornil and Babes (p. 672) say upon this subject: " According to the most recent researches relating to the distinction between tuberculosis and scro- fulosis, the latter has lost all those profound lesions which have made it distinctive-the lesions of the glands, bones, and joints, and lupus-and retains only those superficial dermatoses such as eczema impetiginodes, or those sub- acute and chronic inflammations of the mucous mem- branes not accompanied by chronic adenitis." For impetigo, the bacillary cause has been found in the ordinary microbes of suppuration, and therefore, since the publication of the work of Cornil and Babes, there remain, practically, only subacute and chronic inflam- mations of mucous membranes, not associated with adeni- tis, as lesions of scrofula. It will be seen that the feature which was, up to very recently, characteristic of scrofula, is now considered as characteristic of tuberculosis, viz., the chronic adenitis. It is very difficult to conceive of an inflammation of a mucous membrane which lasts any length of time, without its accompanying affection of the lymphatic glands. But even if we grant that such a thing may exist, we are reduced to a definition of scro- fula, very limited, it is true, as to number of cases, but very precise. However, it is hardly possible that such a condition of things can remain long. The causes for inflammations of mucous membranes are, probably, very numerous, and, when these have been definitely deter- mined, there will be no room left for scrofula. In de- termining the tubercular nature of a so-called scrofulous lesion, it is necessary to do more than make the statement that the bacilli have not been found. It is necessary to make cultures, and practise inoculations ; everyone who has worked with scrofula, especially, will admit the truth of this statement. Frequently the bacilli are not found, there being so few present that they are over- looked, while an animal inoculated with the pus from the same scrofulous gland dies promptly from general tuberculosis. Everyone who has studied the bacterio- logical aspect of scrofula agrees that the tubercular poison is the cause of this clinical picture. The only discussion which still exists is concerning the nature of the poison ; whether or not, in scrofula, it is attenuated or changed in some way so as to make the manifestation milder. In this connection there lias just appeared a paper which certainly seems to settle this point definitely, and from which we quote. Eve has, in this paper, reported the results of inoculating rabbits with small fragments of scrofulous glands. He succeeded in producing tuber- culosis, in one form or another, in four out of five animals experimented upon. In that gland which produced no tuberculosis the bacilli wrere absent, but he fails to state whether they could have been increased by culture. Arloing, quoted by Eve, took juice prepared from a scrofulous gland, caseous in the centre, which was ob- tained from a boy of fourteen. Ten rabbits and ten guinea-pigs were experimented upon,by in jecting the fluid under the skin. All the guinea-pigs showed evidences of visceral tuberculosis, while the rabbits escaped all disease. From this experiment Arloing comes to the conclusion that the virus of scrofula is attenuated tuberculosis, as ordinary tubercular virus should produce tuberculosis in both guinea-pigs and rabbits w hen inoculated. He then tried to increase the virulence of the poison as to the rabbit by passing it through the guinea-pig for two gen- erations. In this he failed, but he found that local tuber- culosis of the joints and bones produced no tuberculosis of the lungs in the rabbit unless it was first augmented by passing through guinea-pigs (although it wmuld pro- duce cold abscesses). From these experiments Arloing drew the following conclusion (from Eve's paper): "This fact merits to be taken into serious consideration at a time when there is a tendency to confound tubercle and scrofula as a single affection. It justifies once more the difference that we have established between the two mor- bid states. If it is not yet proved that they are the work of a distinct virus, it will be granted that true gland scrofula is yet more removed from the primitive viru- lence than local tuberculosis. Perhaps it is sufficiently removed to constitute a fixed variety analogous to those micro-organisms which, after having lived for many generations in a certain species of animals, have be- come incapable in consequence (in spite of all known means) of killing the species which had furnished them, and among which they made numerous victims." Eve made three experiments in the same direction and arrived at "dissimilar results." If anything, the virus wras in- creased in strength by passing through guinea-pigs (in two out of three experiments), and he concluded from his ex- periments that, "while I have shown that the virus of strumous gland disease produced visceral tuberculosis in rabbits as well as in guinea-pigs, yet I admit that the disease in rabbits is not so acute and rapidly fatal as that following inoculation with, for example, acute miliary tubercle. The difference is one only of degree, not of a kind permitting us to infer, with Arloing, that struma is a specialized form of the tuberculous virus." The zooglcea form of Malassez and Vignal has been found in certain cutaneous affections as w7ell as in ab- scesses of bone ; but as it seems probable, from Eberth's investigations, that this form of lower life is distinct from tuberculosis forms, it wrould be hasty to draw conclusions regarding its importance in connection with the subject of scrofula. It certainly is remarkable howr often tuber- cle bacilli are found in children, especially in the en- larged glands-a fact already pointed out by Babes, and which anyone can verify by repeated examinations. The common occurrence of scrofula in children can be most readily understood when the statement is made that the bacillus of Koch is found in almost any enlarged gland of a child, it matters not from what disease the patient has died. The enlarged mesenteric glands of children dying from chronic intestinal catarrh, the en- larged glands of syphilitic or rachitic children, are fruit- ful soils for the bacillus, and, as a rule, there is no difficulty in detecting them. The experiments quoted above settle completely, as we think, the subject of hereditary scrofulosis. There is, however, another form which is certainly very much more common-the acquired form. We do find infants wyho from birth have enlarged glands, and who, if they survive, in the course of their lives show the manifestations of what has been known as scrofula. These are, however, decidedly 275 TubZrcUlar Disease' REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. in the minority as compared with the cases in which these glandular manifestations develop later in life. It will be said, and justly, in one sense, that it is not necessary for a child to be born with the manifestations of scrofula in order to say that the disease is hereditary. But we are then reduced to stating that it is the tendency to scrofula, and not the disease itself, which is hereditary; for, if the development of the disease is taken into con- sideration it will be surprising to see how, in every case, a well-marked sequence will be observed. This sequence is, first, a provoking cause for the enlargement of the lymphatics ; :secondly, a continuance of this enlarge- ment ; and thirdly, a peculiar reaction in those parts which are connected with these lymphatics. The mechan- ism of the enlargement of the lymphatics is the reaction produced by whatever poison or irritation causes the primary inflammation or irritation in the lymphatics through which the lymph passes in coming from those parts. An eczema at the back of the head is followed, for instance, by an enlargement of the lymphatics at the back of the neck. The irritating substance is taken up into the lymphatic circulation, it passes into a lymphatic gland, which acts like a sieve with very fine meshes, re- taining most of the poison, but allowing some to pass into the next gland. The substance taken up irritates the gland just as it did those parts originally affected, it irritates the next gland less because less poison is left, and the gland next beyond this still less. In con- sequence of this irritation there is reaction in the gland, in the form of hyperplasia, producing enlargement, and, as a matter of fact, it will be observed that the gland which is nearest to the source of irritation is the largest, and the farther we go away from the source the smaller do the glands become. The provoking cause may be one of a great many; most commonly a catarrhal inflamma- tion of a mucous membrane; that of the nose, the mouth, and pharynx, the bronchial tubes, or the intes- tinal tract. As a result we have, as all authors admit, the lymphatic glands about the neck most commonly en- larged, then those of the mesentery and bronchi. Or the cause may be a general one, as an infectious disease, most notably measles, because the prominent feature is catarrhal affection of the whole respiratory tract for a comparatively long time ; whooping-cough, for the same reason ; scarlatina - especially in those cases in which the throat and nose are badly affected ; diphtheria, in those cases in which the same condition exists. In typhoid fever the place of origin is usually the intes- tinal tract, and a great many more cases of scrofula have their origin in this manner than we are wont to believe. Lastly, we have general affections characterized, eo ipso, by an enlargement of the glands, e.g., syphilis and rickets. In syphilis, certainly, we have the starting- point from an affection of the glands from within, by a localization of the syphilitic virus serving as a provoking cause. Rachitis may be considered as doubtful, although it is possible that catarrhal affections are due to primary affections of the lymphatics. For the second factor in the production of acquired scrofulosis, a continuance of the lymphatic enlargement, we must look to the bacillus tuberculosis. The bacillus gets into the gland by the route taken by the ordinary poison, and probably at the same time. Fortunately, the role of filters which is played by the lymphatic glands prevents, in a measure, the generalization of the bacillus; otherwise general tuberculosis or local tuberculosis in vital parts would be even more common than is now the case. The only ap- parent exception to this would be sought for in syphilis, yet it will be remembered that syphilis in children is accompanied by lesions in those parts very intimately connected with lymphatics, as the openings of the mucous membranes to the outer world, and the skin, and there- fore the explanation for the taking up of the bacillus would not be a very difficult one. Because the lymphatic system is more active in childhood and infancy than in adult life ; because the distances are less in the former than in the latter; and because the character of diseases differs in both states, notably the greater frequency of in- fectious diseases; therefore, scrofula is more frequent in children than in adults. On account of the slowness of circulation in the lymphatic glands and the peculiarity of the fluid circulating within them (it being a perfect culture medium), the bacillus tuberculosis has time to multiply, and receives most excellent pabulum for its growth. The reaction in the parts connected with the enlarged lymphatics, which has been referred to in an article published by the author in 1877, is as follows : On account of the enlargement of the lymphatics an obstruction is offered to the flow of lymph from the capillaries through the tissues and these glands. The result is that the circulation is retarded in the affected parts, the interstitial spaces are overfilled, and the whole tissue is fuller of fluid than in a normal condition. The effect upon the nutrition of the parts is to cause them to react much more readily to any injury; but, at the same time, it will take longer for this reaction to disappear. A mucous membrane whose lymphatics are affected will be excited to a hypersecretion by the least provocation, and because the increase in fluid due to this irritation is not carried off as promptly as it would be from a healthy mucous membrane, a slight trauma will produce conse- quences of a comparatively chronic nature. Upon bacil- lary irritation a mucous membrane of this character be- comes a veritable culture-tube, and for this reason the so-called scrofulous are subject to repeated attacks of catarrh. Even without irritation of any sort, it is highly probable that such mucous membranes are in a condition of more or less increased functional activity, which may alone explain some of those cases of chronic catarrh which persist under the most favorable circumstances. What has been said of mucous membranes is equally true of the skin, or of any organ in which the relation of the lymphatics is the same. For the condition which has been called scrofula, then, the characteristics of the lesions are a greater vulnerability of the parts, " a greater pertinacity of lesions" (Virchow), "a tendency to re- lapses, and easy implication of the lymphatics" (Frankel). It also follows that a lymphatic gland, already enlarged and irritated, will react more readily than a healthy gland, and this reaction, for the reasons expressed above, which are just as true for gland tissue as for any other, will be less tractable, longer in duration, and more intense in its nature than that in a healthy gland. After all has been said, there remains one question which has not been solved. It cannot be denied that some patients are more liable to tuberculosis and scrofulosis than others. Why is it that one child will be left with scrofula after measles or any other provoking cause, and another remain per- fectly healthy ? The solution must be sought in the working out of what is meant by individual predisposi- tion. When we say that a patient is predisposed to any- thing, it is manifest that we have simply evaded an explanation by using a general term, such as scrofula itself has been. Heredity explains much, but not all, and the attempt to distinguish between histological or phys- ico-chemical differences between individuals which wrould lead them to be more susceptible to poisons than others, has not been made, and might, in our present state of knowledge, possibly be futile. If it is necessary to retain the term scrofula at all in our nosological table (and even from a clinical stand-point this is not the case), we might call those patients who have a tendency to tuberculosis, in its widest sense, scrofulous. As soon, however, as they have the symptoms of what is still known as scrofula they should be called tubercular, for reasons which are especially apparent in connection with treatment. Pathological Anatomy.-Under this heading noth- ing can be said that has not been stated in connection with tuberculosis. There is nothing in the macroscopic or microscopic appearance of the organs or tissues which will permit the pathologist to make a diagnosis of scro- fula. The lesions are those of tuberculosis, either in a mild or severe form ; microscopically always, macro- scopically frequently. From a pathological stand-point scrofula must, therefore, be defined as a local tuberculo- sis ; there is no especial virus, there are no characteristic lesions for scrofula as opposed to tuberculosis. If we 276 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. JubXulii Disease*. are to discuss the symptoms from this standpoint, it will be seen that this must be done under tuberculosis. If we were to find anything characteristic of a predisposi- tion, as far as symptomatology is concerned, it will be admitted that this would be very valuable. Unfortun- ately, however, this is not the case. The statements of authors vary so much in this regard, that by taking them into consideration any child could be suspected of scrof- ula-especially is this true of the older writers (Kortum, Hufeland, Lugol). In one author a scrofulous child must be of the lymphatic temperament, in another it must be of the sanguine, in a third there is a mixture of both ; again, the child has a short neck or a long one, it is fat or it is thin; in one word there is nothing characteris- tic of this stage and, as a priori reasoning would tell us, we are not justified in a diagnosis of a predisposition. For practical reasons, however, it is important to remember that children of tubercular or syphilitic parents, or of par- ents who have been called scrofulous, have a tendency to local tuberculosis. Furthermore, all such parents as are liable to have weakly offspring, whether on account of age, mixture of race, etc., are likely to beget so-called scrofulous children. In this country scrofula is especi- ally well developed among the colored race, pari passu with tuberculosis ; just as it is quite rare to find an adult negro without some change in the apices of the lungs, so it is seldom that we find a negro child with- out more or less enlargement of the lymphatic glands. When scrofula is already developed we find it manifest- ing symptoms which, although not absolutely charac- teristic, are sufficiently well developed to have retained for scrofula a place upon the nosological table. The characteristics are those that have been described under the heading of etiology and pathology. The general ap- pearance of the patient varies very much, in that either a weak or a well-developed child is attacked, or in that the affection is local or more or less general. It is now admitted, on all hands, that the habitus scrofulosus does not exist. A fat and well-nourished child, or a lean, anaemic, or badly developed one, may be a sufferer from local tuberculosis. The tissues that are especially af- fected are the mucous membranes, the glands, the bones, and the skin. As bone affections are discussed separately in this work, we pass them by. The mucous membranes which are most liable to be affected are those of the respiratory, the alimentary, and the genital tract, and those of the eyes and ears. These affections are characterized by long duration, frequent relapses, and involvement of the lymphatics. The discharge pro- duced is muco-purulent, sometimes purulent, and very frequently acid and irritating, so that the skin with which it comes in contact is involved. As a result, an eczema is set up around the openings of these mucous mem- branes, on the upper lip, around the ears, on the arms, or the vulva. Because this eczema lasts for some time, the skin usually becomes thickened, especially where there is an abundance of loose alveolar tissue, giving rise to an hypertrophied condition which is exceeding- ly difficult to relieve. The thickening of the upper lip, due to ozaena or scrofulous catarrh, has been consid- ered characteristic of scrofula. If this discharge be ex- amined microscopically, the bacilli are sometimes found, but just as frequently they are not, probably on account of dilution. As has been stated before, the common symptom of scrofula is the involvement of the glands. These glands are enlarged, hardened, and at first mov- able. This enlargement may persist for an indefinitely long time ; it may disappear, or a true glandular abscess, accompanied by all the symptoms of suppuration, may form. Sometimes the pus is formed so slowly, that the patient is not aware of its presence until the physician detects fluctuation. As a rule, the spontaneous evacua- tion of pus from these glandular abscesses is a very slow process, occupying five or six weeks, or more. When the pus is discharged, either by rupture or by an arti- ficial opening, it may be pus bonum ; more frequently it is serous and thin, and contains flocculi or cheesy masses, both due to disintegration of gland tissue, and in the latter to degeneration. Frequently granulation tissue is formed around the opening of these abscesses, and then their course becomes even more chronic than under or- dinary circumstances. The discharge from one of these abscesses will, frequently, continue for an indefinite length of time, although the cavities are very amenable to proper treatment. In this pus, again, the bacilli are very frequently found, and, by means of inoculation, it is not difficult to demonstrate their presence, even though they are not detected by micro-chemical means. The mucous membrane of the nose is most commonly affected, giving rise to chronic catarrh, thickening of the Schnei- derian membrane, development of true tubercles, ulcer- ation, and consequent affection of the cartilages and bones. This catarrhal condition may extend to the eyes or ears. In the eyes, conjunctivitis and blepharitis may be produced, the latter being one of the so-called scroful- ous affections. In the ears, middle-ear catarrh, from in- volvement of the pharynx, deafness, or otitis media purulenta with all its consequences, may follow. These little patients are subject to earache lasting a few days, caused by purulent inflammation of the middle ear, end- ing in rupture of the membrana tympani and the discharge of a large quantity of pus. The external meatus may become involved independently, and various forms of lesions may be produced. Several forms of eye trouble have been looked upon as characteristic of scrofula ; phlyctenulae and ulcerations of the cornea, often super- ficial, and leading to the so-called pannus scrofulosus. The mucous membrane of the bronchial tubes is the seat of an inflammatory process which is of great impor- tance on account of the sequelae, viz., enlargement of the bronchial glands, phthisis pulmonalis, repeated at- tacks of capillary bronchitis, or catarrhal pneumonia. In the intestinal tract we have repeated attacks of catarrh, and that combination of symptoms which has been called collectively, tabes mesenterica. In the genital tract, es- pecially in girls, the principal symptom is a discharge, leucorrhoea, giving rise to skin symptoms on account of the nature of the discharge. It is necessary, before mak- ing the diagnosis of scrofulous leucorrhoea, in every in- stance to examine the discharge microscopically, in order to determine whether some other cause cannot be de tected for it. The various skin lesions have been re- duced by Cornil and Babes to the impetiginous forms. There are still those who prefer to speak of certain forms of skin lesions as scrofulides or scrofuloderma (which see). Cold abscesses are tubercular, without a doubt, and the reason the bacilli are not found is because the methods for finding them are not used with sufficient care (Ehrlich). After having examined all those cases carefully, the conclusion will force itself upon every im- partial observer that primary tuberculosis or scrofulosis is exceedingly rare. Some other exciting cause will be found in most of the patients, some local lesion or infec- tion which gives rise to an inflammation, and which, in its turn, is followed by the symptoms above described. The importance of this view, from a therapeutic stand- point, cannot be estimated too highly. All local troubles, however slight, in children, especially if they can be sus- pected of a tendency to tuberculosis, should receive full attention and careful treatment. The Prognosis depends more upon the individual than upon general considerations. The thing to be most dreaded is a general tubercular infection, or a localization of this poison in some very important organ, as the men- inges or lungs. For this reason bronchial affections are the source of greater anxiety than enlarged tonsils. Chronic intestinal catarrh in the young is, probably, the most fatal form of scrofula in the greatest number. Al- though a surprisingly great number of children do re- cover, yet in each case the prognosis should be very guarded, as a possible generalization of the affection must not be lost sight of. It is, as yet, undetermined precisely what relation scrofula in the child bears to phthisis in the adult. Careful examination of the chest, in children, frequently reveals slight changes which often develop in later life. Statistical material on this subject would be very desirable. The course of the affection is usually very chronic, unless some localization takes place. Some- 277 Tuberculosi^?868*6' REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. times, though rarely, the affection runs a rapid course, depending more upon the extent than the intensity of the poison. Treatment.-The treatment must, of necessity, be divided into two parts : 1, local, 2, general. Not enough stress can be laid upon the local treatment. It is neces- sary to add that this alone is not all that is needed, al- though, from a prophylactic view, the local treatment is all-important. Frequently extensive infection can be prevented by proper treatment, and this should always be instituted when the physician has reason to suspect that he is dealing with a process likely or liable to be tubercular. Every catarrhal process, from this stand- point, is of sufficient dignity to merit the full attention of the physician. It is not infrequent that, in a child with enlarged lymphatics, the slightest amount of ad- ditional irritation leads to suppuration. A slight attack of follicular angina, for example, will cause the forma- tion of an abscess in the enlarged lymphatics at the angle of the jaw. Children who have enlarged lymphatics should be carefully guarded, isolated when necessary, even from children suffering from simple coryza or acute nasal catarrh. This seems, in practice, to operate very much better than the many useless, and some harmful, methods supposed to prevent catching cold. It is not within the scope of this article to consider the treatment of catarrhal affections. The general line of treatment, as applied to our subject, should be directed toward the cause, and toward the removal of all tissue, when feasi- ble, likely to be the seat of tubercular virus. This is true especially of affections of the nose, throat, and skin. We must, furthermore, remember that it is impossible to cure an eczema of the lip or ear without first removing the cause when it is present, viz., the acrid secretion from the nose or ear. Even the most laudable and persistent efforts at curing such an eczema will result only in disap- pointment, as the affection breaks out again immediately the salves, powders, or what not are discontinued. It is a common observation to see an eczema faciei start up from a discharge from one of the mucous membranes, and to see this eczema persist although the original cause has been removed. The removal of tissue must not be done gingerly ; the scraping out of an old glandular ab- scess will do more toward restitution than months of general treatment. The galvano-caustic treatment of an hypertrophied, thickened, spongy nasal mucous mem- brane gives good results when years of syringing have failed to accomplish anything. Enlarged and hypertro- phied tonsils must be removed as early as possible. The sentimentality which exists regarding the non-removal of tonsils has no raison d'etre when the consequences of general or even partial infection are taken into considera- tion. When the lymphatic glands become very much enlarged, local treatment of the provoking cause is to be carried out. If they, notwithstanding, continue to en- large and become painful, hydropathic treatment, the so- called Priessnitz application, frequently prevents further complication. Or a compressing method may be em- ployed, such as pencilling with collodium, strapping with adhesive plaster, or the application of a bag of shot. An ice-bag also sometimes gives relief. If a few days of treatment do not give relief, it will be evident that infiam* mation has gone on, and then it becomes necessary to use poultices. After they have been used for several days, it will be well to introduce a hypodermic syringe to see whether or not pus can be struck. As soon as this has been done, the abscess is to be opened, and the sooner the cavity is treated the sooner the patient recovers. It must be remembered that these abscesses leave very ugly scars, and if such disfigurement can be avoided it is very de- sirable. If the abscess is opened early a small opening and frequent washing out subserves all purposes excel- lently well. If the abscess is injected three or four times a day with a one or two per cent, solution of car- bolic acid, the results in most cases are surprising. Sup- puration ceases, hardness disappears, and very soon the opening is healed, leaving a small linear cicatrix which can be noticed only upon close observation. At all events this method of treatment can be tried, and if a desirable result is not obtained in a short time, recourse can be had to a long incision with subsequent drainage. Iodine and mercury, applied externally, have been warmly recommended, especially among the French writers, but it is extremely doubtful whether anything is accomplished by their use. In very bad cases ail methods, except the removal of the irritant by means of the curette or the white-hot wire, fail. The question of the excision of enlarged glands is still sub judice-the surgical aspect is not a pleasant one and the medical de- cision as to its necessity is by no means easy. If general symptoms are produced which are traceable solely to an enlarged, apparently cheesy, lymphatic gland, it is clear that the source of trouble should be removed. The general treatment must be two-fold : medicinal and hygienic. It is difficult to say w hich of the two is of greater importance ; certainly a wise and cautious com- bination of both in the hands of a rational physician leads to the best results. Of all the remedies proposed, cod- liver oil deservedly takes the first rank. For its adminis- tration, mode of action, etc., we refer to the proper arti- cle in this Handbook. It is unwise to give this remedy to infants before an attempt has been made, with very small doses, to determine whether the alimentary canal will tolerate it. It is, furthermore, unnecessary to give it in those tremendous doses recommended by the French authors (six to twelve tablespoonfuls in twenty-four hours), as the results are perfect with ordinary doses. When cod-liver oil is not tolerated the malt preparations can be used, the most convenient form being the dry pre- paration made by Merck, but these can hardly be looked upon as substitutes for cod-liver oil. Next, in efficacy, come the iodine preparations ; pure iodine, potassium iodide, or the iodide of iron. Lugol's theory of the speci- ficity of the iodine preparations has been disproved, but no doubt exists of their value. ' The iodide of potassium is used to best advantage in affections of the nose and re- spiratory apparatus with glandular involvement, and the iodide of iron is especially useful in pale, anaemic chil- dren. The flabby scrofulous will receive most benefit from iodide of potassium, unless decided anaemia is pres- ent. Mercurial preparations are rarely indicated, except for local purposes, when they certainly sometimes prove very beneficial. The experiments made by the author with the internal administration of creasote in scrofula have been followed by good results. It is too early to state whether the method will be of permanent service. Creasote can be given to children of from twelve to eigh- teen months of age in doses of from one-fourth to one-half drop three times daily, without producing any evil re- sults. It is best given in milk and, like all other reme- dies, must be continued for a long time. So far, the re- sults have been very gratifying in producing an absolute diminution in all the symptoms. Calcium preparations have also been highly recommended, especially the cal- cium sulphide, given in full doses for a great length of time. It is impossible, in an article like this, to refer to all the remedies that have been and still are being pro- posed for the cure of scrofula-an ordinary-sized book would hardly be large enough to record all the experi- ences and views that have been published. In this mul- titude of remedies there is a certain safety, but unfortu- nately not for the patient, and, after all, nothing speaks more eloquently for our inability to cope with tuberculo- sis than the almost infinite number of medicines that have been used to cure it. The hygienic treatment can be directed either to the prevention of the development of scrofula, or to its cure when once developed. In the first direction, the Ger- mans lay great stress on the process of hardening (Ab- hartung) the patient, by means of cold or cool baths and fresh air, regardless of temperature or weather, and proper clothing. In English-speaking countries, cer- tainly among intelligent people, most children are brought up in this manner, although it has not been reduced to a method, nor are we regardless of the weather. This statement is applicable especially to England, and yet nowhere do we find scrofulosis so prevalent as there, and notably among the higher classes. Although this method 278 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tubercular Disease. Tu bercu iosis. cannot do harm, on the contrary benefits all children subjected to it, yet it must not be looked upon as a di- rect prophylactic agent against scrofula. The best thing to be done for these patients is to give them plenty of fresh air, and good, rational food, and to see that they are kept reasonably clean. Children having a tenden- cy to tuberculosis should be kept away from crowds in confined spaces, schools, churches, theatres, etc. ; they should be guarded in such a way that their risk of in- fection, from any source, is reduced to a minimum. The later in childhood the infection takes place, the less chances there are of general tuberculosis. The physician should make it his duty to advise the parents most mi- nutely in all the directions mentioned above, and as soon as even the most trivial local manifestation, a slight eczema for instance, develops, he should take the case in hand. By warning the parents and by educating them, it is frequently possible to prevent scrofula, when other- wise it would have been a foregone conclusion. When once developed, change to a proper climate is frequently of the greatest benefit to the child. Nearly all civil- ized countries have public institutions at the sea-shore to which scrofulous children can be sent. A city child sent to the country, where it can enjoy plenty of fresh air and wholesome food, will thrive, and the manifesta- tions of tuberculosis will begin to disappear. In gen- eral, the climatic treatment may be stated to be that of tuberculosis. All places that do well for tuberculosis must, eo ipso, do well for scrofula. If a scrofulous child, unless dangerous symptomshave already developed, such as meningitis tuberculosa or caries of the temporal bone, is removed to a non-tuberculous region, the chances are that it will be restored to good health. References. Prix de I'Acaddmie Royale de Chirurgie. Paris, 1757. Kortnm : Commentarius de Vitio Scrofuloso. Lemgovise, 1790. Hufeland: Ueber die Natur, Erkentnissmittel und Heilart der Scrofel- krankheit. Jena, 1795. Treves: Scrofula and its Gland Diseases. Philadelphia, 1883. Brissaud: Article " Scrofule," Nouveau Dictionnaire de Medecine et de Chirurgie Pratiques, xxxii. Paris, 1882. Grancher: Article "Scrofule," Dictionnaire Encyclop6dique des Sci- ences Medicales, vii. Paris, 1879. Friedlander: Ueber locale Tuberculose. Volkmann's klinische Vor- trage, I., xiv. Schiippel: Untersuchungen iiber Lymphdriisen-tuberculose. Tubin- gen, 1871. Cornil: Journal de l'Anatomie, 1878. Lugol: Recherches sur les Causes des Maladies scrofuleuses. Paris, 1844. Frankel: Gerhardt's Handbuch der Kinderkrankheiten, iii., 1. Tubin- gen, 1878. Eve: British Medical Journal, No. 1424, 1888. Forchheimer: Remarks on Scrofula. Cincinnati Clinic, 1877. Cornil et Babes: Les Bact cries. Paris, 1886. F. Forchheimer. TUBERCULOSIS; HISTORICAL SKETCH. Tuber- culosis is the specific infectious disease produced by tub- ercles, which are in turn special products of a distinct micro-organism known as the bacillus tuberculosis, or from its discoverer, bacillus Kochii. The actual or con- tinued presence of tubercles is, however, not a necessary factor in the production, course, or development of tuber- culosis. Pre-existent tubercles may have been dis- charged, or after softening become calcified or absorbed. In acute tuberculosis it is not uncommon to find the spleen enlarged, but free from tuberculous deposit (Mos- ier). So, also, bacilli may not be discoverable in every case of tuberculosis. Old lesion of the lungs, affections of the bones and joints, more especially, may fail to dis- close them. Dead bacilli dwindle and disappear. What question there may be regarding the possibility of tu- bercle formation, or of deposits resembling tubercle by other micro-organisms, or by other causes altogether, may be studied best in connection with the pathology of the disease. At the present time incontrovertible evidence has accumulated to show that the definite disease, tuber- culosis, is produced by tubercles, the products of distinct bacteria. Though the word tubercle * is as old as anatomy, the term tuberculosis, in designation of a definite disease, is modern. Virchow has shown conclusively that tubercle, in its modern specific sense, cannot be found in the works of ancient writers, who used it only to express a morph- ological meaning. Klebs considers it a most unfortunate term. It is a purely anatomical designation, he says, and is the cause of the obscurity which has so long en- veloped the disease. For the single characteristic of nodulation marked all tuberculosis, and everything not nodular was not tuberculous. It is difficult to fix the time when the term began, by common consent, to be limited and confined to the special disease, for the reason that the distinct isolation of the affection is an acquisi- tion of such recent date. But it is safe to say that the day begins with Bayle and Laennec, 1810-1819, when they declared, with proof, that "tubercle is the cause and constitutes the proper anatomical character of pul- monary phthisis." As both Bayle and Laennec literally consecrated their lives to the study of this disease, they may be said to have earned the right to make, or rather to fix, its name. The word " tuberculosis " itself was first employed by Schonlein, 1839, a disbeliever in the specific character of the disease. Phthisis, literally wasting, consumption, was the Greek name, as an expression of the most prominent symptom of the disease. Phthisis was the term for the wasting disease, attended or caused by suppurations of the lungs. It included abscess, gangrene, suppurative pneumonias, empyemas, etc., in short, all varieties of suppurative processes. As each of these affections was gradually eliminated and set upon an independent footing, phthisis came to be limited to the condition which, since the days of Laennec, is more properly known as pulmonary tuberculosis. In more distinct recognition of the cause of the disease, modern French writers, See, 1884, have proposed to call this condition bacillary phthisis ; but as this prescription implies the existence of other forms or causes of the disease not yet established, it has not met with general acceptance. The existence of tubercles in the beginning or course of the disease, at some period or place in the body (for even in the case of the spleen above mentioned tubercles are invariably found elsewhere), justifies the adoption of the general name tuberculosis, while the localizations in the lungs, intestine, testis, etc., are sufficiently defined as tuberculosis pulmonalis, intes- tinalis, testis, etc. History.-The history of tuberculosis falls naturally into five periods, three of which, at least, are quite dis- tinct, in that they date from the discoveries of distinct individuals, Bayle and Laennec, Villemin, and Koch. The first is the period of ancient history. During all this period the disease was observed only from a clinical standpoint. The second period, beginning with the birth of anatomy, in the sixteenth century, furnishes the first definite knowledge regarding changes or lesions of structure. The third period followed the publication of the dis- coveries of Bayle and Laennec, in the first quarter of the nineteenth century, declaring tuberculosis a separate af- fection due to the deposit of tubercle, a specific product independent of ordinary inflammation. This period is made more distinctly memorable by the discovery of aus- cultation as a means of diagnosis. It was the genius of Laennec in the discovery of auscultation which first ren- dered possible a diagnosis of the disease in life. The fourth period was introduced, late in the last half of the nineteenth century, with the inoculation experi- ments of Villemin, 1865 ; and the fifth was announced with the brilliant revelations of Koch, 1882, regarding the cause of tubercle and the etiology of the disease. 1. As stated already, the writers of antiquity had no knowledge of tuberculosis in its present sense. Every nodule, mass, or induration was called tubercle, but with no idea of limitation to any single disease process. Mil- iary tubercles were entirely unknown, and when finally without a thorn.'' The range of meaning of tubercle in antiquity is illus- trated by the statement of Celsus, "Furunculus vero est tuberculum acutum." Condylomata were tubercles in the time of Celsus. * Tubercle, diminutive of tuber, a nodule, induration, projection mass. " Ubi uber, ibi tuber," an old Latin saying, was equivalent to "'no rose 279 Tuberculosis. Tuberculosis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. discovered were regarded as mere curiosities. But the most ancient writers were quite familiar with the fact that a disease marked by progressive emaciation, phthisis, was attended or caused by suppurative processes in the lungs, or, to speak in accord with the ideas of the times, by suppurations or ulcerations of the lungs. Hence phthisis belonged to the general class of diseases charac- terized by suppurations. Thus empyema and phthisis were synonymous terms. The characteristic factoi' and feature of phthisis was pus. Hippocrates, 400 b.c., ac- cepted this view, deriving the pus, from the known pro- clivity of glands to suppurate, indirectly from the brain, the greatest gland in the body. The brain formed mu- cus which, flowing down through the palate and pharynx, produced pus in the lungs. Not every case of phthisis emanated from the brain. Unresolved pneumonias, sup- purative pleurisies, pulmonary haemorrhages, were all followed by phthisis at times. But this phthisis was not so much a distinct disease as a consequence of suppura- tion. Mucus flowing from the brain and failing to be ejected as sputum was converted into pus, or the pus from an empyema eroded the lungs, or the blood of a haemorrhage was changed into pus. Phthisis was the outward expression of pus in the lungs. But not every formation of pus in the lungs produced phthisis. Pent- up collections were called by a different name. Local accumulations, i.e., abscesses in various parts of the body, Hippocrates called phymata, and as these depots were also encountered in the lungs, sometimes as hard masses, tuber cula, it has been thought that Hippocrates was fa- miliar with tubercles as such, and hence with the disease tuberculosis. But Virchow lias abundantly proven that phymata were not tubercles even in the anatomical sense, but were abscesses maturing for spontaneous or artificial discharge, as the same term is used of similar collections of pus in the tonsils, palate, urethra (from which fistulse may develop), and various glands. Phymata were col- lections of pus produced by accumulations of mucus, bile, and blood. They differed from ulcerations in the fact that they were more strictly localized, circumscribed ; and though they were observed in the lungs as well as elsewhere, they conveyed no such idea as is attached to the modern conception of tubercle. Phthisis was still a suppuration or ulceration of the lungs at the beginning of the Christian era. The lapse of four hundred years had enabled Celsus, 50 a.d., to recognize three forms of the disease : the first due to lack of nutrition ; the sec- ond the effect of chronic disease, poverty, injurious med- ication, etc.; while " Tertia est longeque periculosissima species quam Greed <p0iaiv nominarunt." It begins in the head, is distilled into the lungs, which it ulcerates to cause fever, which when quieted recurs. Cough is fre- quent with expectoration of pus, which emits a bad odor on burning in the fire. The medical historian turns always with expectations of pleasure, for the most entertaining as well as instruc- tive exposition of the knowledge of his day, to the works of Aretaeus the Cappadocian, 50 a.d., who was gifted, said one of his biographers, with the rare talent of " giv- ing more striking delineations of a series of morbid phe- nomena in one page than most authors would give in a long treatise." * Aretaeus, with Hippocrates, derived phthisis exclusive- ly from pus, using the term Pye as a synonym of the dis- ease, but he could advance one step further in his pathol- ogy in the separation of empyema, which he recognized as a distinct disease. Still an empyema may erode the lungs and thus produce phthisis; so, also, abscess of the lungs, with whose independent existence Aretaeus was acquainted, may eventuate in phthisis. But while the essential pathology of phthisis is suppuration, the disease being usually attended with ulcers, yet it may develop without ulcers, as a haemorrhage or a chronic cough may cause suppuration. The symptoms of phthisis are de- scribed as follows (Book I., chap, viii.): "It is accom- panied with heat of a continued character, but latent, ceasing indeed at no time, but concealed during the day . . . . for the characteristics are that a febrile heat is lighted up which breaks out at night, but during the day again lies concealed in the viscera, as is manifested by the uneasiness, loss of strength, and colliquative wast- ing. . . . The varieties of the sputa are numerous : livid, black, streaked, yellowish-white, or ■whitish-green ; broad, round ; hard or glutinous ; rare or diffluent; de- void of smell, fetid. There are all these varieties of pus." . . . The frequency of the disease is shown in the following comment: " For if one of the common people see a man pale, weak, affected with cough, and emaci- ated, he truly augurs that it is consumption." The following description of the most prominent features, more especially of phthisis, may spare a repetition in the symptomatology of the disease : " Voice hoarse ; neck slightly bent, slender, not flexible, somewhat ex- tended ; fingers slender, but joints thick ; of the bones alone the figure remains, for the fleshy parts are wasted ; the nails of the fingers crooked, their pulps are shrivelled and flat. . . . Nose sharp, slender ; cheeks prominent and red; eyes hollow, brilliant, and glittering; swollen, pale or livid is the countenance ; the slender parts of the jaws rest on the teeth as if smiling ; otherwise of a cada- verous aspect. So, also, in all other respects; slender, without flesh; the muscles of the arms imperceptible ; not a vestige of the mammae, the nipples only to be seen ; one may not only count the ribs themselves, but also easily trace them to their terminations ; for even the articulations at the vertebrae are quite visible, and their connections with the sternum are quite manifest; the intercostal spaces are hollow and rhomboidal agreeably to the configuration of the bone; hypochondriac region lank and retracted; the abdomen and flanks contiguous to the spine. Joints clearly developed, prominent, de- void of flesh ; the spine of the vertebrae formerly hollow, now protrudes, the muscles on either side being wasted ; the whole shoulder-blades apparent like the wings of birds. If in these cases disorder of the bowels supervene, they are in a hopeless state. . . . The habits most prone to the disease are the slender, those in which the scapulae protrude like folding-doors or like wings, and those which are pale and have narrow chests. As to situations, those which are cold and humid, as being akin to the nature of the disease." Aretaeus was wise enough to know that the treatment should be mainly hygienic and dietetic. Some of his recommendations read as though written yesterday. For example : " And if the patient have it fortunately at his command, gestation and living on the sea will be bene- ficial. For the sea-water contributes something desiccant to the ulcers. After the gestation, having rested, the pa- tient is now to be anointed with fat oil." Milk, he ex- claims in a panegyric, " sufficeth in place of all food. For milk is pleasant to take, is easy to drink, gives solid nourishment, and is more familiar than any other food to one from a child. In color it is pleasant to see ; as a medicine it seemeth to lubricate the windpipe, to clean, as if with a feather, the bronchi, and to bring off phlegm, improve the breathing, and facilitate the discharges down- ward. To ulcers it is a sweet medicine, and milder than anything else. If one, then, will only drink plenty of this he will not stand in need of anything else. For it is a good thing that in a disease milk should prove both food and medicine." Eggs are also recommended, "eggs from the fire, in a liquid state, but hot; they are best when newly laid." The value of prompt interference is quaintly emphasized in the observation of this as of other chronic diseases, that "the postponement of med- ical treatment is a bad thing, for by procrastination they pass into incurable affections, being of such a nature that they do not readily go off if they once attack, and if protracted by time they will become strong and end only in death." After Aretaeus, contributions by ancient writers were few and far between. Galen, 140 a.d., had really nothing to add to the knowledge of his predecessors. Phthisis was still an ulcer (e'Axos) of the lungs, similar to but less * Adams declares indeed that Hippocrates and Aietaeus were almost the only authorities among his predecessors in whose works Laennec could discover any anticipation of his own system of diagnosis in diseases of the chest. 280 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tuberculosis. Tuberculosis. frequent than ulceration of the stomach and intestines, larynx, and trachea. With other ulcers it is often pro- duced by accident, as by rupture of the lungs from strain or cough which leads to inflammation and haemorrhage. Blood which does not escape through the trachea erodes (corrodes was the term of the ancient writers) the lungs, and thus produces ulceration. Galen knew, however, that many cases of phthisis run their course without haemorrhage. Haemorrhage is therefore not a necessity in the production of phthisis, for an ulcer may result from a corruption of the juices of the body. This form of ulceration is fatal. Galen showed his shrewdness not so much in his knowledge of the nature of the disease as in his treatment. Ulcer of the lungs was to be treated in the same manner as other ulcers. To secure cicatrization by desiccation was the chief object. Hence, Galen sent his patients to dry climates and gave internally desiccat- ing agents. Vesuvius was a favored locality, both for its sea-air and its sulphur. The first period thus comes to a close. The medical historian may discover now nothing concerning tubercu- losis for the space of 1,400 years. In the present age of restless activity, when every theory is subjected to search- ing scrutiny, to be subverted often and substituted many times in a single year, it seems inconceivable that four- teen centuries should pass without a single contribution worthy of the name. Such, however, was the superiority of the ancient w'riters, or the inferiority of those of the middle ages, that the views of the former prevailed undis- turbed during all that period of time. The quick-witted Arabian authors, Rhazes (923) for example, who contrib- uted so clearly to our knowledge of some of the acute infections, blindly accepted and repeated the dogmatic assertions of Hippocrates and Galen in regard to tuber- culosis ; and the learned Jews, Maimonides (1135), with all the advantages of necessary inspection of the bodies of animals for food, were content to transfer to animal pathology the views of the Grecian fathers, as they re- jected only such animals as showed ulcers or visible de- fects. Tumors of whatever character, even though they contained pus, provided it was not offensive, did not ex- clude the animal from slaughter as food. 2. Progress in the study of phthisis, as of all other affections, became possible only with the study of anat- omy, which could be pursued with impunity only as late as the beginning of the seventeenth century. Hereupon, however, discoveries followed step by step. For the first disclosures of autopsies revealed in abundance the hard masses which were, as they had been, indifferently known as tubercles or scirrhosities of the lungs. Sylvius, 1680, first made the discovery, inestimable in its value, that these tubercles sometimes softened to form pus in their centre. These tubercles he believed to be glands in the lungs, so small at first as not to be visible. In con- sequence of a certain hereditary predisposition, to wit, the scrofulous or strumous, the glands enlarge to tuber- cles, which subsequently suppurate to form vomicae and cavities. In conformity with this view Sylvius describes small tubercles, tubercula minora, which have been taken to mean miliary tubercles. Willis, a contemporary of Sylvius, almost certainly saw miliary tubercles in a ma- teria sabulosa strewn over the lungs in the entire absence of any cavity or ulcer. This statement, in direct refuta- tion of the view that phthisis of necessity depended upon ulceration, corroborated the opinion of Morton, 1689, who had boldly declared phthisis to be due only to induration of the lungs and tubercles. The undoubted presence of miliary tubercles is next disclosed by Bonnet, 1700, as the result of one hundred and fifty autopsies in cases marked also by the presence of cavities in the lungs. The clin- icians proper meanwhile concerned themselves but little with the results of autopsies or the views of pathologists, which had as yet, of course, no practical value. Syden- ham, 1685, for instance, who may be taken as a typical example, disposed of phthisis in a few' 'words. " The phthisis comes on," he says, " between the eighteenth and thirty-fifth years. The whole body becomes emaci- ated. There is a troublesome hectic cough, which is in- creased by taking food, and which is distinguished by the quickness of the pulse and the redness of the cheeks. The matter spit up by the cough is bloody or purulent. When burnt it smells fetid. When thrown into water it sinks. Night-sweats supervene. At length the cheeks grow livid, the face pale, the nose sharp. The temples sink, the nails curve inward, the hair falls off, and there is colliquative diarrhoea, the forerunner of death." The description is not as good as that of Aretaeus. The cause of the disease he attributes to a checking of the perspiration and the dispersion of humid particles along the branches of the pulmonary artery. " The lungs can now no longer retain their natural status and economy, so that glandules and tubercles arise." His remedies were even more crude and cruel. For fresh cough with- out fever he had tablets of candy, licorice, and aromatics, but for cough with fever "it is folly to trust to pecto- rals." Then the disease " must be attacked by bleeding and purging." If it still continue, "so as to shake the lung, and pave the way for phthisis," the patient is to take the balsam of Peru. One fine suggestion Sydenham made with an emphasis that carried it down : " But of all the remedies for phthisis, long and continued journeys on horseback bear the bell." It has cured patients, he de- clares again, " whom many medicines would have bene- fited as much as many words-and no more." This too, not only in mere cases of cough and weakness, but after wasting night-sweats, and colliquative diarrhoea have signified the approach of death. " Indeed, deadly as phthisis is, killing two-thirds of those who die of chronic diseases, it has a specific in riding, as truly as ague has in bark, or the venereal disease in mercury." • But to return to the observations of the anatomists. A discovery, nearly a century in advance of its general recognition or acceptance, was now made by Mangetus, 1700, in the accurate description of a case of general tuberculosis with dissemination of miliary tubercles, which he likens for the first time to millet seeds, in the lungs, liver, spleen, kidneys, mesenteric glands, and in- testine. Desault, of Bordeaux, 1733, as the result of thirty-six years' observations, now declared in favor of Morton's view, that tubercle is the sole cause of phthisis. Avenbrugger, 1761, deserves mention in connection only with his great discovery of percussion, the value of which was properly appreciated in this disease only at a much later period. Avenbrugger, with Boerhaave, whose pupil he was, makes no mention of tubercles whatever. Phthi- sis they both derived, with Galen, from ulceration of the lungs. But the indurations which Avenbrugger encount- ered he called scirrhus pulmonum-this scirrhus was a transformation of the spongy substance of the lungs into a carniform and indolent mass whose subsequent exca- vation into vomicae and ulcerations produced phthisis. The genius of Morgagni, 1761, which illuminated with floods of light so many obscure fields of pathology, shed no ray in the direction of tuberculosis. Phthisis, he thought, arose from many causes, only one of which was tubercle ; but the common cause in all cases was a certain acrid juice which erodes and ulcerates the lungs. Both Morgagni and his almost equally famous master, Valsalva, believed firmly in the contagiousness of phthisis-a belief quite common at that time. Hence Morgagni says, naively, " Itaque non multa ille, ego vix aliquod dissecui," a valid excuse certainly for invalid views. Morgagni lived to the advanced age of eighty-nine years, a fortune rarely vouchsafed to diligent students of this disease. Stark, 1785 (posthumous publication), has the merit of having first recognized the true value and significance of miliary tubercles, but it remained for Reed, 1785, who adopted and enlarged his views, to show that miliary tubercles were structures entirely different from pul- monary glands. A representative physician of the end of the eighteenth century was William Cullen, various editions of whose celebrated work, "First Lines of the Practice of Physick," were issued in English and Latin, and in most of the modern languages, between 1777 and 1802, to constitute almost everywhere the chief authority of its day. In his pathology Cullen had not advanced much beyond the views of Galen. " The phthisis pulmonalis I would de- 281 Tuberculosis. Tuberculosis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. fine to be," he says, "an expectoration of pus or puru- lent matter from the lungs attended with a hectic fever." Again, " In every instance of an expectoration of pus I presume there is an ulceration of the lungs," and though other authors suggest other explanations, Cullen suspects the accuracy of their observations and " still concludes, agreeably to the faith of all other dissections and the opinion of all physicians, that the symptoms mentioned in our definition depend always upon an ulceration formed in the lungs." Still, Cullen is willing to admit a variety of causes for this ulceration, as, 1, an haemoptysis; 2, a suppuration in consequence of pneumonia; 3, ca- tarrh ; 4, asthma ; and 5, tubercle, which-and here is the advance beyond the old clinicians-he " apprehends to be the most frequent of any." By tubercles are meant "certain small tumors which have the appearance of indurated glands." Though at first indolent, they at length become inflamed and are thereby changed into abscesses or vomicae which, breaking and pouring their matter into the bronchiae, give a purulent expectoration and thus lay the foundation of phthisis. To account for the hectic Cullen assumes that the matter of the ulcers is imbued with a peculiarly noxious acrimony, which prevents their healing and thus produces phthisis. In many cases this noxious acrimony is of the same kind as that which prevails in the scrofula, as scrofula often transmits phthisis. Tabes mesenterica, which is a scrofu- lous affection, is also often found " joined with the phthi- sis pulmonalis." It is seen, thus, that Cullen surpassed his predecessors in matters of clinical observation. All the exanthemata, " the small-pox sometimes, and more frequently the measles, lay the foundation of phthisis." In the sections on symptomatology Cullen shows the habit of the close observer. The disease, arising from tubercles, usually commences with a slight and short cough, which, as it becomes habitual, remains unnoticed or is absolutely denied. The breathing becomes easily hurried by any bodily motion; the body grows leaner, the spirits languid. This state of things may continue for a year, or even two, without complaint, except that such persons are more readily affected by a cold, which being often relieved, gives no alarm either to the patient or his friends. But after some such exposure the cough becomes more considerable, is particularly troublesome on lying down at night, and continues longer. Dry at first, it now becomes attended with expectoration of matter which becomes more copious, more viscid, and more opaque ; at length of a yellow or greenish color, and of a purulent appearance. Cullen recognized, of course, the gravity of this disease, basing his prognosis upon the degree to.which the hectic and its consequences have arrived. For, from a certain degree of emaciation, debility, profuse sweating, and diarrhoea, no person re- covers. With the faith of the physician in contrast to the scepticism of the pathologist, he considered it " doubt- ful whether failure is to be imputed to the imperfection of our art, or to the absolutely incurable nature of the dis- ease "-the latter a supposition which he is extremely averse to admit, though he could readily allow of the former ; for, as he declares later, " I do not despair of a remedy for the purpose being found hereafter." Cullen maintained that tubercles often remain quiescent and in- nocent, and believed that nature often resolved and dis- cussed them, but only when they remained uninflamed. The chief measure of treatment was, therefore, to prevent this inflammation. This result is to be accomplished, in so far as it is possible, by confinement to a vegetable diet and milk, avoiding colds ; and the frequent use of gesta- tion, of all modes of which the best is sailing upon the sea. Vegetable acids, even fresh subacid fruits, on ac- count of their antiseptic (this term is used by Cullen) qualities, together with Peruvian bark, are especially useful adjuvants. Mercury is pernicious. Cullen, as stated, carried the standard in the practice of medicine in his day, and his views may be taken as a fair exposition of our available knowledge of tuberculo- sis at the beginning of the present century. It is only fair to say, however, that the pathologists proper, using the term in its older sense, had advanced a step further in their understanding of the lesions in the lungs. Thus Portal, Baume, and Kortum, 1781-1790, had each ar- rived at the conclusion that phthisis and scrofula were intimately allied ; scrofula being, according to Porta], one of the various causes of phthisis ; according to Kor- tum, a peculiar dyscrasia developing phthisis as a second- ary affection ; and according to Baume, an enlargement of pulmonary glands, the suppuration of which constitutes phthisis. Baillie, 1793, succeeded in differentiating scirrhus from tubercle, which he defined as a rounded tumor containing scrofulous matter, a white, soft, cheesy matter-the caseous contents are thus first remarked- mingled with their pus. Baillie- also clearly described the general dissemination of tubercles in various internal organs. Waldenburg detracts from the value of this contribution with the comment that Baillie still regarded these disseminated tubercles as mere curiosa. They were glands or were derived from glands, and as the in- ternal organs-the liver, spleen, kidneys, testes,etc.-were also endowed with glands, why should they not enlarge under the irritation of scrofulous matter ? The eighteenth century closes with its own termination the second period in the history of tuberculosis. The clinicians still rested largely upon the views of the Gre- cian fathers. Phthisis was still a suppuration of the lungs, and though the more advanced pathologists had brought into prominence the tubercles themselves, they still regarded them either as curiosities, or as enlarged and inflamed pulmonary or lymphatic glands. The causes of the inflammation were vaguely defined as an acrimony, a juice, or a scrofulous matter developed in consequence of heredity, a corruption of the natural juices, or a peculiar constitution. The existence of tubercles elsewhere than in the lungs, though recognized in isolated cases, attracted no attention or established no connection with the process in the lungs. Thus it may be said that, up to the close of the eighteenth century, the disease had by no means as yet an independent existence. It had not as yet a name. 3. The nineteenth century furnishes the third period in the history of tuberculosis, almost exclusively in its first quarter, as the result of the contributions of two in- dividuals, Bayle and Laennec. Though there was be- tween these contributions and those of their predecessors, no lapse of time, in point of value, they were centuries apart, and based as they were upon individual observa- tion, without much reference to the past, they mark a distinct, separate, almost abrupt era in the history of the disease. The observations of Bayle regarding the nature of tubercles, and the discoveries of Laennec regarding the diagnosis of the disease, do not seem to be based upon previous investigations, and are not hence gradual evolutions of previous views. The work of each was almost wholly original, so that their disclosures brought about a revolution in the study of the disease. Bayle, 1803-1810, began his work with the distinct rec- ognition of the miliary tubercle, which he was the first thus to name. The larger forms, which attain to the size of chestnuts, soften in their centres and are finally' destroyed by suppuration, being thus substituted by ul- ceration. Translucent granulations, the size of millet seeds, and cartilaginous in consistence, hence different from miliary tubercles, which are gray and opaque, pro- duce the same ulcerations in underlying tissues. En- countering the same structures in almost every organ of the body, the intestine, mesentery, peritoneum, liver, spleen, kidneys, prostate gland, and more especially in the larynx and trachea-a localization not mentioned be fore-he was not content to look upon them as accidents or curiosities. He saw in them the same characteristics, and considered them as real deposits of the same disease. The disease was therefore a general affection with vari- ous local expressions, cachexia, a diathesis which he distinctly named the " tuberculous," a diseased condition specific in its nature, independent of inflammation of the glands or of the lymphatic system. "11 est necessaire de remarquer que Vensemble des observations que nous venons de presenter prouve que la degenirescence tuberculeuse est une maladie chronique; qu'elle est d'une nature speciale; 282 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tuberculosis. Tuberculosis. et qu'on ne doit pas la regarder comme le resultat dune in- flammation quelconque des glandes ou du systems lympha- tique." Tuberculous phthisis is, therefore, not a disease pro- duced by inflammation of the lungs, pleura, or bronchi. These affections may complicate it or precipitate a fatal end, but they may never constitute its cause. So, too, haemoptysis is either a result or a complication, but is never a cause, of phthisis. In these two sentences is summed up our modern knowledge of the specific nature of tuberculosis, its dis- tinct isolation from all other affections, and its existence as an independent disease. Had the succeeding clinicians and pathologists been content to stand by the declarations of Bayle, our present knowledge of the pathology of the disease might have been advanced half a century. The age of Laennec, 1819, has now arrived. Bayle had described what might be called the dead facts of the dis- ease. He had shown what tuberculosis really is. An individual is affected with tuberculosis so soon as tuber- cles are present in the lungs. Bayle knew of no signs, however, by which the presence of the tubercles was re- vealed in life. Not until pus was expectorated and hec- tic fever had set in, could the disease be distinguished as yet. Consequently, Bayle took a hopeless view of the disease. Laennec discovered signs by which the presence of tubercles could be detected early in the disease, and his view of the prognosis was far more encouraging. Laennec commenced his work at the foundation. He be- gan with the study of tubercles, the importance of which he announces in the statement that " les phthisiques for- ment plus du tiers des malades traiies dans les hopitaux de Paris." As Laennec was par excellence a clinician, he discussed his subject throughout from a clinical stand- point. " Liobjet principal de mon ouvrage," he says in liis preface, " etant defaireconnaUre le parti que Von pent tirer du cylindre (the term Laennec always used for the stethoscope) pour distinguer les diverses lesions des pou- mons, j'ai du tout subordonner d ce dessein; et les faits d'anatomie pathologique memes, quoiqu'occupant une place beaucoup plus considerable, n'y sont que comme acces- soires." His first chapters are devoted to pectoriloquy, the coarse and readily recognizable sound of the disease. The lesions of the lungs he groups about it. The cavi- ties which produce it are commonly known as ulcers. These ulcers, as was formerly believed and as practition- ers still commonly maintain, are not an effect of inflam- mation or suppuration of the tissue of the lungs. Re- cent progress in pathological anatomy has demonstrated "jusqu'd I'Evidence " that cavities are due to the softening and consecutive evacuation of a special accidental prod- uct to which modern anatomists have specially applied the term tubercle-a term formerly used in general for every species of tumor or abnormal protuberance. Here- upon follows a classical description of miliary tubercles, which aggregate to form masses which he calls crude tubercles. It is at this period that the lung tissue, hitherto healthy, begins to grow hard, grayish, and semi-transparent about the tubercles. Next follows an account of the process of tuberculous infiltration of the lungs, then the softening of the tubercles, and their dis- charge into neighboring bronchi. In the order of general distribution of these tubercles he places, first, the bron- chial and mediastinal glands, then the cervical glands, the mesenteric glands, the glands of all other parts of the body, the liver, the prostate, the peritoneum and pleura, the testicle, spleen, heart, uterus, brain and bones, and last of all the voluntary muscles. The six varieties of tubercle of Bayle he excludes. The granu- lar form is only an immature miliary form. There is no other difference between them than between green and ripe fruit. There is but one tuberculosis, and scrofula is only an external form of it. After this discussion, Laennec declares " one may now conclude that pectorilo- quy is a veritable sign of pulmonary phthisis, and that it at times announces the disease with certainty a long time before its presence could be suspected from any other signs." " I may add that it is the only sign which may be regarded as certain." With this ability to make an early diagnosis, Laennec is sanguine concerning the recovery of certain cases. "The cough, the dyspnoea, the puriform expectoration, the hectic fever, haemoptysis, marasmus-in tine the complete ensemble of symptoms which Aretaeus has traced with such frightful fidelity -may all exist in an individual, who may, against every hope, be entirely restored to health." These are of course very exceptional cases. The tendency of the dis- ease is to grow worse, because it is the tendency of tuber- cles to enlarge and soften, but the observation of many cases dead of other diseases, showing the unsuspected existence of tubercles, especially encapsulated tubercles, or cicatrizations, prove that cases recover. Moreover, tubercles of the lungs do not differ in any way from tubercles in the glands, called scrofulous, the softening of which often eventuates in perfect recovery. The fame of Laennec rests, however, more substantially and undisputedly upon the discovery of auscultation, which at once outranked in value all other means of in- vestigation. The discovery of auscultation is an excep- tion in the history of medical discoveries. Of most of them it may be said that they were developed by evolu- tion. Auscultation was the creation of Laennec alone. The value of percussion, some mode of which had been practised since the time of Hippocrates, had been clearly recognized and promulgated by Avenbrugger a half a century before. The entire merit of the discovery of auscultation belongs to Laennec, and the history of it, like the history of a nation founded by a great king, is in large measure the history of an individual. It does not seem strange that auscultation of the lungs should have been discovered after, and in consequence of, auscultation of the heart. For the recognition of the tumultuous action of the heart had attracted the atten- tion of even Hippocrates, and it was his custom, as it was the custom of all his followers, to put the hands over it, that is, to practise palpation, in forming a diagnosis of its condition. It is established in his writings that Hippoc- rates even put his ear upon the chest in the endeavor to recognize the condition of the heart. But with the exception of a statement by a single observer, Robert Hooke, 1680, that he could distinguish the state of the lungs by the sound of the respiration, nothing more was written of auscultation up to the time of Laennec. The further history of auscultation does not belong to the his- tory of tuberculosis, except in so far as it became the means of earlier or more certain recognition of the dis- ease. Laennec was able thus to separate pneumonia, pleurisy, emphysema, empyema, etc., conditions which had been hitherto confounded. He discovered what he considered pathognomonic signs for each affection, an error which remained in practical medicine up to the time of Skoda, who showed that these signs do not re- veal special diseases so much as special conditions of the lungs. But as these conditions belong for the most part to special diseases Laennec was only exceptionally led astray. The fact that tubercle was a specific product and tu- berculosis a specific disease, the fundamental fact, it might be termed, in the pathology of the disease, was not al- lowed to remain long undisturbed. Broussais, 1821, first attacked it in the attempt to consider phthisis a chronic pneumonia, that is a result or product of a sim- ple inflammation, the type of which pneumonia contin- ued to be up to the present decade. Andral, 1827, fol- lowed with a new doctrine, to wit, that the tubercle is not a new substance at all, but a product of secretion ; but Louis, 1825, as the result of twenty years' ' ' assiduous devotion," completely reinstated the views of Bayle and Laennec with the remark that his observations " confirm those of Laennec ... in recognizing tubercles in the lungs as the anatomical character of phthisis." The ob- servations of Louis, which were made with almost pain- ful minuteness and accuracy, were based upon the study of 193 cases of the disease. His work is especially valu- able as showing the frequency of complications of pul- monary tuberculosis, or the order of deposit of tubercle elsewhere than in the lungs. Thus, the pleurae were af- fected in one-tenth of the cases, the larynx in somewhat 283 Tuberculosis. Tuberculosis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. less than one-fifth, the trachea in less than one-third, and the intestines in five-sixths. The intestine was found healthy from beginning to end in but three cases. The liver was fatty in one-third of the cases, the spleen and kidneys were ' ' tuberculized " in a sixth part of the cases. In one individual (Case vii.) every organ in the body, with the exception of the kidneys, was more or less deeply diseased. The predominance of affection of the lungs is emphasized with the statement of a general law, "that after the age of fifteen tubercles do not present them- selves in any organ without being likewise seated in the lungs." This law Louis characterizes as "assuredly one of the most important and eminently practical in the whole range of pathology." Louis' chapters in Semei- ology and Diagnosis are models in medical literature and must remain for all time as sources of information regarding the subjects discussed. Whatever could be appreciated by the unaided senses is noted with such accuracy and completeness as to leave little to emend or add from a purely clinical standpoint. An extract from the chapter on Diagnosis concerning the revelations of auscultation, will best show the advance made with this means of investigation, as well as indicate the state of clinical medicine at the end of the first quarter of the present century. "Auscultation, like percussion, maybe incapable of leading to any positive result, even in cases wherein the general symptoms . . . leave but little doubt as to the existence of tuberculous disease. But in the majority of cases, even before the sonorousness of the chest undergoes change, the character of the respiratory murmur is distinctly altered. The murmur is feeble, imperfectly developed, and obscure under one of the clavicles. . . . The character of the respiration be- comes particularly obvious if both sides be auscultated comparatively, a precaution which should never be neg- lected. Or, again, instead of a weak respiratory mur- mur, incomplete in inspiration, the latter is harsh, strong, and blowing, and the expiration harsh and as it were bronchial." Allowance must be made, however, for the natural blowing murmur at the apex of the right lung, as " pointed out by Dr. Gerhard, of Philadelphia, and recognized by other observers also." The same allow- ance must be made for vocal resonance. Again, " the respiratory murmur, either of the vesicular or bronchial character, may remain pure and unaccompanied with rhonchus for a more or less considerable lapse of time, varying with the course of the disease. But a little sooner or a little later . . . dry or humid crackling, or a few bubbles of subcrepitant rhonchus become discover- able at the apex of the chest." These phenomena, due to mucus, precede the softening of the tubercles. " The simultaneous existence at the apex of the left lung of slightly prolonged and slightly harsh expiration, slight bronchophony, and a few cracklings, in a case where the rational symptoms are very far from decisive, would al- most place the existence of tuberculous disease beyond question." But the same symptoms at the base of both lungs posteriorly, indicate very different affections, more especially capillary bronchitis. The prognosis Louis regarded as " almost invariably fatal after a space of time varying between a few weeks and several years." Periods of quiescence may occur and exceptional cases may recover, but they do not invalidate the rule. Hence the chapter on Treatment is very short. The medical agent most thoroughly discussed is chlorine gas, whose virtues had met with renewed advocacy, more especially by Cottereau. Louis studied the action of chlorine gas on upward of fifty cases, obtaining " in no instance any successful result from its employment." In his despair of therapy he expresses the conviction that progress can only be made by associated investigation on the part of a great number of observers. Hence he invokes the aid of the government, which shall institute a crusade against a disease which he characterizes as " the most relentless enemy of the human race." The researches of Louis, confirming in every essential particular the conclusions of Bayle and Laennec, would seem to have finally settled the question of the specific nature of the disease for all time. But it has been truly said, tuberculosis is the battle-ground of the pathologists, and every succeeding pathologist of prominence ap- peared in the arena with a new challenge. Rokitansky, 1842, while adopting the dogma in the main, brought for- ward the doctrine of the erases, one of which was the tuberculous, explaining tubercle as an exudation of co- agulated protein matter. Addison, 1845, derived tuber- cles from white blood-corpuscles. Lebert, 1844, believed in a tubercle granule, a neoplasm which had distinctive microscopic characteristics, as the sole pathognomonic evidence of tuberculosis ; and Reinhardt, 1847, who main- tained that Lebert's granule was a derivative of pus, re- garded tuberculosis as the result of a chronic pneumonia. But the most powerful and dangerous opponent of all was Virchow, 1847-65, who really succeeded in overthrowing the belief in the specific character of the disease, and rel- egating tuberculosis to a subordinate place in nosology for nearly a quarter of a century. As the doctrines of this most eminent pathologist held undisputed sway so long as evidence was gathered only from morbid anatomy, and as they w'ere allowed to influence the views of all writ- ers, teachers, and practitioners in their day, Virchow's conception of tubercle, or what is here more especially pertinent, of tuberculosis, deserves more than passing no- tice in any sketch of the history of the disease. The lat- est and most concise summary of his views is found in his famous work, "Krankhafte Geschwiilste," published, but never completed, from his lectures in the Institute of Pathology at Berlin, 1864-65. Virchow had already ex- pressed the view that tuberculosis is a product of retro- grade metamorphosis, which consists in a necrosis of the elements of a tissue with subsequent resorption of its fluid elements. This metamorphosis is co-ordinate with the fatty, waxy, atheromatous, and calcareous change, and may attack or occur in the most varied disease processes. Thus there may be an inflammatory, cancerous, typhous, sarcomatous, etc., tuberculization. The term " tubercu- lization " conveys in itself some idea of Virchow's views. Tuberculization is chiefly a cheesy change. So " casea- tion " became a kind of keystone in the arch of this pathology. It was proposed to dignify the process with a Greek appellation, to adopt the term " tyrosis," first suggested by Craigie, 1848. Tyrosis (from i-vpis, cheese) or tyromatosis, expressed caseation ; tyroma, caseous matter, and tyroid, matter which resembled it. Casea- tion represented a particular form of necrosis or necro- biosis of certain elements prone to become tuberculized, hence " vulnerable " to this attack. Miliary tubercles are lymphatic or lymphoid growths of " heteroplastic" de- velopment. By tlie term heteroplastic is meant out of place. Heteroplastic growths occurred in places where they do not belong anatomically, that is, by natural birth. " If we look back again over the whole field of tubercu- losis," he says " we see in the foreground two peculiari- ties of tubercle ; its heteroplastic development and its tendency to multiple eruption." These peculiarities are responsible for the development of the theory of a tu- berculous dyscrasia. Bayle first called it the tubercu- lous diathesis, and Rokitansky developed it into a dyscra- sia. But a dyscrasia does not explain the development of tubercle granulations. What, then, is the irritation which produces tubercle? "Search was made for a specific agent, and this seems to show itself in an unfa- vorable mixture of the blood, in the reception into the cir- culation of different matters." Bennet referred it to an acid condition of the chyle, and since Jenner and Baron, many others have attempted to produce it experiment- ally upon animals by bad nourishment and bad air. But these theories concern phthisis rather than tuberculosis, for it is doubtful if the animals operated upon, rabbits for instance, ever suffer with tuberculosis. Virchow cannot say that he has ever found true tubercles in ani- mals. "No one has ever yet been able to make tuber- cles experimentally." Foetal tuberculosis is unknown). Tuberculosis is essentially a disease of extra-uterine life, and if it be hereditary, a fact that may not be disputed, it is not congenital. It is hereditary not as a disease, but as a disposition. This question of heredity may be solved only by cellular pathology. " The tissues are the 284 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tuberculosis. Tuberculosis. carriers of the disposition, of the hereditary vulnerability, and the younger and more immature (unfertig) they are, the easier will this vulnerability betray itself at a suit- able opportunity. In this connection it is worthy to note that the disposition to tuberculosis always signifies also a disposition to inflammation." Virchow repeats again that youth is the age of especial predisposition, and in this regard tuberculosis comes so close to scrofula that no other differentiation exists than the greater frequency of scrofulous inflammation in such parts (skin, conjunc- tivae, pharynx) as are seldom or never visited by tuber- culosis. But this predisposition may also be acquired. Two facts are to be held fast : first, the infectiousness of tubercle, and, second, the specific predisposition of the tissue, whether hereditary or acquired. Scrofula as well as tubercle is a lymphoma, but tubercle as a heteroplas- tic growth has also " the prejudice of malignity," which does not belong to scrofula. The true therapy of the disease, so far as it will reach, is extirpation as soon as possible. This procedure applies, of course, only to ex- ceptional cases, as the external lymph-glands, testicles, bones, and joints. For the rest, two factors are to be borne in mind : the avoidance of the predisposition and of all irritation. These points are to be secured, first, by improvements of nutrition, by cod-liver oil, whey cures, sojourn in the open air, moderate exercise, care of the skin, etc. ; and, secondly, by avoidance of " colds," and scrupulous attention to a cold when it develops. " Hence the inestimable value of a uniform climate and a bland but nutritious diet." Thus tuberculosis was again reduced to a secondary affection, a neoplasm it is true, or rather a heteroplastic growth, having its origin or matrix in proliferating con- nective, but never in epithelial, tissues. As for phthisis pulmonalis, it was not of necessity tuberculosis at all, but a mere caseous degeneration of any process of in- flammation. From this rough and superficial draft or abstract of Virchow's views, it may seem remarkable that they should have exerted such a profound influence upon the minds of succeeding pathologists and clinicians. It is not to be forgotten, however, that they were advanced with great clearness and acumen and that they were the views of one of the most eminent scholars and original investiga- tors of which the science of medicine may boast. How nearly Virchow reached the truth at times may be shown in his discussion of Buhl's theory that miliary tuberculo- sis is a disease which results from the absorption into the blood of minute masses of caseous matter. Buhl, 1856, based his doctrine upon the pre-existence or coex- istence of caseous matter in all cases of miliary, the only true, tuberculosis. The caseous matter was the product of any or of many inflammations. Tuberculosis was the result of its absorption into the blood. Thus upon Buhl's theory the individual infects himself. From the absorp- tion of cheesy matter from any source auto-infection with tuberculosis might occur. Is there such a thing, Vir- chow asks, as a miliary eruption without the pre-exist- ence of cheesy matter ? "I must confess that this is extremely rare. If we make thorough search we may almost always discover somewhere a caseous deposit of older date. Cheesy bronchial and mesenteric glands, in- dividual, perhaps absolutely solitary, cheesy nodules in the lungs or isolated ulcers of the intestine may be dis- closed, and the temptation is strong to regard these de- posits as the centres of infection. Nevertheless, there are individual very rare cases where these primary nodules and ulcers are entirely absent, and where the miliary tu- berculosis seems to be the primary effect." Theoreti- cally, he continues, and nowT he strays further and further from the truth, theoretically this observation is not difficult of explanation. "For why should not a large number of parts of a predisposed organ undergo simultaneously the tuberculous exuberation (Wucher- ung)^" Thus the genius of Virchow was able to il- luminate the field of tuberculosis in many directions, but only by side lights which, followed too closely, led his disciples astray. Niemeyer, 1866, was one of these followers who soon outstripped his leader in excess of zeal to such a degree as to make himself the clinical representative of Virchow's views. According to Niemeyer, phthisis pulmonalis is a caseous pneumonia. Any pneumonia may become caseous or result in caseous degeneration in a debilitated subject. This degeneration follows croupous pneumonia rarely, acute catarrhal pneumonia more frequently, and chronic catarrhal pneumonia as a rule. " The consolida- tion and destruction of the lungs which form the ana- tomical basis for consumption are usually the products of inflammatory action, and the greater the quantity of cellular elements collected in the vesicles, and the longer the duration of the inflammation, so much the more read- ily will pneumonia lead to consumption, since these are the conditions most favorable for the production of caseous infiltration." With Virchow, Niemeyer could not believe the disease to be directly inherited, though its tendency is in many cases congenital. The inherited vulnerable constitution need not of necessity proceed from ancestral phthisis, as parents who are afflicted by other exhausting maladies, or whose constitutions are ruined by debaucheries, or who beget children late in life are quite as liable as consumptive parents to produce children with this predisposition. This liability is also often acquired from many causes, as, first, improper food. " Feeding a suckling babe with bread, pap, etc., instead of mother's milk, may sow the seeds of the malady." With these views, Niemeyer could not but consider " fluxionary hypersemias" and bronchial catarrhs as the most frequent exciting causes where the predisposition exists. Consequently he is very severe with Laennec, whose ideas of the specific character of the disease could not admit such a cause. " The deliberate assertions of Laennec and his pupils that * catching cold ' and other irritation had no influence in producing pulmonary con- sumption, and that it never arose from a neglected ca- tarrh, has had the most pernicious effect both upon the prophylaxis and the treatment of the disease." Upon this theory of the disease Niemeyer was not even willing to grant acute tpiliary tuberculosis a place as a primary affection. It, too, is secondary, mostly to case- ous pneumonia, but occasionally to some cause as yet unknown. Thus, "in the great majority of cases the disease is seen in persons whose lungs or other organs contain old caseous deposits. This fact, and the circum- stance that the symptoms and course of acute miliary tuberculosis bear a strong resemblance to those of the acute infectious diseases, would make it appear highly probable that the malady arose from infection of the blood by the caseous products (Buhl), were it not that the occasional although rare occurrence of the disorder, un- preceded by caseous deposit, contradicts this plausible hypothesis. We must, therefore, content ourselves by stating that in most cases acute miliary tuberculosis is a secondary disease, arising, in some manner as yet un- known to us, from the pernicious effect of the cheesy de- posit, but that may also proceed from other causes of whose nature we are entirely ignorant." Still Niemeyer is unable to surrender entirely the seductively "plausi- ble hypothesis " of Buhl, as he says, in a sentence which sums up his views : "The caseous masses upon which the consecutive (secondary) development of tubercles in the lungs depends are situated, in the great majority of cases, in the lungs themselves, and consist of the products of chronic pneumonia, in a state of caseous degeneration. We have no hesitation in stating that the greatest danger for the majority of consumptives is, that they are apt to become tuberculous." Thus acute miliary tuberculosis is put further and further back, so that the sequence now is, first, an inflammation, second, a caseous degenera- tion, and, third, tuberculosis, in a chain of disease-pro- cesses as consecutive and about as substantial as the links in the construction of the celebrated Jack's house. To these extremes was Niemeyer led in the progress of the attempt, of which he makes frequent boast, to "gradu- ally emancipate myself from the views of Laennec." But the mass of medical men not under the immediate influence of Virchow's fame declined to be emancipated from the views of Laennec, and the clinicians who ad- 285 Tuberculosis. Tuberculosis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. vocated the new doctrine could not fail to feel its dis- crepancies in the field of practice. For, as Oppolzer re- marks, almost w'ith a sigh, " what made Laennec's views regarding the unity or identity of tuberculosis and phthi- sis so seductive was the fact that they harmonized so generally with clinical experience." Thus, wdiile the leaders were enticing their followers wfith new strains, the rank and file of the profession persisted, in the main, in the straight lines so clearly marked out by Laennec, if only because "they harmonized so generally with clini- cal experience." Nevertheless, much confusion was cre- ated in the conception of tuberculosis. Morbid anatomy seemed to have reached its utmost limits with the declara- tion of Virchow that tuberculosis was a retrograde meta- morphosis, and that any tissue might undergo, under proper conditions, the peculiar change, exuberation (Wucherung), constituting "tuberculization." Morbid anatomy could indeed go no further. It was handi- capped with the idea that the process was wholly local, that is, that it arose from within. For although tuber- cle was admitted to be a neoplasm in a sense, this sense was very limited. Tubercle was a new process only in that it was heteroplastic, that is, foreign to its native place. Tubercle was at most a deposit. But the cause of it was intrinsic to the body. It was either a vice of constitution, that is, of the whole body, or a vice of cer- tain tissues or cells, parts of the body, due to an "un- favorable mixture of the blood," or an "acid condition of the chyle," etc. It did not occur to the pathologists that the cause of tuberculosis might arise from without the body altogether, that it might be foreign to it alto- gether, that it might be entirely extrinsic. Busied as they were with the changes which take place in the cells themselves, the pathologists could see in tuberculo- sis nothing else than a change in the cells resulting in that peculiar aggregation and degeneration which con- stituted tubercles. The pathologists could see no further, because the horizon of medical science at this time bor- dered at this line. Until the horizon could be enlarged, all further investigation was sipiple speculation. New rays of light from another, an entirely different and quite unexpected, source soon lifted the horizon and illumin- ated for more perfect vision the real nature of the disease. Meanwhile, however, an important discovery in the diagnosis of the disease was announced in the detection of elastic tissue in the sputum. This discovery was first made by the distinguished alienist and microscopic anat- omist of Holland, J. L. C. Schroeder van der Kolk, " Over de aanwezigheid van elastische vezels in de sputa van teringlyders als teeken eener vomica," 1845 ; French, 1850 ; English, 1857; but was not brought prominently and practically before the profession until the publication of a paper " On the Detection of Lung Tissue in the Ex- pectoration of Persons Affected with Phthisis," by Sam- uel Fenwick, of the London Hospital for Diseases of the Chest,1 in the Transactions of the Medico-Chirurgical Society, 1866, vol. xlix., p. 210. This paper was based upon results obtained from the examination of the sputa of one hundred real or suspected cases of consumption, an examination which the author maintains "should always be made as adjunct to auscultation." The chief merit of Fenwick's contribution consisted in his rec- ommendation of the plan whereby the process of ex- amination was simplified, of "liquefying the sputa by means of pure caustic soda, when any particles of lung that may be contained in it fall to the bottom of the vessel, and can be removed and placed beneath the micro- scope." It is possible in this way, the author claims, to detect the to ktAto part of a grain of pulmo- nary structure in the sputa of patients affected with phthisis. In one case the author counted, in the sputum of twelve hours, "as many as eight hundred fragments of lung, and we generally find from fifty to sixty pieceseven where, from auscultation, wTe should have expected but a small amount of destruction to be going on." The elastic tissue is most markedly present during the process of softening or destruction of lung tissue, but may be detected at times-in fact, in seven of thirteen cases-in the earliest stage in which the disease "was either sus- pected or was diagnosed by the stethoscope." In seven of the author's twenty-four cases the microscope failed as completely as auscultation "in proving the existence of phthisis in this difficult class of cases," whence the author suspects that the subjective symptoms present- cough, expectoration, and loss of flesh-"arise rather from the general derangement of health preceding the formation of tubercle than from an actual deposit in the pulmonary tissue." The presence of this tissue is of value in demonstrating the existence of softening, and its absence in proving that ulceration has not yet occurred, " for such a fact should induce us to look hopefully upon such a case, and should encourage us to persevere in our endeavors toward off attacks of inflammation." Subsequent investigations, it is almost needless to state, have not confirmed the expectations entertained of the value of this discovery. For, inasmuch as elastic tissue is present only in cases of at least partial destruction of the lungs, the disease may in the great majority of cases be diagnosticated without it, and before it appears. The fact that other destructive processes, such as abscess, and ulcerations about foreign bodies, likewise furnish it does not detract so much from its value, because of the rarity of these affections as compared with tuberculosis. It is of value, as its original discoverer declared, as a sign of vomicae, a condition present, as a rule, only in advanced cases. The sputa of acute miliary tuberculosis, and of consolidations, however extensive, unless coincident with cavities, do not show it at all. Ten years after the publication of this discovery by van der Kolk, another interesting contribution to the diagnosis of tuberculosis was made by Ed. Jager, 1855, in the recognition of tubercles in the choroid during life by means of the ophthalmoscope. Tubercles had been described in this situation post mortem ever since the first observations of Autenrieth, 1808, but could not have been seen in life before the invention of the ophthalmo- scope by Helmholtz, 1851. This discovery has little more than historic interest, as the choroid is now known to be one of the rarest sites of tuberculous deposit. The occasional cases recorded, as by Fraenkel and Steffen, where the choroid showed the first discoverable evidence of the disease, remain such exceptions as to be curiosities in clinical experience. Allbut searched for them for years and never saw them, and Garlick in two years' ob- servation encountered but a single case. The presence of choroid tubercle indicates a general dissemination of the disease ; the absence of it does not exclude the diag- nosis. It was about this period of time that cod-liver oil came into general use in the treatment of the disease, to put a new phase upon its prognosis, if only in the prolonga tion of life, by conferring upon the cells and tissues in- creased resistance to its invasion. Thus the elder Will- iams, in speaking of the first ten years of his practice- 1830-40-remarks, that the beneficial effect of treatment was limited to incipient cases, and especially to those who were able, at an early stage, to take long voyages- as to Australia or India. " My general recollection of the histories of the developed disease," he continues, " is that of distressing tragedies, in wffiich no means used seemed to have any power to arrest the malady ; and life was rarely prolonged beyond the limit of two years, as- signed by Laennec and Louis as the average duration of the life of a consumptive." Improvement began in the next decade-1840-50-with the administration of a more liberal diet, the use of iodine, and, more especially, of a mineral acid-generally nitric acid-but it was only in the latter half of this pe- riod, when chemistry began to produce cod-liver oil of sufficient purity and freshness to be fit for the human stomach, that decided change for the better was ob- served ; " and I have no hesitation," to use the language of this conscientious observer, " in stating my convic- tion that this agent has done more for the consumptive than all the others put together." The most conclusive evidence in this direction was furnished by the younger Williams, who succeeded his father in the charge of the Brompton Hospital, in 286 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tuberculosis. Tuberculosis. Observations based on two hundred and fifty cases win- tering at foreign health-resorts. Of these patients, forty took oil irregularly or not at all, with a duration of life of four years and eight and one-half months ; the re- mainder furnishing a duration of life of eight years for those who died, and nearly nine years for those still liv- ing at the time of the observation. " Pulmonary Con- sumption," Williams, 1887, p. 336. 4. Mention has been made already of the belief, quite common in the days of Morgagni, in the contagiousness of phthisis, and individual advocates of this belief had maintained the view long before the disease had secured for itself an independent existence. The attempt to pro- duce the disease by direct inoculation was therefore but a natural expression or demonstration of this belief. Kortum, 1789, an advocate of the identity or likeness of scrofula to phthisis, made the first experiments with scrofulous matter, which he attempted to rub into the unbroken skin of the neck of a boy, and in another case inserted in a small wound of the neck. As no infection followed in either case, Kortum came to the conclusion that the benign matter of scrofula is not contagious. Nevertheless, he maintained, the acrimony of scrofula may become depraved in the body and then become ma- lignant. Hebreard, 1802, repeated Kortum's experiments on animals, with the same negative results. Lepelletier, 1816, more boldly inoculated himself with the serum from a blister on a scrofulous and tuberculous patient, with the result that the wound showed slight suppuration, but healed without a trace in four days. Laennec, 1821, reports, in answer to the question if the disease may be inoculated, the single observation that in making a sec- tion of the vertebral column he had accidentally cut him- self slightly in the index-flnger with the saw. Erythema developed in the hitherto unnoticed wound on the fol- lowing day, and gradually, thereafter, a small oval tumor which had the exact appearance of a crude tubercle. Under repeated cauterizations with the butter of anti- mony, it faded away. Albers, 1834, reported five cases of similar nature, all of exceeding obstinacy, one persist- ing for eight years, to disappear only after a long suppu- ration, excited by a blister. Malin, 1839, narrated the case of a dog who died of the disease after swallowing the phthisical sputum of his master. A second dog who showed the same taste died in six months, in the same way. Both lungs were found in a state of suppuration, one, the right, enclosing a large cavity. Disregarding, now, the mercurial injections of Cruveil- hier and Gaspard, made in the attempt to prove tubercu- losis to be a product of ordinary inflammation, as well as the inoculations with matter from glanders by Vines and Erdt, under the belief that glanders was identical with tuberculosis, because of the crudity of the methods em- ployed, whereby the accidental introduction of "mixed infections" could not fail to occur, conditions which also invalidate the much later conclusions of Panum in his ex- periments in the production of emboli; disregarding, also, the observation of Klencke (1843), that he had observed a widely disseminated tuberculosis in the lungs and liver of a rabbit which he had killed twenty-six weeks after the injection of tuberculous matter into its jugular vein, the same matter from the rabbit having been subsequent- ly injected into a crow without result, the single observa- tion having made little impression upon its author, and less upon his associates and followers, we arrive finally at the discovery of the inoculability of tuberculosis by Villemin (1865), which marks a distinct epoch in the his- tory of the disease. Villemin's experiments and conclusions were presented as papers before the Paris Academy, December 4, 1865, and October 9, 1866, published in the Bulletin de I'Aca- demic de Medecine of the same months, and were finally presented in full in book-form under the title "Etudes sur la Tuberculose ; preuves rationelles et experimentales de sa specificite et de son inoculabilite," Paris, J. B. Bail- liere et fils, 1868. The experiments consisted in the sim- ple introduction of tuberculous matter from the lungs and elsewhere into subcutaneous incisions behind the ears of rabbits. The wounds healed after slight local symp- toms and when the animals were killed, at periods vary- ing from twenty-one to fifty-five days, tubercles were found in the lungs, pleurae, peritoneum, and intestines. Control experiments with pus from abscesses and cholera ulcers showed no trace of tuberculous deposit. Besides rabbits, Villemin experimented likewise upon guinea- pigs, dogs, and cats with the same results. The injec- tion of sputa of patients affected with tuberculosis also produced the disease. Hence, Villemin concludes: 1. Tuberculosis is a spe- cific disease. 2. It is an inoculable disease. 3. It may be successfully inoculated in rabbits from man. 4. It be- longs therefore among the virulent affections, and takes its place in nosology with small-pox, scarlet fever, syph- ilis, and, more especially, with glanders. The disease arises, therefore, either by direct inoculation, by conta- gion, or, finally-and this he declares as if illumi- nated by a flash of inspiration-by germs suspended in the air or contained in the peculiar tuberculous matter. Heredity, constitutional predisposition, avocation, "tak- ing cold," etc., are therefore never the direct causes of the disease. Moreover, previous disease, pneumonia, pleurisy, catarrh, and haemoptysis, though they may in- crease the liability of the body to be infected by the poi- son in the air, may never directly produce the disease. There is nothing peculiar in tubercle itself. The process of caseation is found in other pathological processes- typhus, scrofula, etc. The sole sure criterion of tuber- culosis is its inoculability. Hence caseous pneumonia, much of what is called scrofula, the pearl disease of cat- tle, any of which inoculated produces tuberculosis, is tuberculosis itself. These conclusions, clear and precise, presented with the force of conviction and rendered complete and seem- ingly incontrovertible by control experiments with nega- tive evidence, at once excited an interest in the study of the disease to a degree unknown before since the publi- cations of Laennec. The Paris Academy appointed a committee consisting of Messrs. Colin, Louis, Grisolle, and Bouley to repeat and report upon Villemin's work, which fully confirmed his conclusions, July 16, 1867, wfith the additional statements on a subsequent occasion, June 16, 1868, that the extent and gravity of the inocu- lated disease is directly proportional to the quantity of matter introduced, and that the deposits found in the body consist of tuberculous matter itself and not of any kind of virus absorbed by lymph-vessels and subsequent- ly deposited in the lungs; moreover, that the injection of finely divided foreign bodies, while producing emboli without any marked peripheric irritation or becoming encysted within small pneumonia-islets, never produces tuberculosis. The specific nature of tuberculosis, and its entire inde- pendence of any other affection, seemed to be thus estab- lished beyond all criticism or cavil. It is quite impossi- ble at the present time to portray the " sensation " which Villemin's conclusions produced, attained as they were by experiments easily repeated on every hand. And in the repetition of these experiments the first observers, Lebert, Cohnheim, Roustan easily reached the same con- clusions. But with the multiplication of observations on every hand, it seemed soon to be shown that the same lesions could be produced by the injection of the prod- ucts of other diseases or of entirely indifferent and in- nocuous substances, as elder pith, threads of cotton, bits of glass, hairs, etc. Simon, Sanderson, Wilson Fox (1868), and Waldenburg (1869) more especially, made ex- tensive series of observations which apparently proved the production of tubercles and tuberculosis in this way, and lent new support to the doctrine of the pathologists that the disease might result from any kind of inflamma- tion. It is needless now to review these observations, the fallacy of which rested partly upon the actual use of tuberculous matter in the products of diseases then known by other names, as caseous pneumonia, simple bone carjes, etc., and partly in the accidental introduc- tion of the ubiquitous micro-organisms of the disease with mechanical particles. With our present knowledge of the difficulty of securing the isolation of individual 287 Tuberculosis. Tuberculosis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. micro organisms, it is easy to understand the gross errors of mixed infections or contaminated inoculations at a time when pure cultures or the means of securing them were quite unknown. It will suffice now to say that at this time the experiments referred to were regarded, more especially by the pathologists and more conserva- tive clinicians, as conclusive refutations of the views of Villemin. It was a short-lived triumph for Villemin. Scarcely five years had elapsed when his experiments were forgotten and his conclusions consigned to oblivion. Students of medicine in the seventh decade of the pres- ent century heard reference made to them from chairs of pathology as curious conceits in the history of tubercu- losis. Up to the year 1878 tuberculosis was still a sec- ondary affection, a possible incident to any kind of in- flammation, and the possibility of individualizing it was seemingly as hopeless as that of curing it. Yet there were always individual clinicians amid the mass of disbelievers who considered the disease specific, and there was one especially, famous already for his ad- vocacy of the specific nature of cholera, typhus, etc., William B. Budd, of Clifton, England, who, about this period of time, and seemingly without knowledge of the work of the experimenters, as a pure bed-side deduction, boldly published the following statements in the London Lancet, October, 1867: " The following are the principal conclusions to which I have been led regarding phthisis or tubercle : " First. That tubercle is a true zymotic disease of specific nature, in the same sense as typhoid fever, scar- let fever, typhus, syphilis, etc., are. " Second. That, like these diseases, tubercle never originates spontaneously, but is perpetuated solely by the law of continuous succession. " Third. That the tuberculous matter itself is (or in- cludes) the specific morbific matter of the disease, and constitutes the material by which phthisis is propagated from one person to another, and disseminated through- out society. " Fourth. That the deposits of this matter are, there- fore, of the nature of an eruption, and bear the same re- lation to the disease, phthisis, as the yellow matter (the stools), for instance, of typhoid fever. " Fifth. That by the destruction of this matter on its issue from the body, by means of proper chemicals or otherwise, seconded by good sanitary conditions, there is reason to hope that we may eventually, and possibly at no very distant time, rid ourselves entirely of this fatal scourge." These conclusions touch the highest point which clinical medicine ever reached in the whole history of tuberculo- sis. They are the expressions of a keen, clear, and logical mind, drawing deductions from daily observations, and they appear, in the light of subsequent events, as little less than prophecies. Unfortunately, such minds were few then as now, and as the conclusions were incapable of demonstration, they failed to penetrate or remove the apathy which had settled about the study of the disease. A comparatively trivial observation, the result of a very simple experiment, became now the source of new interest in the subject, and the cause of rescue or revival of the views of Villemin. Tappeiner {Virchow's Archie, vol. Ixxiv., p. 393, 1878) caused a number of dogs to in- hale atomized tuberculous sputa, and thereby succeeded in producing the lesions of the disease in the lungs as well as, in certain cases, elsewhere. These experiments were in reality simply confirmations of the conclusions of Villemin, and repetitions of his experiments in a dif- ferent way ; but they attracted wide attention at once, be- cause of the use of natural avenues in the production of the disease. From this time on, the doctrine of the specific nature of tuberculosis gained new advocates daily. Cohn- heim, 1880, had by this time come to the conclusion that his previous observations, to the effect that tuberculosis could be variously produced, had been incorrect, and that tuberculosis could be caused only by itself. In conjunc- tion with Salomonsen, 1882, he systematically adopted the ingenious method first practised by Harnsell, of in- troducing tuberculous matter into the anterior chamber of the eye, whereby subsequent changes in the iris could be distinctly observed during the life of the animal. In his account of the process, Harnsell {Graefe's Archie, Part 25, iv., 1879) mentions first the cases of tuberculo- sis iridis as reported by Peris, Manfredi, Koester, Leber, Samelsohn, Sattler, and Angelucci, and then adds three cases from his own (Gottingen) clinic. He thus estab- lishes the fact of the infection of the iris. After notic- ing the experiments of others in direct and indirect inoculation of the eye with tuberculous matter, the au- thor proceeds to detail his own. He found that the in- sertion of tuberculous matter into the anterior chamber of the eye invariably inoculated the iris. The cornea and conjunctiva could be inoculated directly, and in all cases the tuberculous matter inserted " disappeared by the third day, and after from fifteen to twenty-three days of incu- bation tuberculous collections showed themselves." Par- ticles of these collections were thereupon introduced into the peritoneal cavities of dogs and guinea-pigs. The dogs died of suppurative peritonitis. The guinea-pigs were kept under observation for three months and then killed, when "all the internal organs and the skin w-ere found, without exception, to be filled with deposits of miliary tubercles. The investigations of Cohnheim fully confirmed these conclusions. Moreover, the fact that his experiments were undertaken in the spirit of scepticism, made his conclusions more convincing. For Cohnheim was the most authoritative opponent of the specific char- acter of tuberculous "virus" after his first adoption of the views of Villemin. Cohnheim found that the intro- duction of the smallest particle of tuberculous matter through a linear incision into the eye of a rabbit was fol- lowTed, after a period of about six weeks, by an eruption upon the iris of minute nodules, "which increase to a certain size, and then undergo caseous degeneration, to be followed in turn, in the course of months, by a more or less general tuberculosis of the lungs, peritoneum, and various other organs." Cohnheim became so convinced of the inoculability of the virus that he proposed to util- ize it as a diagnostic criterion of tuberculous products. We are unable, he declares, to differentiate tuberculous matter with certainty in any other way. " Neither the nodular form, the histological structure, the occurrence of giant cells, caseation, nor all these circumstances to- gether, are absolutely characteristic of tuberculosis. The only absolute, perfect, and certain criterion is the capacity for infection." Cohnheim tried in vain to excite tuber- cles in the iris " by introducing into the anterior chamber portions of non-tuberculous animal tissues of the most varied kind," and Harnsell failed to produce them by the inoculation of fresh trachomatous matter. "On the other hand, the tuberculous matter used, when introduced into the peritoneal cavity, excited, in turn, general tuberculo- sis of all the organs." Thus, as Cohnheim concludes, in tuberculosis " everything depends upon the virus. We dis- cover at all points the closest analogies between tuberculo- sis and syphilis. Both require above all things infection, transmissibility of the disease from person to person" (ital- ics ours). Meanwhile, the belief in the specific nature of tuber- culosis received additional support in the establishment of the identity with it of scrofula and the pearl distemper of lower animals, at the hands of many observers. Thus Villemin had in his original experiments proven that the injection of matter from scrofulous glands, and from the pearl disease, produced tuberculosis ; Koster, 1869, de- monstrated miliary tubercles in scrofulous affections of the joints; and Wagner (1870), Schiippel (1871), and Friedlander (1874), disclosed them in scrofulous glands, bone caries, and ulcers of the skin, including lupus vul- garis. Gerlach, Schiippel, and Aufrecht likewise estab- lished the histological identity with tuberculosis of the pearl disease of cattle, which became henceforth known as bovine tuberculosis. The close of the fourth period in the history of tuber- culosis, at the end of the seventh decade of the nineteenth century, witnessed the establishment of the fact that the disease was specific, and that its cause was a "virus" capable of propagation by inoculation. The character of 288 Tuberculosis. Tu bercuioais. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. this virus, or the proper cause of the disease, remained as yet, as Cohnheim declared at the end of his investiga- tions, " a riddle as unsolved as before." 5. But no sooner had the inoculability of the disease been clearly established-no sooner, in other words, had the disease been classed among infectious maladies, than search began to be made systematically for a specific cause in the direction already declared in the field of other in- fections. For, as Klebs, the pioneer observer in this di- rection, remarked, "inasmuch as the development of tubercles and the advance of the disease corresponds with the deposit and dissemination of the poison, it must be believed of this, as of other infectious diseases, that the poison is not a chemical substance, but an organism whose penetration and multiplication in the body pro- duces the symptoms of the disease." Klebs himself, 1877, first claimed to have isolated certain micrococci the in- jection of which into the body of animals produced the disease. Schiiller, 1880, confirmed the observations of Klebs, with the additional claim that he had succeeded in cultivating these micrococci from miliary tubercles, scrofulous glands and joints, and from lupus. Aufrecht next, 1881, discovered two kinds of micro-organisms, to wit, micrococci, single and in chains, and bacilli, short rods, in tubercles produced by the inoculation of tuber- cles of man as well as of the products of the pearl disease of animals. Each of these observers regarded the micro- organisms mentioned as specific causes of the disease. There! can be now no doubt that each observer was right in the declaration that he had succeeded in producing the disease, though it is equally clear that the disease was produced, not by the micro-organisms mentioned, but by others unconsciously introduced at the same time. Satisfactory demonstration of specific micro-organisms was impossible at this time, from lack of knowledge of the conditions necessary to separate them from each other. Claims made in this direction were regarded, therefore, as expressions of enthusiasts or fanatics, " un- dismayed pioneers," as they were termed, whose state- ments were greeted with incredulity, ridicule, or con- tempt. Up to the year 1882, it may be said that the medical profession stood divided in opinion as to the nat- ure of tuberculosis. The few, informed as to recent investigations, warmly espoused the views of those path- ologists who stoutly maintained the specific character of the disease as proven by experiments in the inoculation of the tuberculous "virus;" while the vast majority, many members of which were equally intelligent but not equally informed, adhered to the doctrine still taught by most of the pathologists, that tuberculosis was a sec- ondary affection incidental to any kind of inflammation. Neither the observations of Villemin nor those of Cohn- heim seemed sufficient to overthrow this deeply-rooted and ever recurrent doctrine, so fatal to every advance in the study of the disease. Perhaps a few extracts from text-books on practice current at this time, will best exemplify, the status of clinical medicine at the beginning of the eighth decade of the present century. The first extract is selected from the text-book on Clinical Medicine, by Austin Flint, Philadelphia, 1879. This selection would be un- just to the memory of one of the most distinguished clinicians of modern times, were it not prefaced with the statement that this author was one of the most early advocates and zealous supporters of the-doctrine of the specific nature of the disease so soon as its specific cause was definitely established, but maybe considered, because of the sound judgment and quick perception of the author, all the more an appropriate illustration of the doctrines of its day. " Pneumonic phthisis" is the name the author proposes, p. 114, as the name of the disease whose synonym is pulmonary consumption. " Consider- ing it as a form of chronic pneumonia, its inflammatory character is of course assumed. It is nosologically placed among the local diseases, but from this it is by no means to be inferred that the affection does not involve an underlying constitutional morbid condition, that is, a cachexia. Indeed, the existence of such a condition is logically certain, and this fact enters into both the diag- nosis and treatment." Of miliary tuberculosis the author says, p. 123, " This affection differs essentially from pneu- monic phthisis, although having pathological relations with the latter and the two affections not infrequently coexisting." Interstitial pneumonia, fibroid phthisis, cir- rhosis of the lung, pulmonary sclerosis, are synonyms to express a condition which, p. 124, "enters more or less largely into the morbid anatomy in many cases of pneu- monic phthisis. It is the anatomical characteristic of a substantive affection when it exists independently of either ordinary phthisis, or the presence of tubercles." Roberts (" Theory and Practice of Medicine," Fifth American Edition, P. BlakistonJ Son & Co., Philadel- phia, 1884), observes, p. 439, "Until within a compar- atively recent period pulmonary phthisis was almost uni- versally regarded as a manifestation of the tubercular diathesis, and as being due to the formation of tubercles in the lungs and the destructive processes consequent thereupon. This is still the opinion of many eminent authorities ; but I must, at the outset, express my entire concurrence with those who regard the term as includ- ing cases arising from morbid processes essentially dis- tinct from each other, and not merely tubercular ; all of which, however, tend to produce similar results, namely, consolidation followed by destruction of the lung text- ure, and wasting of the blood and tissues of the body." Loomis (" A Text-book of Practical Medicine," Second Edition, William Wood & Co., New York, 1884), begins the chapter on Pulmonary Phthisis with the statement, p. 171: "At the present day there is no sub- ject in the domain of practical medicine, concerning which competent observers differ so widely as in the in- terpretation of the anatomical changes which are met w'ith in pulmonary phthisis. For one class of observers, phthisis is an inflammatory process which may or may not be secondarily complicated by tubercle ; another class maintain that tubercle is the primary and essential lesion of all phthisis. Still more recently, certain inves- tigators maintain that there is a specific material in phthisical processes which may or may not be accom- panied by the histological elements of miliary tubercle, but which always has a specific form of bacteria as the sole exciting cause of its development." Again, of acute miliary tuberculosis, p. 706 : This disease " is an acute general disease of an infectious nature and non-inocu- lable. . . . The question whether it is, strictly speaking, primary, awaits its answer in an accepted definition of tubercle and a demonstration of its etiology." Such selections, which might be indefinitely multiplied, serve sufficiently to show the confusion which prevailed in the minds of the best clinical observers in the early years of the eighth decade of the present century. Meanwhile, the stage had been quietly set for the final scene in the history of tuberculosis ; so quietly that only the few workers behind the scenes could fully appreciate its character. The mass of the profession, unprepared for the results, refused recognition to views-to sustain the simile-which differed so much from accepted opinions. But revelations seem sudden, startling, and subversive only to those who are unac- quainted with preliminary facts. The preliminary facts leading to the final disclosure of the cause of tuber- culosis were discovered in fields of work with which the mass of the profession was entirely unfamiliar. The one established, and yet but partially accepted familiar fact, wTas the inoculability of the disease, which was supposed to be due to a specific virus. All the rest of tli£ evidence was gathered from the study of the causes of other infec- tious diseases, of quite different nature, and was the result of the work of a single investigator who had solved the difficulty of separating, that is, isolating, in- dividual micro-organisms as the cause of these affections. The result of this memorable work first appeared in the Berliner klinische Wochenschrift, No. 15, April 10, 1882, under the title " Die Aetiologie der Tuberculose nach einer in der physiologischen Gesellschaft zu Berlin, am Marz 24, gehaltenen Vortrag von Dr. Robert Koch. Koch prefaced his disclosures with an acknowledgment of the work of Villemin, whereby the specific nature of 289 Tuberculosis. Tuberculosis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the disease seemed to have been established, and with a statement of the objections urged against it; mentioned the experiments of Cohnheim, Salomonsen, and later of Baumgarten, in injecting the anterior chamber of the eye, which reinstated the doctrine of Villemin, and spoke of the inhalation experiments of Tappeiner, all of which left no doubt of the inoculability of the disease. The importance of its study is evidenced by the fact that it destroys one- seventh of all mankind, a proportion increased to one- third at the productive period of life. The author now quotes from Cohnheim the observa- tion that the peculiar cause of the infection still re- mained a problem unsolved. His own first investigations were also futile, and these means of study he abandoned for others, whereby his first suspicions seemed to have been aroused by the detection of a micro-organism which differed from other forms in its peculiar reaction to coloring matters. This peculiarity consisted in its resist- ance to certain colors, as well as in its persistent main- tenance of color, having once been thoroughly stained, in the presence of decolorizing agents. In this way Koch first arrived at the discovery of a rod-shaped micro- organism which he proposed to call the bacillus tuber- culosis. The bacillus tuberculosis he next describes as a slender, motionless rod, about five times as long as broad, seldom seen perfectly straight, generally curved, often bent upon itself, with rounded ends, and provided with spores which represent its permanent form. The giant cell, hitherto regarded as a foreign body, is caused by the direct invasion of lymphoid cells by these bacilli, whereby the nuclei of the cell undergo marked multipli- cation in number, and the whole cell enlarges to giant size. These bacilli were discovered in all forms of tuberculosis, to wit, in eleven cases of miliary tuber- culosis in man, in twelve cases of caseous bronchitis, in one case of tubercle of the brain, two cases of intestinal tuberculosis, three freshly-extirpated scrofulous glands, four fungous joint-inflammations, ten cases of pearl dis- ease, three cases of chalky nodules in the lungs of animals, one cheesy lymph-gland of the hog, three spon- taneous cases of tuberculosis in apes, nine guinea-pigs and seven rabbits naturally ill of the disease, and a " not unimportant number" of other animals. The author next mentions the micro-organisms discovered by Schul- ler, Klebs, and Aufrecht, as different from the bacillus tuberculosis; describes the cultivation of his bacillus upon sterilized and gelatinized blood serum as the best culture soil, and details inoculation experiments with control cases, at first in four of six guinea-pigs, then in six of eight guinea-pigs, subsequently in rats, mice, hedgehogs, marmots, pigeons, frogs, and dogs. The sputum of tuberculous patients is equally effective with fresh tubercle in the production of the disease, and des- iccation of the sputum for periods varying from four to eight weeks does not destroy the bacillus nor invalidate the result. Inasmuch, therefore, as the tubercle bacillus is found invariably in all cases of the disease, and is found' in no other disease, and inasmuch as the introduction of the ba- cillus from a pure culture, that is, isolated from all other micro-organisms, invariably produces the disease, the tu- bercle bacillus must be regarded as the sole cause of the disease. " Wir konnen mit Hug und Hecht sagen dass die Tuberkel-baciUen nicht bloss eine Ursache der Tuberkulose, sondern die einzige Ursache derselben sind und dass es ohne Tuberkel-baciUen keine Tuberkulose giebt." We ha^e therefore to deal in the future study of tuber- culosis, not with an indefinite mystery, but with a demon- strable (fassbare) parasite, whose life history is definitely known. Our attempts at its destruction are favored by the fact that it is not an outside, but a strictly inside, parasite, which may be destroyed by the destruction of sputum, disinfection of clothing, bedding, etc. " So soon, therefore," the author concludes, "as the fact is generally recognized among physicians that tuberculosis is an exquisitely infectious disease, the means of attack- ing it must develop themselves." In a subsequent communication made in the same month, April 20, 1882, in the form of a lecture before the Congress of Internal Medicine at Wiesbaden, and published in the Verhandlungen des Congresses fur Innere Medicin, Wiesbaden, 1882, p. 56, Koch dwells at more length upon the points which led up to the final discovery of the cause of this disease. He had imposed upon him- self, in his previous investigations with micro-organisms, the necessity of establishing three premises, viz., the demonstration of the parasite, its isolation, and its suc- cessful inoculation, in proof of its genetic relation to a disease. Hitherto he had been successful in disclosing parasites by Weigert's method of coloring nuclei, which answers for most cases. This method failed, however, in tuberculosis. Other observers had failed in the same way. But in these investigations he got on some occa- sions an inkling that a change in the reaction of the col- oring agent might furnish different results. He found then that when the coloring matters, which before had been employed in acid or neutral reaction, had been ren- dered alkaline, " things appeared colored which had not appeared at all before." Of the aniline colors with which he was acquainted, methylene blue best endured the strongest additions of ammonia, soda, or potash. Hence he used this color in subsequent investigations, permit- ting the specimen to be examined to remain in the color solution for twenty-four hours. In this way the whole field was deeply stained. But there is a peculiarity re- garding certain aniline colors, in that one often displaces another. Thus vesuvin will displace methylene blue. But tubercle bacilli once stained with methylene blue will not surrender their original color. Thus, while everything else in the field takes up the new color, the tubercle bacilli stand out, in the case of the colors re- ferred to, blue upon a brown field. Ehrlich has since shown that tubercle bacilli may be similarly colored with other dyes, and has materially simplified as well as abbre- viated the whole process. The only known bacteria which resemble those of tuberculosis in this regard are the bacilli of leprosy, with which they are not likely to be confounded. The next step was the isolation and cultivation of the bacilli of tuberculosis upon a pure culture soil. Here, again, great difficulties were encountered. As the gela- tine hitherto used became liquefied at 30° C., a tempera- ture necessary to the growth of tubercle bacilli, and hence could not act as a solid culture soil, it was neces- sary to discover a medium which should possess all the qualities of gelatine and yet remain firm. " I had acci- dentally observed that blood serum subjected for a long time to a temperature of 65°-70° C., becomes solid and still preserves its translucency. The blood serum must of course be previously sterilized, which object is accom- plished by heating it each day one hour at 58° C. for a num- ber of days consecutively. Germs of any micro-organ- isms introduced into blood serum thus prepared begin to develop in a short time." Individual colonies remain thus separate, which would not be the case, of course, in fluid media. The great difficulty in the separation of tubercle bacilli consists in the fact that they are so often found in connection with other micro-organisms of more rapid growth. Tubercle bacilli grow extremely slowly. A time of at least ten to twenty days is required, under the most favorable circumstances, to develop distinctly recognizable colonies. Thus if colonies show in two or three days, the specimen is worthless because contami- nated. Once obtained in pure culture, however, further cultivation is very easy. Hereupon the author exhibited pure cultures which had been maintained from three to six months, some of which represented fifteen to twenty successive generations. In experiments with inoculations the objection is to be met that many animals suffer spontaneous tuberculosis. But newly-bought animals are almost always entirely free of the disease, which develops only after a stay of several months with animals already infected. If, therefore, the disease showed itself within five weeks after inocu- lation by simple subcutaneous injection, it was fair to as- sume that it had been artificially induced. But to be able to refute every objection of this character, such means of inoculation were employed as would exclude 290 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tuberculosis. Tuberculosis. all possibility of spontaneous infection. Tubercle bacilli in pure culture were introduced into the peri- toneal sac and into the blood-current, as in the auricu- lar veins of rabbits, a very convenient avenue to the general circulation. In this way most extensive erup- tions of miliary tubercles are produced in a very short time, with exclusion of all caseation of lymph- glands, the intermediate step or stage of ordinary inoculations. Still another absolutely unobjectionable proof of the transmissibility of the disease is fur- ished in the inoculation of the anterior chamber of the eye. The introduction of a few drops of a fluid rubbed up with a culture of tubercle bacilli produces a miliary tuberculosis of rapid course, or the insertion of a minimum quantity develops a tuberculosis of the iris which remains local for a long time. So, also, tubercu- losis may be produced in other animals which are natural- ly but little or not at all susceptible to the disease. Thus, rats remain refractory to subcutaneous injections or long- continued feeding with tuberculous matter, but yield to the injection of great numbers of tubercle bacilli into the peritoneal cavity ; and dogs may be infected in the same way to a degree which it is not possible to produce by any other mode of infection. " Thus is furnished the proof that the disease may be reproduced by bacilli in pure culture. We know now that they constitute the absolute cause of the disease." As to the mode of spon- taneous infection of man, we must have regard first to the contents of the cavities of phthisical lungs. It was safe to assume that the sputum contained bacilli. " This led me to examine the sputum, wherein I found in fact numerous bacilli often provided with spores." Such spores were also demonstrable in caseous masses where the bacilli were diminishing in number. Desiccation of sputum does not destroy its power of infection, as animals inoculated with sputum dried for eight weeks showed the same infection as after the use of fresh matter. " It is, therefore, fair to assume that the chief infection of man results from the inhalation of the universally dissemi- nated dried sputum." To what extent infection may oc- cur in other ways, as from tuberculosis of domestic animals, remains for further study. But infection by sputum would seem to be the most common means. " The etiology of tuberculosis is thus in its main outlines distinctly deciphered, and it is fair to hope that any de- fects still existing will be speedily filled in." The author concludes thus the most remarkable con- tribution to our knowledge of tuberculosis that has ever been made, with each link in his chain of evidence equally strong, because each and every link wTas forged by his own hands. No subsequent review or repetition of his work, by competent hands, failed to appreciate the value of his work, or to accept the validity of his conclu- sions. The discovery of the tubercle bacillus gave the final death-blow to the doctrine that the disease was ever in any sense secondary. The spectre of inflammation which perpetually stalked to the front to obscure the true nature of the disease was quieted forever. Instead of producing the disease, inflammation is itself relegated to a secondary place in pathology, as a mere result of infec- tion. Thus, not with a side light, but with a light in its very centre, has Koch illuminated this most obscure dis- ease, and though shadows still hang about the borders, they must be gradually dissipated with the penetration of its rays in time. We may therefore sum up the history of tuberculosis by noting that it was first regarded as a process of sup- puration (pus); then as consisting of nodules ; in the third period there are seen to be distinct tubercles ; fourthly, these tubercles contain a virus ; and in the final period this takes shape in the tubercle bacillus. James T. Whittaker. 1 Read before the Medico-chirurgical Society, June 26, 1866. TUBERCULOSIS : PATHOLOGY.-There is no other disease whose history is so interesting and so important, as showing how the gradual growth of our knowledge of its different phases has led to the present conception of its nature. We shall not attempt to give a complete his- tory of our knowledge of the disease, but only briefly refer to those points which are of importance for a clear conception of its anatomy. The first epoch in the history of the disease is marked by the description of tubercle by Baillie, in 1794. Up to that time the name tnberculum had been used to desig- nate every small nodular growth. Baillie described as tubercle a small, transparent, grayish nodule which was found in the lungs and in other organs of the body. Bayle, in 1810, as the result of autopsies on nine hun- dred phthisical subjects, called especial attention to the frequency with which these tubercles were found in the phthisical lung, and supposed that they represented something that was specific for phthisis. He believed that phthisis is not a local disease, but the local expression of a constitutional affection, and spoke of the tuberculous diathesis. Bayle himself used the word tubercle to de- scribe other changes in the phthisical lung, which were much more constant and striking than the small gray tubercles, and these views were further extended by Laennec. According to the latter author it was not the miliary tubercles which were most constant, but larger or smaller non-vascular, caseous nodules, and a caseous infiltration. He saw a connection between these and the small tubercles, in the common caseous centre of each, and also in the fact that the larger nodules could arise from a confluence of the smaller. These larger caseous masses he designated as yellow tubercles. The great im- portance of the work of Laennec was his recognition of the unity of phthisis. Virchow made a careful study, both macro- and micro- scopical, of the changes found in phthisical lungs, and divided these changes into those which were of a purely inflammatory character, and those in which the forma- tion of tubercles was the main feature. He threw the whole weight of his authority against the identification of caseation with the formation of tubercles, and showed that caseation was a very common pathological process, and met with in tumors, old infarctions, etc. He showed further, that the formation of tubercles made up but a very small part of the changes in the phthisical lung, and that cases were often met with which were not accom- panied by the formation of tubercles, and were non- tubercular in character. These views of Virchow had the widest acceptance both by pathologists and clini- cians, although Laennec's teaching was still followed to a large extent in France and in Vienna. The third most important epoch in the history of the disease was the discovery, by Villemin, that the disease could be conveyed from man to other animals by inocu- lation, that it was infectious. Moreover, he demonstrated that the same results were obtained whether the material used for inoculation was the small miliary tubercle or the large caseous mass. Much of importance was derived from a purely ana- tomical study of the disease, and from this side the iden- tity of what had been regarded as different but nearly related diseases, was established. Koster, and following him, Volkman, showed that the fungous joint affections were tubercular in character. Schuppel found char- acteristic tubercles in scrofulous lymph-glands. Fried- lander, from an anatomical study alone, advanced the idea that lupus and tuberculosis were one and the same disease. All of this was based upon the discovery of structures identical with miliary tubercles in the tissues, and upon this alone the diagnosis of the character of the pathological process was made. Support also for the be- lief in the infectiousness of the disease was derived from its anatomical study ; the course of the disease, and its spread from point to point, showed that there was devel- oped something capable of serving as a further source of infection. It was found that from a primary focus other parts of the body could become infected, the infection fol- lowing along definite paths. These paths were found to be the lymphatics of a part, or the blood-vessels, or certain other channels, as the bronchi, or the alimentary canal. It was seen that the disease did not attack the organs here and there at random, but that something had to be 291 Tuberculosis. Tuberculosis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. taken from one focus and conveyed to another place be- fore the disease could be established there. Villemin's experiments were repeated by numerous ob- servers, and always with success when exactly carried out. It was found that the method of inoculation was the surest way of deciding whether or not a given affec- tion was tuberculous. If it were tuberculous, a definite disease, tuberculosis, would be produced in certain ani- mals. With few exceptions, pathological anatomists ac- cepted the idea that the disease is infectious, and Weigert gave the name of tubercle virus to the infecting sub- stance, although its exact nature was unknown. It was finally reserved for Koch, in a work so complete in all its details that since its appearance, in spite of the im- mense amount of anatomical and experimental work which it incited, nothing has been retracted from it, and but little added, to complete the pyramid which had been so long building, and to which so many observers had contributed something, We may now define tuber- culosis as an infectious disease caused by the tubercle bacil- lus, and characterized by the production of tissue and of inflammatory products, which appear both in the form of nodules and as a more diffuse infiltration, and which rap- idly undergo caseation. The tubercle bacilli are short rods about | as long as the diameter of a red blood-corpuscle, and about as broad as they are long. Their length varies more than their breadth, and may be from 2 to 6 y. Their diameter is constant, they do not have the enlargement at the ends which is seen in many bacilli. They are usually slightly curved. The first description of them was given by Koch, in 1882, and no material alteration in his descrip- tion has been made since that time. They are found in all tuberculous lesions, and in fluids ■which come from the affected parts, as in the sputum which comes from tuberculous lungs, in the urine in tuberculous affections of the urinary tract, in the blood in cases of miliary tu- berculosis, in the pus from tuberculous joints, and in the stools in cases of tuberculous ulcerations of the intestines. In short, being the causative agents of the disease, they are always met with in the lesions which they cause. They cannot be readily distinguished either in the fluids or in the tissues, except they be colored by a method which stains them alone, leaving unstained the other bac- teria with which they may be mixed. It is possible to see them in the sputum which has been rendered trans- parent by the addition of caustic potash (Baumgarten's method), but neither their size nor their shape is sufficient- ly characteristic to differentiate them from the numerous other bacilli so commonly found in this fluid. The first method of staining that was used by Koch consisted in staining the bacilli together with the tissue which contained them, and then replacing the staining of the tissue with another dye for which it had a greater affinity, leaving the tubercle bacilli stained in the first color that was used. The procedure consisted in first coloring the t issue intensely with methylene blue to which some caustic potash was added, and then staining deeply with a strong solution of Bismarck brown or vesuvin. By this means all of the blue color is driven from the tis- sue and is replaced by the brown staining, but the bacilli retain the blue color first given them. This method of staining was soon replaced by that of Ehrlich, which is much simpler and yields much better results. It con- sists in first staining everything very deeply, and then re- moving the color from everything but the bacilli, by the use of dilute nitric acid. It is often desirable, in order to make the bacilli more prominent, to stain a second time with a reagent which will color everything else ex- cept the bacilli, which remain colored by the first reagent used. The exact method consists in first staining with a fluid made by dissolving fuchsine or gentian violet in a saturated solution of aniline oil, which is made by shaking together aniline oil and water and then filter- ing. The exact formula given by Koch, in his last pub- lication on tuberculosis, and which will always be found to give good results, is as follows : The aniline water is made by adding 5 c.c. of pure aniline oil to 100 c.c. of distilled water. The two are mixed thoroughly by shak- ing them together in a bottle or test-tube, and then fil- tered to remove the excess of oil. To this aniline water 11 c.c. of a saturated alcoholic solution of fuchsine or gentian violet are added, and to this 10 c.c. of alcohol. If fluids are to be examined for the bacilli they should be spread in a thin layer on cover slips and allowed to dry. When they are thick and tenacious, as is the case with sputum, a small particle should be placed between two cover slips, which are then pressed together and drawn apart; this will give a thin, even layer on both. If bits of tissue are to be examined, as the caseous matter from a lung or elsewhere, this should be broken and crushed on the cover glass. Especially in the case of sputum, some care should be exercised in the selection of the portion to be examined. That first expectorated in the morning should be obtained if possible, and placed in a flat glass dish on a black background, and the small whitish masses so common in such sputum sought for. These small masses most probably come from tlie walls of cavities, and will often be found to consist of little more than masses of bacilli. After the cover slips have been allowed to dry they should be heated, in order to render the albumen insoluble and prevent a diffuse stain- ing. This is best accomplished by slowly passing the cover slip, with the side on which the sputum is spread uppermost, three times through the flame of a Bunsen burner, taking care not to scorch the sputum. In the lack of a Bunsen burner an alcohol lamp will do just as well, and A little experience will soon teach one the amount of heat that is necessary. The cover slip so treated may be placed in the staining fluid for twenty- four hours, but this time can be greatly shortened by heating the fluid to the boiling point. I am generally in the habit of placing a few drops of the fluid on the cover slip and holding this over the flame until it boils. By this means everything that was on the cover slip will be intensely stained, and if it should be examined without further treatment the bacilli could not be dis- tinguished. The color is now to be removed from every- thing except the bacilli, by treating the specimen with a solution of nitric acid-one part of the pure acid to three or four parts of distilled water. The specimen becomes somewhat decolorized as soon as it is placed in this, but on washing it again with seventy per cent, alco- hol, some of the color returns. The color may be re- moved even from the bacilli by too long an exposure to the acid. A slight amount of practice here also will teach one the necessary time of exposure. The acid is removed by washing the cover in seventy per cent, alcohol, and it may now be stained with some one of the anilin colors, which will give a contrast to the colors with which the bacilli were stained, washed in' water, dried, and mounted in Canada balsam. If gentian violet and Bismarck brown have been used, the tubercle bacilli will have an intense violet color, and the nuclei of the pus and epithelial cells, and all other bacteria which may have been accidentally present, will be colored brown. If tissues are to be examined, they should be hardened in strong alcohol. In case it is necessary to make any special histological study of the tissues, they may be hardened by Muller's fluid or in some of the various so- lutions recommended by Flemming, but the bacilli will then be found more difficult to stain than if alcohol was used. Sections should be made of the hardened tissues, and placed in the staining fluid for twenty-four hours ; the time may be shortened to four or five by heating the fluid up to 110° to 120° F. ; of course the tissues would shrink and be spoiled for examination, were they heated to the boiling point. The sections may then be placed in the decolorizing acid solution, washed in seventy per cent, alcohol to remove the acid, and then stained again with some contrasting color. There are various modi- fications of this method of staining. The fluid recom- mended by Orth is generally better for decolorizing the tissues than the nitric-acid solution is, as it has little effect on the cells. It consists of water, seventy parts ; alcohol, thirty parts ; and hydrochloric acid, one part. The time necessary for decolorization is somewhat longer than with the nitric-acid solution. 292 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tuberculosis. Tuberculosis. The number of bacilli found in tuberculous sputum varies greatly, and depends in part upon the nature and extent of the changes in the lungs. When the case is far advanced, and the lungs contain large cavities which communicate with the bronchi, they are present in large numbers; in other cases, and when the disease is in its incipiency, or when there are large areas of caseous pneumonia without much formation of cavities, not more than two or three may be found in a preparation. They are entirely stained, generally slightly curved, and frequent- ly two or more lie together. Sometimes they are free, at other times they are enclosed in the pus and epithelial cells. When a double stain has been used, the contrast between the bacilli and the other elements of the sputum is so sharp that it is possible to make a diagnosis of their presence from seeing a single one. In the examination of the sputum which contains very few bacilli, it has been recommended to boil the sputum after adding caustic potash, and place it in a conical glass vessel, when the bacilli, now freed from the mucus, pus, etc., which en- closed them, will settle to the bottom. Bacilli are frequently met with in the sputum which do not present a homogeneous appearance, but consist of rows of bright dots separated by unstained intervals. It has been found that these are more plentiful after the sputum has been allowed to stand for a number of days or weeks, and they are also more frequently seen in the pure cultures which have been kept for several months than in the new ones. On examination with very high powers, the edges of the rod at the unstained intervals can be seen, so that this appearance is not due to a num- ber of isolated, small round bodies arranged in a row. These unstained spaces have been considered to be spores which have developed in the rod. It is by no means certain, however, that this is the case, and they may represent simply degenerated forms of the bacilli. Many facts in tuberculosis are best explained by the assumption of spore formation ; but, on the other hand, in experiments made on the bacilli in order to determine under what influences they are destroyed, there has not been found that difference between these supposed spore- containing bacilli and the ordinary ones, that there should be if they were spores of the same nature as those de- veloped in other bacteria. All such spores are much more resistant to heat and to all disinfecting agents than are the bacilli, but these dotted tubercle bacilli are not more resistant than the ordinary ones. The tubercle bacilli can also be distinguished from all other bacteria by their manner of growth. The culture media on which they will grow are very limited in num- ber. The first pure cultures of them were made by Koch, who used blood serum which was made sterile by heat- ing it for a number of days at a temperature of 55° C., and was then gelatinized by heating it at 75° C. for one hour. . It has been found that when the blood serum is collected with antiseptic precautions, the various heat- ings for the purpose of sterilization may be neglected, and it can be at once gelatinized. Tuberculous material containing the bacilli is best obtained, free from any contaminating substances, by using a nodule from a rab- bit or guinea-pig which has been rendered tuberculous by inoculation. A small portion of this caseous material is then planted on the surface of the solid blood serum. It will not come within the limits of this article to give a detailed description of the various steps necessary to prepare and inoculate the serum (see articles Bacteria, Micro-Organisms, Schizomycetes). After the tuberculous material has been planted on this culture medium no change at all will be seen for from ten to fifteen days. Then small colonies of bacilli grow out from the edges of the bits of broken-up caseous material. The colonies first appear as whitish points, or small scaly spots, lying on the surface of the serum ; they have no lustre, and stand out clearly on the moist surface. They are best compared to tiny dry scales ad- hering loosely to the surface of the serum. The number of these scales and the extent of the surface covered by them vary with •the richness in bacilli of the material which was used for planting the culture. The single scales attain only a limited size, so that if but few are present they remain distinct; but when they are more numerous the scales coalesce and finally form a thin, grayish-white, lustreless covering on the surface of the serum. The bacilli never penetrate within the serum, nor do they cause it to liquefy, but the entire growth is a superficial one. The cultures generally attain their maxi- mum growth at the end of four weeks, and remain un- changed after that time. Although the general macroscopic appearances of the pure cultures of the tubercle bacilli can be distinguished from cultures of any other organisms, still their most dis- tinctive features only appear when they are examined under a low power of the microscope. Examined with a power of 60-100 diameters, the colonies of bacilli are found to have a peculiar form. This begins to appear as early as five or six days after inoculation. The bacilli are arranged in curved or spiral masses, with the long axis of each bacillus in the same general direction. Some of these masses have the shape of the letter S, and very often several seem to be intertwined with one another. These spiral and S-shaped figures are composed of im- mense masses of bacilli, which are probably separated from one another by a slight amount of a gelatinous cement substance. The masses are pointed at the ends and often very much swollen out in the middle. Koch obtained these characteristic pure cultures from a great many different tuberculous affections, both of man and of the lower animals. He inoculated suscept- ible animals with these pure cultures and invariably pro- duced tuberculosis. Whether the material used in the first instance was from the human phthisical lung, from a caseous lymph-gland, or from a miliary tubercle, the resulting pure cultures were always the same, and the disease produced by inoculation was the same. In this way he definitely established the identity of the process which produced the pearly disease of cattle, most forms of lupus, caseous pneumonia, etc., with that which pro- duced, what was at one time regarded as the essential lesion of the disease, the miliary tubercle. These experiments of Koch have been repeated by numerous observers, they have been confirmed in every respect, and but little has been added to them. The proof of the causal connection of the tubercle bacillus and tuberculosis is so direct and absolute that there does not remain a doubt on the subject in the mind of any pathologist, and there should be no doubt in the mind of any reasonable man. Koch further studied the man- ner in which the bacilli produce the anatomical changes, and his work in the field of pathological histology is little, if any, inferior to his work in bacteriology. It is difficult to find, in the whole range of medicine, any work which has been so complete and accurate in all its details, and which has had such an influence on the minds and opinions of medical men. It came at a time when the profession was prepared to receive it, and the opposition to it was weak and uncertain as the paper of Koch was strong and convincing. We shall now consider the anatomical changes pro- duced by the presence of the bacillus in the tissues, and shall begin with the study of the miliary tubercle, be- cause this, up to within a few years past, has been con- sidered the essential, and by many the only, lesion of the disease. It was the presence of the miliary tubercle which gave the disease the name it bears. For us, how- ever, the miliary tubercle forms but a part, and that a very small part, of the lesions met with in tuberculosis. The miliary tubercle, in the first place, is a nodule which is more or less sharply differentiated from the tissue in which it is situated. How sharp this differen- tiation is, depends for the most part upon the age of the tubercle, and also upon the character of the tissue in which it is situated. When it is so small as to be barely visible to the naked eye, it has a more or less pearly, transparent appearance, but as it becomes larger it loses its transparency and becomes white and opaque, the opacity beginning at the centre and extending to the periphery. When it is seated in an organ whose struct- ure is loose and has a tendency to contract when cut, 293 Tuberculosis. Tuberculosis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. as the lung, the tubercles stand out sharply and clearly, and can be felt as well as seen. The vascular lung-tis- sue, moreover, serves as an excellent background for the opaque tubercles. In some organs they are very difficult to see ; in the liver they are usually of small size and transparent, and though they are often present in im- mense numbers, they can, as a rule, be made out readily only on microscopic examination of the organ. In the spleen they can usually be readily seen, but here may be confounded with the Malpighian corpuscles. The connection of the tubercle with the surrounding tissues is a very close one. On endeavoring to lift one out with teasing needles, it will be found difficult or impossible to separate what macroscopically appears to be a perfectly distinct nodule, from the tissue sur- rounding it; also in endeavoring to break up the nodule itself and to tease apart its elements, considerable diffi- culty will be found. It is impossible to give any definite size as that of the tubercle ; it may be so small that it is not visible to the unaided eye, or much larger. Single tubercles may attain the size of a pea. The small ones are generally compared in size with that of a millet or timothy seed, and are called miliary. Those smaller than this, appearing as very fine points, are called submiliary. known as the epithelioid cells. These are by no means peculiar to the tuberculous process, but are found more often in connection with it than elsewhere. They are not only found in miliary tubercles, but principally compose the cellular' exudation found in the lungs in cases of caseous pneumonia, and are also found in all of the caseous inflammations. They vary considerably in size, and may be from two to six times that of the lymphoid cells. They have a nucleus which is small in comparison to the cell body, and a pale, slightly granular protoplasm. The cells are round and rather make the impression of being swollen by the imbibition of fluid. They are like some of the forms of epithelial cells, the similarity being most evident from the character of the nucleus, which has the vesicular appearance common to the nuclei of epithelium. In most cases but one nucleus is in a cell, but sometimes two or more are found; they do not stain so brightly as do the nuclei of the lymphoid cells. The next sort of cells are large round, or irregu- larly-shaped masses of protoplasm which contain a great number of nuclei. These are the giant cells, and though not peculiar to the tubercle, they are so commonly found in 'connection with it that their presence, before the dis- covery of an absolute diagnostic means, viz., the presence of the bacilli, served in a way, though not absolutely, to distinguish the tubercle from other small nodules of in- flammatory or granulation tissue of somewhat similar structure. The protoplasm of these large cells is pale and finely granular. Their shape varies, they may be either round or oblong and of smooth contour, or pro- vided with a number of irregular processes. These pro- cesses are best seen by teasing apart the fresh tubercles arid examining them in salt solution. The nuclei are ob- long, and their situation in the cell is generally different from that seen in the giant cells of sarcoma, they being generally situated around the circumference of the cell with their long axes pointing to the centre. Sometimes they are arranged in masses at one or both ends of the cell. Their number varies, as many as a hundred may be present in a single cell. These giant cells are general- ly situated in the centre of the tubercle, or at a little dis- tance from this, just on the edge of the central caseation. Often these various cells are separated from one an- other by small bands of tissue in the meshes of which they lie. Wagner described such a reticular tissue as typical of the tubercle, and from the general resemblance to lymphatic tissue which its presence gave the tubercle, he called this a lymph-adenoma. Such a reticular tis- sue, however, is not at all typical of the tubercle, and is absent as often or more often than it is present. When best seen it appears as a network of fine smooth fila- ments in the meshes of which the cells lie; and it is often closely connected with the giant cells, and the pro- cesses of these seem to be directly continuous with it. It is more often present, and appears most typical, ■when the tissue has been hardened in chromic acid. Nothing is knowm positively about its formation. Probably it is in part the old fibres of the tissue in which the tubercle was formed, and which have simply been pushed apart by the cells and formed into something of a reticulum. A good deal of it may be albuminoid matter or fibrin which has been hardened by the preserving fluid. In part, it may be newly formed by the conversion of some of the cells into connective tissue. That feature of the tubercle which serves more than any other to distinguish it from similar formations, is the absence of blood-vessels. No newly-formed blood-vessels pass into it, and the old ones in the tissue where it was formed are occluded. This is probably due in part to thrombus formation, and in part to the pressure exerted on the vessels by the cellular infiltration. This non-vas- cularity is beautifully shown by injecting the blood-ves- sels of the organ containing the tubercles. When the lung is injected with Berlin blue in a case of miliary tu- berculosis, each nodule is conspicuous by the absence of color. The caseation of the tubercle always begins in the centre, in the part which is first formed. It is a process of necrosis belonging to what Weigert has described as Fig. 4125.-Miliary Tubercle. A branched giant cell is in the centre, and around this a collection of epithelioid cells lying in the meshes of a reticulum which is connected with the processes of the central giant cell. On the outside is a collection of lymphoid cells. The drawing is somewhat diagrammatic. X 350. ' Microscopic examination shows that the larger tubercles, and even those miliary in size, are often not single nod- ules, but composed of an agglomeration of several. Histologically, the tubercle has no constant structure. It is principally composed of cells which vary in size and number, and which have a tendency to undergo necrosis when they arrive at a certain stage of development, and become more or less fused together, forming a firm, dry, white, or grayish-white mass, which has some similarity to cheese. This product is the caseous material which Laennec considered characteristic of tuberculosis, and the process of its formation is called caseation. In general, three different sorts of cells enter into the composition of the miliary tubercle; in some cases most of the cells will be of one variety, and in others the several varieties are found. The most common of these are the so-called lymphoid cells. They are small, round cells of about the size of white corpuscles, with a nu- cleus which fills up almost the entire cell, only a small margin of protoplasm being seen around it. They are similar in appearance to the cells found in the lymphatic glands, the spleen, and in all inflammatory and granula- tion tissue. Next in importance to these are what are 294 Tuberculosis. Tuberculosis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the coagulation necroses, that is, death of the cells with coagulation of the protoplasm. There results a tolerably firm dry mass, which has a yellowish tinge when seen in large mass, and which stains a bright yellow with picric acid. No nuclei are apparent on staining. The cells usually fuse together, forming a smooth mass, but on the edges of the caseation their outlines may occasionally be made out. The fragments of cells which may be ob- tained by teasing out the caseous mass were described by Lebert as tubercle corpuscles, and he supposed them to be peculiar to the tubercle. On staining specimens hard- ened in alcohol with the aniline colors, small, irregular, brightly-stained points may often be seen in the caseous matter. These are fragments of the nuclei of the cells which still retain their power of staining. This necrosis of the cells is not due entirely to the absence of vascular supply, because we find other collections of cells as large as the miliary tubercles, with no vessels immediately in the collections, which do not undergo necrosis. It may in part depend upon the absence of vessels, but is rather due to the action of the specific virus of the disease, the tubercle bacilli, upon the cells. It is not characteristic of tubercle, but may be found in other pathological pro- cesses, particularly in old infarctions and in certain tu- mors ; in which places it is simply a necrosis of the part from deprivation of blood-supply. The cells here have not the same tendency to fuse together, forming a smooth solid mass, as they have in the tubercle. No other for- mation as small as the miliary tubercle ever shows it. The connection between this process of caseation and fatty degeneration is a very close one. In specimens which are cut with the freezing microtome, when first taken from the body and examined, in salt solution, with- out any further treatment, it seems probable that fatty degeneration of the cells always precedes the caseation. In the miliary tubercle a dark line is always seen just outside of the central necrosis, which, when examined with a high power, is seen to be due to a fatty degenera- tion of the cells. In the caseous pneumonia, also, the cells in the alveoli just outside of the caseation are com- pletely filled with fat-drops. Many of these cells, when seen with a low power, appear as though filled with pig- ment, this being due to the minute globules of fat. On staining the sections, nuclei are found to be absent in some of these cells, in others they stain very slightly. In the caseous mass itself only here and there scattered drops of fat are found. In the youngest tubercles which have not undergone any, or but very slight, caseation, the giant cell is usually situated in the middle of the nodule. There may be two or more such cells situated near each other, and often connected by their processes. The epithelioid cells are generally situated around the centre, and outside of these and between them are the lymphoid cells. The tuber- cles which are just beginning to form are often nothing more than a collection of epithelioid cells without casea- tion. Others, again, are seen which are entirely com- posed of lymphoid cells. The tubercle may be defined as a small non-vascular nodule, composed of cells varying in form and size, with some basement substance between them, and with an inherent tendency to undergo central necrosis. When examined microscopically, the tubercle is never a sharply circumscribed formation. It is impossible to say just where it begins, for it is always surrounded by a zone of small-cell infiltration, the cells of which merge gradually into the tubercle. It is difficult to say whether this cellular infiltration is simply an inflamma- tory process excited by the presence of the tubercle, or whether it actually forms a part of the tubercle itself. Nor does the caseation terminate abruptly. Cells in all stages of necrosis may be seen, the beginning of it being marked by a diminution in the intensity of the nuclear staining. Caseation is not the only metamorphosis which the tubercle undergoes. In some cases a variable amount of connective tissue is formed in it. The source of this newly-formed connective tissue here is as obscure as is its formation in other pathological processes. In most cases it follows the new formation of blood-vessels, but in the tubercle there are no blood-vessels. It is probable that it proceeds from the old connective-tissue cells of the tissue in which the tubercle was formed ; it is prin- cipally found on the outside of the growth, where the cells are under better conditions as regards nutrition than those in the interior. In general the advancing caseation puts an end to this connective-tissue formation, but in some cases the whole tubercle may be changed into a hard fibrous mass in which here and there shriv- elled nuclei are seen. It seems that even after the con- version of part of the tubercle into connective tissue caseation may still take place, the result being a hard, smooth mass which may be distinguished from the case- ation where the cells alone are affected. This process of connective-tissue formation in the tubercle is very like what is seen in the gumma. In the gummata of the liver there is this conversion of the cells into connective tissue before caseation takes place, resulting in the formation of a substance which is much denser and harder than the caseous material in tuberculosis. We have in one case found large conglomerate tubercles in the liver, some of which wrere as large as a walnut, which were very similar to gummata. Elsewhere in the liver there were single tubercles which had a marked ten- dency to become converted into connective tissue. Cor- nil and Ranvier have found in these fibrous tubercles blood-vessels containing red corpuscles, which showed that there was still some degree of circulation in the nodule, and have supposed that the formation of connec- tive tissue was due to the cells preserving their vitality longer than they ordinarily do. We must assume in these cases that the cells do preserve their vitality longer than under ordinary circumstances, which may be due to a greater resistance of the cells to the bacilli or to diminished virulence of the latter. In some cases there seems to be this tendency in all the tubercles of the body, in others it is seen only in one organ or in scattered tubercles. It is best seen in the tubercles which have slowly formed around old foci of the disease in the apices of the lungs. In other cases there is a tendency to a hyaline meta- morphosis of the tubercle, which results in the formation of a perfectly smooth, homogeneous, highly refractive substance. The source of the hyaline change is as doubt- ful here as it is in other places where it is found. Not only are the miliary tubercles so affected, but there may be such formation in other tuberculous processes, as in the caseous pneumonia. It is possible that it results from the action of the tubercle bacilli on the cells and tissues, and that they may produce this hyaline degener- tion as well as caseation. Tubercles are more often found in groups of several closely united together than singly. These nodules which result from the grouping of several are called conglomerate tubercles. Virchow called attention to the fact that often miliary tubercles would be found, on mi- croscopic examination, to have several distinct centres of formation. Where one tubercle is formed there is a marked tendency to the formation of others, this de- pending either upon the presence of scattered tubercle bacilli in a small area of tissue and the simultaneous formation of several, or one tubercle may be formed first and this serve as a focus of infection, resulting in the formation of others around it. In each of the sepa- rate tubercles the caseation advances from the centre toward the periphery, and these caseous centres finally meet and coalesce with each other and form a large caseous mass. This may increase in size by the contin- ued formation of tubercles in the tissues around it, with the result that they are amalgamated with the large mass, by the advance of caseation both in this and in the small tubercle. The large nodule may grow as a miliary tubercle by the continued formation of tuberculous tis- sue in its periphery while the caseation extends. In these conglomerate tubercles the origin from several dis- tinct centres may be traced even after caseation of the whole has taken place. The primary centres of each tu- bercle being composed entirely of cells, the caseation 295 Tuberculosis. Tuberculosis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. which results from their necrosis presents a different ap- pearance from the caseation of the periphery of each, in which there had been some formation of fibrous tissue before caseation. In some cases, notably in the large conglomerate tubercles of the liver already referred to, a thick capsule may be formed around the whole, and the process of enlargement seemingly comes to an end. Many of the larger caseous masses found in the lungs may owe their origin to this process, but many are formed in a dif- ferent manner. These circumscribed nodular growths, the tubercles, whether single or conglomerate, form but a small part of the tuberculous changes. Wherever the bacilli enter tissue changes take place which, briefly stated, may consist in cellular multiplication with the formation of epithelioid and giant cells, or an inflammatory small-cell infiltration, or an exudation of serum, fibrin, and red and white blood-corpuscles. These changes may occur singly or in combination with each other. From these changes there may result either small and concrete nod- dules, miliary tubercles, or a more diffuse process involv- ing at the same time a considerable amount of tissue. In all these changes there is the same tendency of the newly-formed material to undergo coagulation necrosis, to become caseous. This caseation is common to all the products of tuberculosis in whatever form they appear. Whether the disease shall appear in the form of miliary nodules or as a diffuse infiltration, depends in part upon the structure of the tissue, the number of bacilli which enter it, and the manner in which they enter it. The various forms are often combined, especially in the lungs. In the most typical miliary tuberculosis of the lungs one will frequently find areas where the process is more or less diffuse, the nodule representing a miliary focus of cheesy pneumonia. Often a tissue resembling that of the miliary tubercle is found in tuberculous organs without the formation of miliary nodules. Such tissue has the appearance, the manner of growth, and shares the same fate as the mili- ary tubercle. It is composed of epithelioid, lymphoid, and giant cells, between which, in some cases, the ap- pearance of a reticulum can be made out. Such a tissue may be found in the lining of tuberculous cavities in the lung, around cavities and sinuses in other organs, and around and between miliary tubercles. On a section of this tissue we find on the outside, next to the sound tis- sue, an area which is almost entirely composed of lym- phoid cells, which gradually passes into the small-cell infiltration of the neighborhood. In this first area there is a good deal of connective tissue, often arranged in a reticulum. The lymphoid cells may be diffusely scat- tered through this, or they may be arranged in long rows or in round masses. Here and there in this tissue a few blood-vessels may be seen which often contain well- preserved blood-corpuscles. Within this area there is another, in which the cells are more closely packed to- gether, and along with the lymphoid cells the larger epi- thelioid cells are found. These also are sometimes col- lected in groups. Here and there in this tissue charac- teristic giant cells are found. The nuclei no longer stain so vividly as they did in the outer zone, and where any connective tissue is present it has lost its fibrillar appear- ance and become smooth and hyaline. This area grad- ually merges into another in which the contour of the cells is entirely lost, and they have all fused together into a solid caseous mass. In general a wrell-marked tuber- cular cavity can be compared to a very large tubercle whose centre has become caseous and fallen out. We can also find in this diffuse tubercular tissue all those minor differences in structure that we found in the mili- ary tubercle. Sometimes the formation of connective tissue is very extensive, and the outside zone may form a firm connective-tissue capsule which offers great resist- ance to the advance of the caseation. In some cases, in connection with the caseation, or even without it, there is a considerable formation of hyaline tissue. The casea- tion seldom forms an even line, but makes greater inroads into the tissue in one place than in another. Here and there small foci of caseation are seen which are separated from the large interior caseous mass (or zone, in the case where the tuberculous tissue surrounds a cavity), but which soon join it by their continual enlargement and the involvement of the intervening tissue. Distinct circumscribed miliary tubercles may be, and often are, found in the outer zone of this tissue. These become caseous and lose their distinctness in the advance of the interior caseation. It is especially in the tubercu- lous ulcers of the intestine that this combination of mili- ary tubercles with the diffuse tubercular tissue is seen. They are very numerous in the floor and the sides of such ulcers, but between and around them the diffuse process goes on. The recognition and appreciation of this dif- fuse tubercular tissue-formation is of the greatest im- portance for a clear understanding of the subject. The tuberculous processes should be studied as a whole and with low powers of the microscope, and the attention should not be confined to the study of the miliary tuber- cle, which forms, as we have said, but a very small part of the sum of changes produced by the tubercle bacillus. The study of tuberculous organs, especially the lung, by means of frozen sections of the fresh tissue, is also of the greatest importance. In this way the degenerative changes are seen which accompany and precede the caseation, and which are lost sight of in hardened tis- sues. Always in the neighborhood of both the tubercle and the tuberculous tissue, and passing directly into these forma- tions, there is found an infiltration and inflammatory exudation in the tissue. In the lungs we find an exuda- tion into the alveoli which consists either of epithelioid or lymphoid cells, or the alveoli may contain a fibrinous exudation similar to that of croupous pneumonia. The walls of the alveoli themselves are thickened and infil- trated with small cells. Is this an inflammation depend- ing merely upon the irritation which the presence of the tubercle produces, or is it a part of the tubercular pro- cess depending upon the action of the bacilli ? The probabilities are that it depends upon both. Tubercle bacilli have been found in this inflamed area, either in the cells of the exudation or in the walls of the alveoli. We find, however, a small-cell infiltration surrounding other formations in the lungs, around the small fibrous nodules which are produced by the inhalation of foreign substances, and around small secondary tumor nodules ; but it is always less in extent and different in character. In the case of other than tuberculous nodules it is a con- servative process, tending, by connective-tissue formation, to form a capsule around the foreign matter. Around the tubercle, on the other hand, the formation of connec- tive tissue which results from it is always slight in ex- tent and the whole rapidly undergoes caseation. If it be regarded as a simple inflammation due to the presence of the nodules, it is difficult to understand why it should undergo this caseation. The best examples of this in- flammation are afforded in the tuberculosis of serous surfaces. We rarely see an eruption of tubercles on the pleura, for example, without finding at the same time an inflammatory exudation, which is generally fibrinous in character. It is often so extensive that it entirely masks the tubercles beneath it, and it is only after carefully stripping away the membrane that they come into view. Not uncommonly the exudation is hannorrhagic as well as fibrinous. Purulent exudations are often met with in tuberculosis. The best examples of this are seen in the abscesses formed in connection with tubercular caries of bone, as the psoas abscess in caries of the vertebrae. It is probable that the tubercle bacillus also belongs to the category of organisms which can produce a purulent inflammation. (See Inflammation.) These inflammations for the most part must be re- garded as due to the action of the bacilli on the blood- vessels. It is of little importance whether this action is a direct one proceeding from the bacilli themselves, or an indirect one due to some of their chemical products. The one thing that is common to all tuberculous processes, whether they appear in the form of nodules, or as a more diffuse formation of what may be regarded as tubercu- lous tissue, or as inflammations whose exudation does 296 EXPLANATION OF PLATE XXX. Figure 1. Section from the Lung in a Case of Miliary Tuberculosis, a, Tubercle containing numerous bacilli; b, tubercle with fewer bacilli; c and d, tubercles with cheesy centre and containing no nuclei; e, cross-section of a blood-vessel surrounded by a deposit of pigment. Magnified 50 diameters. Figure 2. The Blue-colored Portion of the Tubercle a in Fig. 1. The tubercle bacilli are stained blue, the nuclei of the cells brown. Magnified 700 diameters. Figure 3. A Small Artery surrounded by a Mass of Tubercle Bacilli. From a bronchial gland in a case of miliary tuber- culosis. Magnified 100 diameters. Figure 4. A Portion of the Wall of the Artery shown in Fig. 3. Magnified 500 diameters. Figure 5. Section from a Phthisical Lung, showing the Crowding of the Tubercle Bacilli into the Alveoli. Magnified 100 diameters. Reference Handbook of THE Medical Sciences Plate XXX. Tubercle Bacilli. from R.KOCHS ' DIE AETIOLOGIE DEB TUBERCULOSE" Mitthei I unqen aus dem Kaiserlichen GesunJ heitsamte. BerIirl*1884. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tuberculosis. Tuberculosis. not materially differ from that met with in other inflam- matory processes, is the coagulation-necrosis, the casea- tion which they undergo. This caseation differs in some respects from other forms of coagulation-necrosis due to the cutting off of blood-supply from a part, etc. In these other forms there is not the same tendency for the cells to fuse together and form a solid mass. It also differs from that of the syphilitic gummata in that it is formed by the fusion of cells, and hence is not so firm and hard as that found in the gumma. It is not due, or at least is only in part due, to the shutting off of the blood-sup- ply from the centre of the nodule, but is rather the re- sult of the specific action of the tubercle bacilli on the tissue. The histogenesis of the tubercle is a question which has for a long time engaged the attention of pathologists. Virchow supposed that it was always formed in connec- tive tissue by a multiplication of the cells of this tissue. It is certain, however, that no one tissue enters solely into its formation, but all the cells of the tissue, whether con- nective-tissue corpuscles, gland-cells, or the endothelium of blood- and lymphatic-vessels, take part in it. The source of the giant cells has been especially studied. These remarkable bodies were first observed in the tu- bercle by Virchow, but were more carefully studied and described by Langhans, who recognized as distinctive of them the mural arrangement of their nuclei. Their origin has been assigned to various tissues. Schiippel described them as being formed from a proliferation of the endo- thelial nuclei of lymphatics and blood-vessels. Cornil and Ranvier also think that in many cases they represent simply a cross section of an occluded vessel, the nuclei at the edges being nothing more than the nuclei of the en- dothelium. Ziegler found them between two lamellae of glass which he introduced beneath the skin, and supposed that their origin was from the white corpuscles which had wandered into the space between them. Arnold and others think that in glandular organs they are formed by a proliferation of the nuclei of glandular ducts and are simply cross sections of these. He has studied their for- mation especially in the tubercles of the kidney and liver, and supposes that in the kidney they are formed from the epithelium of the tubules, and in the liver from the small bile-ducts. Weigert regards them as formed from the epithelioid cells of the tubercle. The tubercle bacil- lus so affects these cells that, instead of division of the cell following the division of the nucleus, the cell remains undivided, though it increases in size. Though their presence is more common in tubercles than elsewhere, so common that they may be considered as one of the land- marks by which this can be recognized, they are also found in other formations, in many of the other infec- tious tumors, and in simple inflammatory and granula- tion tissue. In tuberculosis they are found both in the miliary tubercle and in the diffuse granulation tissue. They may also be met with inside of the alveoli in case- ous pneumonia, where they must have been formed from some of the elements of the exudation. They form around foreign bodies of every sort, as around small bits of hair which have been introduced into the tissues, and around eggs of parasites. It is possible that in tubercu- losis they may be formed from any of the cells, and the exciting cause which leads to their formation is the presence of tubercle bacilli in these cells. The most thorough and painstaking observations on the histogenesis of the tubercle have been made by Baumgarten. He studied the tubercles which are pro- duced in lower animals by the direct inoculation of the tubercle bacilli. By obtaining the tissues perfectly fresh and hardening them in suitable media, he was able to study the karyokinesis, and by this means see what cells were multiplying. As the result of his investigations, he found that the fixed cells of the tissue took a much more prominent part in the formation of tubercles than had generally been supposed. He found that the first changes in the tissue were coincident with the appear- ance of the bacilli. Under the influence of these the fixed cells-whether gland cells, endothelial cells of blood- or lymphatic-vessels, or connective-tissue cells-became enlarged, pale, and finely granular, and changed into the epithelioid cells. The earliest and smallest tubercles simply represented a collection of these epithelioid cells. The lymphoid cells of the tubercle were white corpuscles which had wandered into the mass of epithelioid cells. In the lungs the first changes were found in the cells of the alveolar capillaries and in the lining cells of the al- veoli. Whatever the part played by these large epithe- lioid cells, it seems certain to us that they are not always the first cells formed. One often meets in the liver, where the formation of tubercles can perhaps be better studied than in any other organ, small nodules which are entirely composed of small lymphoid cells. The tubercle in this case resembles nothing more than a mili- ary focus of inflammation. The same thing can be seen in the lungs. Miliary tubercles are often seen here which are nothing more than a focus of caseous pneu- monia, and proliferation of the fixed cells of the alveolar walls plays but a very small part in their formation. The epithelioid cells are not always formed from the fixed cells. In the alveoli of the lungs, cells in all re- spects similar to those in miliary tubercle are found, which could only have been derived from the white cor- puscles of the exudation. It is probable that the ana- tomical structure of the organ may influence to a great extent the formation of tubercles. In some cases this especially favors exudation, and the tubercles will be formed principally from this. In other more solid and less vascular organs, they will principally be formed by proliferation of the tissue cells. It is impossible to sep- arate the exudative processes from the proliferative. The place which the tubercle occupies in pathological formations will be found treated of under other heads. (See Growths, Pathological, Tumors, Inflammation.) The modifications which it undergoes in different organs will be treated farther on in a consideration of tubercu- losis of these organs. The part which the tubercle bacillus plays in the for- mation of the tubercle has been much studied and is most interesting. Our knowledge of this is due to the careful work of Koch, Baumgarten, and others. The number of them found in the various tuberculous prod- ucts varies very much. Occasionally they are found in such numbers that the brightly-stained masses may be recognized under a low power. Sometimes but one or two will be present, and can be found only after a long search. In general it may be said that where the process is most active and advancing most rapidly they will be plentiful. This is particularly the case in the walls of rapidly-growing cavities in the lung, where they are found in enormous numbers in the caseous tissue lining the cavity. The presence of air in the cavity seems to favor their growth. The cultures show them to be aerobic. They grow on the surface and do not extend into the depths of the serum. They may be found in large masses in a lymphatic vessel or space. They are probably more difficult to find in miliary tubercles than in any other of the tuberculous processes. Especially is this true of miliary tubercles of the liver. They are always present, but in such small numbers that they are easily overlooked. They are often seen only by making a series of sections through the tubercle and examining each of these. In the tissues they are generally found in the cells, lying near the nucleus. The epithelioid cells often con- tain two or three bacilli. When the caseation is rapidly advancing the number of the bacilli is often much in- creased. They are then frequently grouped in small, closely-packed heaps, in which the bacilli lie parallel to each other and so near together that the single ones are with difficulty recognized. The cheesy mass itself con- tains very few bacilli; they are either dead with the balance of the tissue, or have undergone some change, possibly a spore formation, in which state they cannot be stained. They have a definite relation to the giant cells, and are often found in these. In slowly progress- ing tuberculous processes, as in the scrofulous lymph- glands, or in fungous arthritis, where the giant cells are very numerous, they may be found exclusively in these, 297 Tuberculosis. Tuberculosis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. and frequently not more than two or three are in a single cell. In many cases the giant cells contain them in large numbers ; more than fifty may be counted in one cell. When but one or two bacilli are found in a cell these may lie at right angles to the plane of section, and then will appear as dots rather than as lines. They may be recognized, however, by focusing up and down, because they remain longer in focus than would be the case were they round dots. When they are present in the cells in large numbers their arrangement is often characteristic. They are placed as the nuclei, with their ends turned to the cell wall, and often form a compact row just within the nuclei. If the section is doubly stained-the nuclei, for example, stained brown and the bacilli blue-there appears to be a blue ring inside of a brown one. How the bacilli get into the tissue is a matter of conjecture. They can only reach it by means of chan- nels which communicate with the air, or by the blood- and lymph-channels. From these channels they are most probably taken into the tissues by the white cor- puscles. They have been found enclosed in these. Or they may attack the cells of the channels along which they pass, and these cells may form the nucleus of a tubercle. Thus the beginning of a tubercle may be found in the epithelium of the blood- or lymph-vessels, or, in the lungs, in the epithelium of the bronchi. It is probable that the wandering cells play an important part in their distribution. Koch supposes that the white cor- puscles are changed directly into epithelioid cells by the action of the enclosed bacilli. When a pure culture of the bacilli is injected in any quantity into the auricular vein of a rabbit, and the animal is soon after killed, there will be found in the blood numerous white corpuscles enclosing one or more of the bacilli, and here and there in the substance of the lung, spleen, and liver these cor- puscles containing bacilli will be found outside of the vessels. It is probable that the nature of the tubercu- lous lesions is greatly influenced by the manner in which the bacilli are brought to them, and by the number of the bacilli. We cannot, however, suppose that it is due entirely to this, but depends in part upon the resistance of the tissue. We know probably more about the con- nection between the virus and the pathological lesions in tuberculosis than in any other disease, with the excep- tion, perhaps, of anthrax ; but we are not yet able to say positively why in the one case we have a miliary tuber- cle formed, in another a diffuse tuberculous tissue, and in still another an inflammation whose products cannot be distinguished from ordinary inflammatory products, save by their tendency to undergo caseation. We have to fall back upon the vital resistance of the tissues, or the still more uncertain factor of differences in the virulence of the bacilli themselves. In parts that have undergone complete caseation it is often extremely difficult to demonstrate the bacilli. This is especially the case in old caseous lymph-glands. Often twenty or thirty sections will have to be examined before a single bacillus is found. They are seldom in groups, but only here and there one is found inside of a giant cell, and unless it lies parallel to the plane of the section it is easily overlooked. Still we know that such tissues are tuberculous, even when a careful examination does not reveal the bacilli. They may be present in such small numbers that they are easily overlooked, or pos- sibly they may have lost their power of staining. Under these circumstances, it will generally be found easier to make the diagnosis by inoculating a guinea-pig or rabbit, preferably the former, with a portion of the material. In a week or more, evidences of the nature of the process will be found in the part inoculated, by the presence of a caseous inflammation with quantities of bacilli, and in three weeks from the time of inoculation the animal generally succumbs. In the study of tuberculosis of the different organs we find considerable differences in the nature of the changes produced. These differences can, in general, be explained by the anatomical structure of the organs and the mode of entry of the tubercle bacillus. In this study we shall take up the lungs first, because they are more frequently attacked than any other organ ; the changes produced are of greater extent and importance for the life of the individual, and every phase of the tuberculous process can be studied here to perfection. We have in the lungs the three principal varieties of the tuberculous process : the formation of miliary tubercles, of diffuse tubercular tissue, and of inflammation with caseation of the exuda- tion. In addition to this, we have inflammatory changes in the interstitial tissue of the lung, which are not of themselves specific, and are due to the influence exerted by the pure tuberculous processes. The miliary tubercles of the lung may be seated in any part of the lung tissue, either in the interalveolar tissue, here almost always with extension into the alveoli, or in the peri-vascular or peri-bronchial connective tissue. It was generally supposed that they had an especial prefer- ence for the small masses of lymphatic tissue scattered through the lungs and more abundant in the upper lobes, but it is difficult to say whether these small masses of tis- sue are by any preference attacked. The tubercles in the peri-vascular and peri-bronchial connective tissue do not differ in structure from tubercles developed in con- nective tissue elsewhere. Sometimes they are entirely composed of lymphoid cells, in others the more typical epithelioid cells with a reticulum and giant cells are found. Even when developed here, there is generally some extension of the process to the alveoli, which we find filled with an exudation, and, by the extension of the central caseation of the tubercle the alveolar contents also undergo caseation. This formation of tubercles in the peri-vascular and peri-bronchial connective tissue does not compare in importance to their formation in the lung parenchyma. Here the point of origin in most cases is the interstitial interalveolar tissue, and in their formation the epithelium of the alveoli, and even the ex- udation within the alveoli, take part. Virchow, regarding the tubercle as a connective-tissue new formation, only called such nodules tubercles in whose formation exuda- tive processes took no part. We may have nodules, formed almost exclusively by exudation, which do not differ in a certain stage of their growth from those formed in the connective tissue. Ziegler calls these no- dules foci of miliary broncho-pneumonia. Most of the recent authors, however, acknowledge the part that exu- dative processes play in the formation of the miliary tubercle of the lung. All the fixed cells of the inter- alveolar tissue can take part in their formation. There is a proliferation of the connective-tissue cells, of the cells of the capillaries, and of the alveolar epithelium. The part that the epithelial cells play has been shown by Arnold, and especially by Baumgarten, who has seen in them the nuclear figures denoting proliferation. In many cases there is a decided thickening of the wall of the alveoli, the tissue often growing into the spaces, pushing the epithelium before it. In other cases the exudation into the alveoli plays the principal part. In a case of the most typical miliary tuberculosis, which recently came under observation, and in which the lungs were every- where sown with the smallest miliary and submiliary nodules, many of which had not undergone caseation, most of the tubercles, when carefully analyzed, proved to be miliary areas of caseous pneumonia, which often did not involve more than two or three of the alveoli. There are a number of factors which may influence, not only the situation, but the number and character of the tubercles in the lung. The bacilli may enter the tis- sue in different ways ; the number of them entering in a given time may vary ; further, the virulence of the ba- cilli may differ somewhat in different cases ; and finally, the process must also be influenced by the varying re- sistance of the tissue to their growth. The form in which the tubercles are most evident and can be best studied is the disseminated miliary tuberculosis of the lungs. This is characterized by the presence of very small nodules thickly scattered through the lung tissue, which is otherwise but little altered, and which contains air. The disseminated miliary tuberculosis may appear under two forms : it may be either general or partial. The general miliary tuberculosis of the lung, in most 298 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tuberculosis. Tuberculosis. cases, is a part of a general infection of all the organs of the body with the tubercle bacilli. In typical cases all parts of the lung are strewn with very fine miliary and submiliary nodules. The lungs are very hypersemic, and do not collapse when taken from the body. Small pieces cut from the parts most affected may sink in water. On section of the lung the tubercles project slightly above the cut surface, and can be readily felt when the hand is passed over it. Those in which casea- tion has taken place show very clearly against the red hy- persemic lung tissue. The pleura, both parietal and vis- ceral, is covered with multitudes of tubercles. In many cases there is a slight adhesive pleuritis, especially be- tween the lobes of the lung. The mucous membrane of the bronchi is hyperajmic, and often miliary tubercles are found in it. The tubercles in most cases appear sharp and circumscribed, but this is not found to be the case on microscopic examination. Many tubercles are then seen which were not visible to the unaided eye. Not only immediately around the tu- bercles, but elsewhere in the lung parenchyma, some exudation is seen in the alveoli. This exudation con- sists of large epithelioid and lymphoid cells, and in some cases there is fibrin mixed with it. The walls of the alveoli around the tubercles show some small-cell infiltration. The solidity of the lung is due not only to the presence of the tuber- cles, but to the exu- dation around them and elsewhere. There is consid- erable differ- ence met with in different cases. In some the tube rcles are larger and not so abundant, and on mi- cros copic examination the evidences o f inflamma- tion are not so marked. In almost all cases there is also a difference between the tubercles in the upper lobes and those in the lower. Those in the upper lobes are larger and more opaque. Even in acute cases they may reach the size of mustard or pep- per seed. The cause of this difference in size is not clear. It is known that the upper lobes are by prefer- ence attacked, in that they offer better opportunities for bacilli entering the lung by the air-passages to invade the tissue. In acute miliary tuberculosis the bacilli are conveyed to all parts of the lung by the blood-current and distributed equally. It must be that the tissue of the upper lobes in some way affords a better soil for their growth and the tubercles develop more rapidly. Even on careful examination with the unaided eye, it may be seen that the tubercles stand in very close rela- tion to the blood-vessels, but this becomes much more evident on microscopic examination. Not only are tu- bercles formed around the small vessels, especially the veins, but they are very often found within their lumen, so that a small vessel may be entirely closed by a tuber- cle. (See Fig. 4126.) This relation of the tubercles to the blood-vessels points to the way in which the bacilli have entered the tissue in these cases. We know from the work of Ponfick and Weigert that general miliary tuberculosis is always due to the entry of a large number of tubercle bacilli directly into the blood-current. This is effected either by means of a tuberculous ulceration in the wall of a large vein, or by means of a tuberculosis of the thoracic duct. The most acute cases are those in which a tuberculous inflammation of a vein is found, by means of which large numbers of bacilli, within a com- paratively short time, find entry into the blood. Other cases are met with, especially in children, where the tu- bercles are much larger and fewer in number, and where the disease takes a more protracted course, lasting for months, w'hereas the more acute form may run its course in two weeks. In such cases the entry of the bacilli into the blood is much slower, and may take place only at in- tervals. In these there is often found a tuberculosis of the thoracic duct. The second form of the disease is the partial dissemi- nated tuberculosis of the lungs, and this is very much more common than the first. In this form the eruption of tubercles is not a dif- fuse one over both lungs, but is con- fined to limited areas of the lung tissue. The tissue around them is not so much involved as it _ is in the general infection. Often the arrangement of these tubercles is very typical. They will be found around a caseous focus in the lungs, generally an area of caseous pneumonia or a caseous bronchial gland, and extend for some distance into the lung tissue. Orth has aptly compared this to the cloud of spores on the ■window- pane surrounding flies which have been killed by the empusa, the spores being scattered around by the bursting of the sporangia. We very often see the lower lobe of the lung containing small areas of case- ous pneumonia, and in the lung tissue around these an eruption of very fine tu- bercles. It is evident in these cases that the eruption of miliary tubercles is second- ary to the caseous pneumonia, and due to the presence of bacilli which have come from this. Most probably the route of infection is along the lymphatics and is a comparatively slow one ; the tubercles nearest the caseous focus are the largest, and in them the caseation is most advanced. Another form is the peri-bronchial and peri-vascular tuberculosis. We may have here the formation of tuber- cles in the connective tissue around the bronchi and blood-vessels, and extending along these. These tuber- cles may be large nodules made up of a number of single foci. These may, in their turn, serve as further centres of infection, and miliary tubercles be formed in the tissue around them. We may also have scattered tubercles in the lungs as a result of metastases from other organs. We know that without having a general tuberculosis we may have a few tubercles in the kidneys or liver in advanced tuberculosis of the lungs. We must assume that these are due, not to any general infection of the blood-current with tubercle bacilli, but to the occasional entrance of a very few bacilli, possibly from the involvement of small veins. In a primary tuberculosis of the kidneys or other organs we may have a few tubercles formed in the lungs in the same way. Fig. 4126.-Miliary Tubercle of the Lung developed inside of a Blood-vessel. From a case of acute miliary tuberculo- sis following primary tuberculosis of the uterus. X 60. 299 Tuberculosis. Tuberculosis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Apart from these forms of miliary tuberculosis we find almost every variety of tuberculosis of the lungs as- sociated with the formation of tubercles. We find them in and around the walls of old cavities, about foci of caseous pneumonia and caseous bronchitis, about caseous bronchial glands, etc. Sometimes they may be due to the entry of the bacilli through the bronchi, though in these cases a caseous pneumonia or bronchitis is more often the result. In such cases the processes of exudation into the alveoli are apt to play a greater part than in others. Frequently in such cases a very small bronchiole is found in the centre of such a nodule. This is filled with caseous matter which is apt to fall out on section, leaving a small cavity. Various authors have proposed different names for all these conditions. Ziegler, espe- cially, has endeavored to divide miliary tuberculosis of the lungs into a great many different things which he has called by various names. We do not think that any good end will be served by this. For us a miliary tuber- cle of the lung is simply a miliary focus of tuberculosis, and it does not matter whether this begins in the walls of the alveoli or in any other tissue. We have seen how large a part exudative processes play in the production of tubercles everywhere in the lung, and we should not hesitate to call by the name of miliary tubercle a nodule which is formed by exudation alone. The whole process becomes clear when we consider the different paths by which the bacilli can enter the lung and the anatomical structure of the lung tissue. The most important form of tuberculosis of the lungs, that which con- stitutes by far the greater part of the tuber- culous changes here, is an in- 11 a m m a t i o n with caseous degeneration of the exudation- the caseous pneumonia. It may appear in small circum- scribed areas around the bron- chi, or it may affect an entire lobe, or even an entire lung. In most cases it is accompanied by the formation of miliary tuber- cles, or of more diffuse tuber- culous tissue, but it may appear without these. The inflamma- tion consists essentially in an exudation into the alveoli, but in part it is formative, since there is a proliferation of the interalveolar tissue, and of the epi- thelium lining the alveoli. It begins with hyperaemia and the exudation of a thick, gelatinous, albuminous fluid. The presence of this in the alveoli gives to the lung a peculiar grayish, gelatinous appearance. It is somewhat similar to the ordinary acute oedema, but differs from this in that the fluid does not readily flow from the cut surface and cannot be fully pressed out. The alveoli, even at this early stage, contain in addition to the fluid, large, pale, granular cells which are similar to some forms of epithe- lium. On account of the presence of these cells the exu- dation was supposed to be composed principally of cast-off epithelium, and the pneumonia has been called desquam- ative and catarrhal. The last name is a confusing one, for we have a circumscribed pneumonia generally start- ing around the bronchi, and most often due to the inha- lation of irritating substances, which is often called by this name and which has nothing to do with tuberculosis. The name desquamative pneumonia was given it by Buhl, but it is by no means true that the cells in the al- veoli are entirely, or even for the most part, desquamated epithelium. We know that white corpuscles can, and often do, under certain circumstances, change into just such cells. It has been shown that if a part of a lung is hardened in alcohol and then placed in the abdominal cavity of a rabbit or any other animal, it becomes tilled with these ceils, which could be nothing else than white corpuscles which had wandered into the tissue. In many cases the alveoli containing these large cells have an in- tact epithelium, easily recognized from its swollen cells, lining them. Along with these large granular cells, there are a small number of white corpuscles which are but little altered, and in the acute stage of the process some red corpuscles as well. A very important part of the contents of the alveoli is fibrin, which is remarkable from the coarseness of its threads. This, however, does not form a constant part of the exudation. There are cases in which the most careful examination will not show a trace of it between the cells, and others in which it constitutes the greater part of the contents. In these cases certain areas in the lung may present a great simi- larity to croupous pneumonia, but may always be distinguished from it by the great differences in the exudation which the alveoli show. Neighboring alveoli may, one, contain a fibrinous, and the other, a cellular, exu- dation. The interalveolar tissue is altered at the same time. It is much thicker, filled with leucocytes, and in some cases contains also numbers of the large epithe- lioid cells. Also, the denser mass- es of connective tissue that lie along the larger blood-vesselsand bron- chi are swollen and infiltrated with cells. Even in this stage the marked hypersemia which accompanies all other forms of pneu- monia is absent. This cedematous gelatinous condition of the lung soon passes into another state, in which the lung is white or grayish-white in color. The color is largely influenced by the amount of coal pigment which the lung con- tains. The tissue is now com- pletely solid, deprived of all air, and sinks in water. It is firm and cuts with a perfectly smooth surface, like cheese. All elasticity of the tissue is gone, and a cut made into it has no tendency to gape. As a rule not all parts of the tissue are affected in the same degree. We very com- monly find small areas of consolidation surrounded by a gelatinous infiltration. The larger masses often seem formed by the confluence of smaller masses, in much the same way that the large conglomerate tubercles are formed. There appears at a first glance to be some sim- ilarity between this condition of the lung and the gray hepatization of croupous pneumonia, but the difference between the two is at once apparent on section. The cut surface of the caseous pneumonia is perfectly smooth, and there is an absence of that fine granular appearance which is due to the projection of the fibrinous plugs in croupous pneumonia. On pressing it and scraping it with a knife, the contents of the alveoli cannot be forced out. On microscopic examination it is found that the whole tissue-not only the alveolar contents but the in- teralveolar tissue as well-has undergone the fate that is Fig. 4127.- Conglomerate Tubercle of the Lung, surrounded by an Area of Tuberculous Pneumonia. Giant cells are seen in the centre of the tubercles. X 60. 300 Tu berculosis. Tuberculosis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the common end of all tuberculous processes, viz., casea- tion. In this caseous area no trace of a cell nucleus can be seen. The elastic tissue in the walls of the alveoli retains its integrity longer than anything else, and this serves to mark out the mass into small fields which correspond to the alveoli. In the older portions, however, nothing but a solid, finely granular mass is seen. On staining sec- tions of this tissue, hardened in alcohol, with some of the aniline colors, small, irregular, brightly stained dots are often seen. These are fragments of the brok- en up and destroyed nuclei. In some cases the process seems to advance rapidly, in others more slowly. Even in the same lung such differences are seen. The rapid ex- tension is marked to some degree by the width of the infiltra- tion around each caseous focus. In some cases the pro- cess seems to come to an end. The caseation does not ad- vance, and may even be sepa- rated from the healthy tissue by capsule-for- mation. It is where the ad- vance is not so rapid that one is more apt to find miliary tu- bercles in the neighborhood. The nature of this pneu- monia was for a long time a matter of dispute. Vir- chow denied that it formed any part of the tuberculous process, and limited this in the lungs to the formation of miliary tubercles. Laennec recognized its relation to tubercle, and in this he was fol- lowed by the Vienna school under Roki- tansky. Laennec was the first to introduce the term gelatinous in- filtration as descriptive of the stage preceding the caseation. It was found by experiment that this caseous material, when used for the inoculation of guinea-pigs and rabbits, just as surely produced tuber- culosis as when miliary tubercles were used. Moreover, on inoculation with any sort of tuberculous material a caseous pneumonia often appeared along with miliary tubercles. Weigert called attention to another way in which the identity of caseous pneumonia with tuberculo- sis could be established, in that it so often furnished the virus for an infection of the tissue around it. Miliary tu- bercles are formed in and around the lymphatics coming from such a part. When the periphery of the lung is af- fected, the pleura covering this is always inflamed, and the character of the inflammation is usually the same as that in the lungs, the exudation becoming caseous. With this there is often an abundant eruption of miliary tubercles over the pleura. In some cases, however, a typical fibrinous pleurisy is found. Whether or not this would in time become caseous is uncertain. Tubercle bacilli are found in the affected part, and often in great numbers. They are most frequent in those cases where the advance is a rapid one. They are not often found in the dense caseous mass, but at the periphery of this. It is probable that the caseous pneu- monia is due to the presence of a large number of bacilli which enter the lung tissue by means of the bronchi. Its favorite seat is in the lower lobes or in the lower portion of the upper lobes. We usually find a large tuberculous cavity in the upper lobe communicating di- rectly with a bronchus. We know also that enormous numbers of bacilli are produced in these cavities which can be aspirated into other parts of the lung. In some cases, just as in the miliary tubercle, a hyaline degeneration may accompany the caseous pneumonia. Large masses of completely homogeneous hyaline ma- terial are found. In a case where this was very evident the exudation was in great part fibrinous, and in some places it seemed the fibrin passed directly into the hya- line material. It cannot be said, however, to what ex- tent this hyaline degeneration is due to the direct action of the bacilli. One of the most frequent forms of the caseous pneu- monia is the caseous broncho-pneumonia. In this we have to do with an inseparable connection between case- ous bronchitis and pneumonia. The process is often confined to a very few bronchi, so that scattered nodules often no larger than miliary tubercles are found. As we have said, we consider it rather better to call the smaller of these nodules tubercles, where the lung tissue around the bronchiole is not affected to any great extent. The caseous pneumonia often seems to pass directly into a diffuse formation of tubercular tissue. In this tissue we have lymphoid cells, epithelioid cells, and giant cells, but no formation of distinct nodules. It is prob- able that the formation of such a tissue points to a slower advance of the caseation, the cells having time to under- go certain further changes before being overtaken by it. The blood-vessels early become occluded. This is not due to the pressure which the exudation exerts upon them, but to a degeneration of their walls. The casea- tion cannot here, any more than in the miliary tubercle, be considered as due to this shutting off of the blood-sup- ply. We would rather regard both the caseation and the occlusion of the vessels as co-effects of the same cause,the tubercle bacillus. When this necrotic caseous material is once formed it can undergo other changes. Lime-salts can be deposited here as in other dead tissues, and this frequently happens when the tuberculous process has reached its end. With the continued deposit of lime-salts the caseous matter changes its character, and becomes converted into a mortar-like or chalky material which in time becomes like stone. Such calcareous masses, surrounded by firm indurated tissue, are often found in the apices of the lungs of persons who present no other signs of the dis- ease. This calcification must be regarded as the most favorable termination of the caseous pneumonia, for in the most cases the bacilli are entirely destroyed, and the disease comes to an end in this portion of the lung. Still sometimes miliary tubercles are found in the surround- ing lung tissue, just as they are around the foci of caseous pneumonia. It is possible that some may be preserved in the calcareous mass, and when for some reason the resist- ance of the tissue is lowered, and they find conditions favorable to their growth, they may again exert their action. It is rare that this- calcification is very extensive. As a rule, it is confined to the apices of the lungs, but may be met with elsewhere. At times, along with this calcification in the apices, the most advanced tubercular changes are found elsewhere. The softening of the caseous matter is a much more frequent and more important metamorphosis. The mass, Fig. 4128.-Section of Left Lung from a Case of Rapid Phthisis. The upper lobe contains large patches of caseous pneumonia, some of which have soft- ened, resulting in the formation of cavi- ties. In the lower lobe smaller areas of caseation are found, generally with an occluded bronchus in the middle, and around these miliary tubercles. The in- fection of the lower lobe is secondary to that of the upper. (X natural size.) 301 Tuberculosis. Tuberculosis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. which was before distinguished for its dryness, absorbs water and becomes changed into a thick yellowish fluid resembling pus. It is difficult to understand the cause of this change. Rindfleish supposes that the coagulated albuminous substance undergoes a sort of digestion in the body by which it again becomes soluble and absorbs water from the surrounding tissue. This is not the only explanation possible. It can scarcely explain the fact that the more quickly the caseation takes place the more quick- ly does it soften. Not only does the softened material look like pus, but pus-corpuscles are often found within it. One might suppose that its softening was due to a more intense action of the bacilli. These may set up a puru- lent inflammation in the lung tissue around it, and this may lead to its softening, or the chemical compounds produced by their abundant growth may influence this. One thing must be taken into consideration. The case- ous material in no part of the body shows the same ten- dency to soften and break down as it does in the lung. A caseous focus in the liver or spleen may apparently ex- ist for years and have no such tendency. All the causes which we have mentioned as possibly favoring its soften- ing must exist in all these tissues as well as in the lungs. Here, however, it forms a suitable place for the growth of other bacteria, especially the various pus-organisms once the softening, resulting in cavity formation, has begun. After the caseous matter has softened and been expelled from the lung by the bronchi, that most distinc- tive clinical sign of the lung tuberculosis, the cavity, re- mains. When once formed, the cavity vefy speedily en- larges. This enlargement is favored by the pressure exerted on the walls of the cavity by the air in the move- ments of inspiration and expiration. This, however, is secondary to the enlargement caused by the extension of the caseous process. The cavities so formed present many points of differ- ence. In some cases their walls are rough and uneven, and surrounded by a zone of caseous tissue which passes into a caseous consolidation of the lung. In other cav- ities the surface is covered with a red granulation tissue, with only here and there patches of caseation. In these the caseous matter has been thrown off, and its place taken by the granulation tissue. This points, rather to a healing of the process, for this tissue must offer a certain resistance to the advance of the caseation. The cavities can enlarge by the formation of miliary tubercles in their walls, which soon, by the advance of the caseation, be- come taken up by the cavity, further by a caseous pneu- monia in the lung tissue around them, and by the forma- tion of tubercle tissue. In some cases they are surrounded by a dense mass of connective tissue in which few or no tubercles are found. By the contraction of this the cav- ity is lessened in size, the contents become less abundant, and may undergo calcification, so that all that remains of the cavity is a hard irregular mass of tissue, with the sur- face of the lung over it puckered, and in this tissue some calcareous material. The contents of the cavities may vary. Sometimes they contain a thick, creamy fluid, at others one similar to thin pus. In the contents small masses of necrotic tissue are almost always found. The number of cavi- ties formed in a lung varies. Sometimes they are very numerous. They communicate with each other, and the whole of the lung, or a lobe, is filled with a system of ir- regular ragged openings. They are much more common in the upper than in the lower lobes. The process of en- largement of the cavities goes on irregularly. Certain structures of the lung are more resistant than others, and none are more so than the dense walls of the larger pul- monary arteries. When one of these is encountered in the advancing destruction, this goes on in the tissue around it, so that a cord either along the side of the cav- ity or stretching across it, is formed. These larger ves- sels are soon thrombosed, so that even when they are eroded no haemorrhage takes place from them. In other cases the vessel remains pervious, the wall is weakened at one spot and gradually yields to the pressure of the blood, forming an aneurism which projects into the cav- ity. It is from the rupture of such aneurisms that the sudden and fatal haemorrhage, which sometimes occurs in the course of tuberculosis of the lungs, results. The more frequent and smaller haemorrhages, in this stage of phthisis, are the result of bleeding from the granulations on the surfaces of the cavities. Another great danger that is encountered by the advance of the cavity is the perforation into the pleura with the production of a pneumothorax. The opening of the cavity into the pleura may be quite small and overlooked at the au- topsy. When the process is a slow one this danger is not so great, for there is a preceding inflammation of the tissue which firmly binds the lung to the chest-walls. It is especially in those cavities which rapidly advance by a caseation of the surrounding lung tissue, and where no connective-tissue wall is formed around them, that this danger of perforation is greatest. All of these changes which we have described com- prise the phthisis of the lungs, and we regard this as an etiological entity. The general aspect of the phthisical lungs varies so much that it may be said that no two cases ever present the same picture. All the changes we have described may be found in the same lung. In the apices, old cavities with walls covered with granulation tissue, and in the lower lobes, more irregular cavities with caseous walls and surrounded by caseous pneumo- Fig. 4129.-Formation of Tuberculous Cavities in the Lung of a Cow. The lobules of the lung are more distinct than in the human lung. The connection between the cavities and the bronchus is seen. There are numerous tubercles and areas of caseous broncho-pneumonia, and the cavities are formed from softening of the caseous mass which resulted from this. Around each cavity is a line of caseation. The cavities were filled with a rather firm caseous mass which has been washed out, and on the walls of several of them caseous nodules are seen. (Natural size.) which may find entrance to the place through the bronchi. In the softened material other bacteria than the tubercle bacilli are found. The softening begins at the edges of the caseous mass and advances toward the centre. In most cases it takes place in one portion of it and grad- ually affects the whole mass, and in others there seems to be a puriform inflammation around it, by means of which the whole mass becomes separated. If the structure and function of the lungs favor the softening of the caseous mass, it is also due to this that the consequences of the softening are so much more seri- ous here than in any other organ. The lung is tilled with a branching system of rigid tubes. When the softened matter enters any of these it is carried along them, by the ciliated epithelium and acts of coughing, into the larger tubes, and is expelled with the sputum. A portion, how- ever, is carried into other bronchi by the inspirations. The softened material contains large quantities of tuber- cle bacilli, and wherever they come into contact with the tissue new foci of the disease are established. Clinically, it is known how rapid is the course of the disease when 302 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tuberculosis. Tuberculosis. nia. Patches of caseous pneumonia not yet softened are found, and around these and around the cavities are seen miliary tubercles. A general miliary tuberculosis may be added to the phthisical changes, and' not only tubercles in various stages are found whose foci of infection come from the various tubercular changes in the lung, but others scattered through the entire lung, wherever the bacilli may be carried by the blood-vessels. To these strictly tuberculous changes in the lung must be added the inflammatory. It could not be supposed that such extensive changes could take place without the production of a reactive inflamma- tion in the surrounding tissue. We not only have the tuberculous changes in the cavities, but we have also sup- puration. The sputum of the phthisical subject is for the most part com- posed of pus. In any advanced case of phthi- sis the cavities represent an enormous suppurat- ing area, which in any part of the body would be of great importance. In addition to this puru- lent inflammation there is a formative one, as shown by the extensive formation of connective tissue. This is seen in the walls of cavities, where it evidently tends to increase the opposi- tion to the extension of the caseation. It very often is much more ex- tensive, and around the cavities and elsewhere there is an interstitial pneumonia. The lung tissue may by this be converted into a solid fibrous mass, in which the alveoli may be rec- ognized as irregular spaces lined with a cu- boidal epithelium. The connective tissue around the bronchi and larger blood-vessels is often so much increased that it forms large, solid mass- es. This connective-tis- sue formation in the lungs, though in part due to a reactive inflam- mation set up by the tu- berculous lesions, is to a much greater extent due to the direct influence of the bacilli. All tuberculous le- sions are accompanied by more or less formation of con- nective tissue ; this is seen in the fibrous tubercles and in the thickening of the alveoli in caseous pneumonia. In the phthisical lung the connective-tissue formation is often so extensive that it would be impossible to regard it as anything else than a part of the process. The im- mediate connection between this and the tubercle bacilli has not been carefully studied. It may be that the first growth excited by the bacilli passes into connective tis- sue, having overcome to a certain extent the necrotic action of the bacilli; or it maybe that the bacilli directly excite this formation of connective tissue without any intermediate change. Its extent and its importance are recognized in giving one of the varieties of phthisis the name fibrous phthisis. Other important changes are produced in the lung by the mechanical effects of these various processes. One of the most important of these is the atelectasis which is produced in small areas of the lung by the closure of bronchi. Emphysema is also a more or less constant phenomenon, especially in the tuberculous lungs of children. It is due to the partial closure of the bronchi, or it may be more or less vicarious in character. A further consideration of these changes and the effect which they produce on the functions of the lungs would not come within the limits of this article. We have devoted con- siderable space to a con- sideration of tuberculo- sis of the lungs, because the disease here is of so much greater impor- tance than elsewhere not only from its greater frequency, but because it is more often primary. Though it is really not the case, the lung af- fections are considered more complicated than elsewhere in the body. The whole subject of phthisis becomes clear on a careful study of the structure of the lungs and a knowledge of the essential features of the disease. The variety of the lesions depends more on the different ways in which the bacilli enter the tissue. The resist- ance which the organism in different cases offers to the extension of the process is also of great importance. We shall next take up the study of the tuber- culous changes in the mucous membranes, and as a type give the most attention to intestinal tuberculosis. In the mucous mem- branes the most marked lesion is the ulceration, and this has many char- acteristics which distin- guish it from ulcers produced by other causes. We have here the same combination of the formation of miliary tubercles, diffuse tuberculous tissue, and inflam- mation that we have found in the lungs. The disease ordinarily begins by the formation of tuberculous tissue in the mucous membrane. As the first lesion of the dis- ease we may have either a formation of miliary tubercles or caseous inflammation. The caseous material softens just as in the lungs, and opens into the intestine, and there is formed, not a cavity, but an ulcer. A close study of the process shows us the importance of recog- nizing the various different lesions which are produced by the tubercle bacilli, and of not considering here, any Fig. 4130.-Tuberculous Ulcers of the Ileum. In the bottom of the deep excavated ulcers miliary tubercles are seen. (Natural size.) The apparent cicatricial condition of the mucous membrane in the lower part of the drawing is artificial, and due to stretching. 303 Tuberculosis. Tuberculosis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. more than in the lungs, the miliary tubercle as nec- essarily the primary and principal lesion. Tuberculosis of the intestinal tract is the most frequent of all the infectious diseases found in this part, and the changes produced here by tuberculosis rank next in im- portance to those in the lungs. In the intestines tuber- culosis generally takes the form of ulcerations, whose seat is the same as those produced by typhoid fever, namely, the lower portion of the ileum. The ulcers, however, are not so closely confined to this portion of the intestine as are the typhoid ulcers, and often the whole of the ile- um, and even the jejunum, is more or less affected. In rare cases ulcers may be found in the duodenum or stomach. The large intestine is more often affected than in typhoid fever, and no part of this so often as the rec- tum ; in fact, next to the lower end of the ileum, tuber- cular ulcers are most frequently found in the rectum, and I have repeatedly seen cases in which this was the only portion of the canal which was affected. The ulcers here also derive an importance from the fact that they give rise to complications, such as fistulge, which come under surgical treatment. The most frequent form under which tuberculosis of the intestine appears is that of extensive ulcerations, which, having in general the same seat, might be mis- taken for typhoid ulcers. They lack, however, most of the features of these, and have distinguishing charac- teristics of their own. Whereas the 6dges and base of the typhoid ulcer are clean, smooth, and sharp cut, the edges of the tuberculous ulcer are elevated and irregular, and the base covered with small elevations and caseous masses. On section of the tuberculous ulcer the edges are found to be deeply undermined, and in the elevated edges miliary tubercles can be seen. The tuberculous ulcers, in general, have their long axes across the intes- tine because they tend to spread in the direction of the lymphatics and blood-vessels. The differences between the two are easily understood when their respective modes of formation are considered, the typhoid ulcer being formed by the casting off of a mass of necrotic tissue, and the tuberculous by the gradual formation of caseous masses and their destruction. It is the difference be- tween necrosis and caries. The tuberculous ulcers are most frequently found in that portion of the mucous membrane which is opposite to the mesenteric attachment. The peritoneal surface over them is covered with a fine eruption of miliary tu- bercles, the bacilli being conveyed here by the lymphat- ics. The number of these miliary tubercles varies with the depth and extent of the ulcers ; over the small ulcers there may not be more than two or three, while over the larger there may be a considerable thickening of the serous membrane, due almost entirely to the formation of miliary tubercles. The mucous membrane at the edges of the ulcers may not show any alteration, but frequently there is a marked hyperaemia. There is also a hyperaemia on the serous covering around the miliary tubercles. The ulcers are formed by preference in the lymphatic tissues of the intestine, in the agminated and solitary glands. The number and size of the ulcers vary greatly, the whole intestine from the anus to the duodenum is sometimes filled with them, and in other cases but a single one is found. Numerous large ulcers in the lower portion of the ileum may join together, forming immense ulcerated surfaces ; others forming in the solitary follicles are found, which are no larger than the head of a pin. The ulcers which develop in the patches of Peyer may follow the direction of these and have their long axes in the same direction as the intes- tine. They generally, however, enlarge in the opposite direction, and may extend entirely around the intestine, forming the so-called girdle ulcers. This form is charac- teristic of the tuberculous ulcers. It is due to the ten- dency which the process has to extend in the course of the lymphatics. Frequently, over the ulcer and extend- ing fro'm this along the mesentery to the nearest lym- phatic glands, large whitish-yellow cords, with small nodular swellings along them, are seen. These cords represent the lymphatics coming from the affected por- tion of the intestine, and which are in part the seat of the formation of miliary tubercles, and in part are affected by a tuberculous lymphangoitis, by which they become filled with a caseous mass. In many cases they form a network, which extends along the serosa for a consider- able distance above and below the seat of ulceration. In addition to the small ulcers formed from the solitary follicles, tubercles are often formed here which project as Fig. 4131.-Small Tuberculous Ulcers of the Ileum resulting from Tuber- culosis of the Solitary Glands, with following Ulceration. (Natural size.) small, hard, whitish nodules covered with an intact mucous membrane. On microscopical examination of the ulcers we find both a formation of typical miliary tubercles and an inflammatory tissue. The tubercles are seated in the floor of the ulcer, and in the undermined and elevated edges. Around and between them is a small-cell in- filtration, in which, occasionally, the large epithelioid cells are found. Giant cells may also be found in this tissue without any connection with the miliary tubercles. 304 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES Tuberculosis. Tuberculosis. This infiltration with lymphoid cells also extends into the mucous membrane, and is found between the glands of Lieberkuhn. The formation of tubercles extends downward in the muscular coat at some distance from the floor of the ulcer. The smaller ulcers result from a formation of miliary tubercles combined with caseous inflammation in the solitary glands. The whole follicle enlarges and becomes changed into a caseous mass, which softens and is discharged into the intestine. In some cases there is simply a caseous inflammation in such follicles without any formation of tubercles. Here, just as in the lungs and in the tuberculous lesions everywhere, there is an inseparable con- nection between tubercle for- mation and tuberculous in- inflammation that is seen in the small intestine. In the rectum there may be but a small opening on the mucous surface, which communicates with a cavity which has undermined the muscular layers for a considerable dis- tance. These cavities may communicate with each other, and when seated near the anus, perforate exter- nally, forming the tuberculous fistulae. The consequences arising from tuberculous ulcers are various. They may perforate into the peritoneal cavity, giving rise to a fatal peritonitis. Happily, this is rela- tively rare, owing to the inflammation which precedes them, and by means of which they become adherent either to some other viscus or to the abdominal walls. Perforation between adherent loops of the intestine is by no means infrequent. In one case in which the entire extent of the mucous membrane of the small intestine was covered with ulcers, and in which the intestine had become rolled up into an inextricable mass by means of adhe- sions, no less than eight perforations between adherent loops were found. The tubercle bacilli pass through the mucous membrane into the folli- cles. No lesion is necessary to enable this to take place. A tuberculosis of the follicle is often seen without any lesion of the mucous membrane. Cornil has studied the manner in which the bacilli enter the tissue in a case of tuberculous ulceration of the pharynx, and has found that they are carried through the mucous membrane by the wandering cells. In many cases it seems probable that they may pass into the lymphatics without producing any lesions at the place of entry, and be carried to the mesenteric glands, where they produce a caseous inflam- mation. In children there is often an enormous tuberculous enlargement of these glands without intestinal ulcer- ation, and the same thing is seen in cattle. It is not easy to see how these glands could become infected in any other way than by the passage of the bacilli along the afferent lymphatics. Baumgarten has studied carefully the intestinal lesions which are pro- duced in animals by feeding them on tuberculous material. If the animal be inoculated in the ordinary way, no intestinal lesions are produced, but they always are seen when the tubercle bacilli are conveyed into the animal by its food or drink. There is no multiplication of the bacilli in the intestinal canal, but they are taken up and carried into the solitary and agminated glands. This is more particularly the case in the large gland of the appendix. This artificial tuber- culosis of the intestine always begins in the lymphatic structures, and not in the mucous membrane. The bacilli enter into the lymph follicles, and the first lesions are the formation of epithelioid cells from the fixed cells of the gland. From the follicles the disease spreads first flam mation, terminat- ing in caseation. The formation of the intestinal ulcers is anal- ogous to the forma- tion of cavities in the lungs, and the large ulcer may be compared to a spread-out cavity. The microscopic ap- pearance of the ulcer is similar to the wall of a cavity ; of course, with such difference as would be due to the difference in the ana- tomical structure of the two parts. In both there is the same com- bination of miliary tu- bercles, diffuse tuber- culous tissue, and tu- berculous or caseous inflammation. In some cases the tuberculous ulceration is accom- panied with the forma- tion of a considerable amount of fibrous tis- sue. Cases in which the ulcers have healed with the formation of a dense mass of cica- tricial tissue, whose re- traction may almost occlude the lumen of the intestine, have been seen. The ulcers in the large intestine differ in many respects from those in the small. As a rule, they are not so large. When the large intestine is very much affected, which may be the case without a corresponding degree of severity in the small, the surface may contain innumerable ulcers, many of which communicate and form large, irregular, ulcer- ated surfaces, in which only here and there patches of intact mucous membrane are found. The edges are undermined, and in the floor and sides of the ulcer there is the same combination of miliary tubercles and caseous Fig. 4132.-Primary Tuberculosis of the Uterus with Secondary Acute Miliary Tuberculosis. The whole interior of the fundus is convert- ed into a granulation tissue filled with miliary tubercles. They are also scattered through the muscular tissue. The mucous membrane of the cervix is retained ; in it are miliary tubercles and small tu- berculous ulcers. Small ulcers are also found in the vagina. The tubes are dilated and filled with caseous contents. (Natural size.) 305 Tuberculosis. Tuberculosis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. into the submucous tissues and into the crypts of Lieber- kuhn. Proliferation of the epithelial cells takes place also with the formation of epithelioid cells. The bacilli are also carried downward into the intestinal wall by the lymphatics, and there is always a lymphangoitis of the vessels of Auerbach's plexus before tubercles form in the muscular coat. It is especially in tuberculosis of the uterus that the combination between inflammatory changes terminating in the caseation and the formation of miliary tubercles is seen. Tuberculous affections of the uterus are more common than is generally supposed, and in most cases follow a tuberculous peritonitis, the bacilli finding en- trance into the uterus through the Fallopian tubes. The uterus is generally enlarged and its cavity filled with a caseous mass. On removal of the contents there is often seen a deep-seated caseous inflammation of the lining membrane. In most cases the entire mucous membrane of the fundus is affected, in others portions of intact mu- cous membrane may be found. On section of the uterus, the caseous mass is seen to extend down for some dis- tance, and may or may not be associated with the forma- tion of miliary tubercles. The surface is never smooth, but has a rough, gnawed-out appearance similar to the inner surface of rapidly forming tuberculous cavities in the lungs. On microscopic examination an intense small- cell infiltration, with some formation of epithelioid cells is seen, and this becomes caseous on the surface. In this tissue giant cells are frequently found, both alone and associated with miliary tubercles. In other cases there is an exquisite formation of miliary tubercles, both in the mucous membrane and extending down deeply into the muscular tissue. The internal surface is then finely granular, and in the place of the diffuse caseation caseous tubercles are seen mingled with those in which this process has not yet begun. The disease nearly always begins in the fundus and ex- tends downward. It is remarkable how often its first appearance is shortly after delivery, before the involution of the uterus is completed. In such cases it originates in the seat of the placental insertion, and the fatty degen- eration of the muscular tissue is so much increased that such a uterus appears softer and more brittle than nor- mal. The cervix is rarely affected, and when this is the case it is secondary to the affection of the fundus. The tuberculosis of the uterus is nearly always accompanied by a tuberculous salpingitis, the tubes becoming much dilated and filled with caseous pus. Tuberculosis of the liver deserves mention, not so much from its importance as from its frequency. The liver is, next to the lungs, the organ most frequently attacked. The disease is probably never primary here, but depends upon a secondary infection from some other source. Not only does it constantly follow tuberculosis of the intes- tine, which we should expect from the ease with which the bacilli could be carried to the liver by means of the portal vessels, but it is also very frequent in advanced tuberculosis of the lungs or of the bones, without any in- testinal ulceration. Its frequency was formerly under- estimated, owing to the fact that the tubercles are in most cases so small that they cannot be seen with the un- aided eye. Not only are they very small, but their growth seems a slow one, and many are found with little or no central caseation. In some cases larger nodules, some of which may be even as large as a cherry-seed, are seen ; they are more common in the livers of children. It is characteristic of the tuberculosis of the liver that it appears in the form of isolated miliary tubercles scat- tered through the tissue. The diffuse formation of tu- berculous tissue, and the tuberculous inflammations with caseation, are never seen in the ordinary form of tubercu- losis here, although in that form known as bile-duct tu- berculosis these diffuse processes play a considerable part. Microscopically, the tubercles appear to be more sharply circumscribed than they are in any other part of the body, though even here there is some small-cell infil- tration around them. The type of the tubercles varies. The most common type is that of a combination of lymphoid and epithelioid cells, with a giant cell in the centre. Nodules may be seen, however, which are noth- ing inore than a inass of epithelioid cells, and others in which the whole mass is composed of lymphoid cells, w hich could not be distinguished from the small masses of such cells found in many of the infectious diseases, were it not for their tendency to caseation. In others, again, there is a remarkable tendency to the formation of fibrous tissue, the outer portions of tubercles, no larger than an alveolus of the lung, being formed of it. In Baumgarten's study of artificial tuberculosis, he found that the miliary tubercles of the liver were formed by a proliferation of the cells of the capillaries and the epi- thelial cells of the liver and bile-ducts, and the formation of the large epithelioid cells was from these. While it is true that small nodules in the liver, formed solely of an aggregation of these epithelioid cells, may be seen, it is also true that sometimes the tubercles are formed solely of lymphoid cells. Arnold has also made tuberculosis of the liver the subject of careful study. He supposes that there is nearly always a new formation of bile-ducts, just as in interstitial hepatitis, and the tubercles develop in their walls, the giant cells being formed from their epithelium. In liver tuberculosis there is a tendency to the formation of conglomerate tubercles. Nodules, which are just vis- ible to the naked eye, are often found to be composed of many smaller ones, each with a caseous centre. There may be nodules as large as a w'alnut formed in this way. The tubercles are principally found in the interlobular tissue and in the outer margins of the lobules. Their number varies considerably. In some cases they are so numerous that several will be found in one field of the microscope, and in other cases a number of sections must be looked over before a single one is found. We have already alluded to the difficulty that is experienced in finding tubercle bacilli in them. The bacilli may be car- ried into the liver either by the arterial or by the portal blood system. In cases of general miliary tuberculosis the arterial system is the carrier, and in the tuberculosis following intestinal ulceration they enter by the portal system. This explains the frequency with which they are found in the interlobular tissue, and in the outer mar- gins of the lobules. The frequency with which they are formed here depends upon the low blood-pressure and slowness of the circulation, this favoring especially the deposit here of any solid particles carried in the blood. Weigert has shown that in cases of advanced anthracosis of the lungs pigment could be found in the liver when it was not present in any other organ save the lungs. Though the liver is so frequently the seat of tubercle formation, it probably does not offer a very favorable place for the development of the bacilli, for the tubercles rarely attain any considerable size, and there is an ab- sence of the inflammation which marks the more rapid progress of the disease elsewhere. Tuberculosis of the bile-ducts may accompany the or- dinary forms of liver tuberculosis, but more often it is found alone. It is characterized by the formation of larger or smaller nodules which often have in their mid- dle a cavity filled with caseous greenish contents. It consists in a tuberculous inflammation of the walls of the bile-ducts with the production of caseous material which softens and breaks dowm. By the continuation of this process cavities reaching the size of a cherry or a hazel-nut may be formed in the liver. There may be either this form of caseous inflammation of the ducts, or a formation of miliary tubercles around them with an affection of the epithelium secondarily. Generally but few of the bile-ducts are affected in this way. It is prob- able that the bacilli in this case do not come from the blood, but enter the liver in some other way. Either they come from the intestine along the large bile-ducts, or they are brought along the lymphatics. Tuberculosis of the kidney appears under two princi- pal forms. Either there is an intense tubercular inflam- mation resulting in the formation of large caseous masses, which by their destruction constitute the affection known as nephro phthisis, or there is a formation of miliary tu- bercles. The destruction of the caseous masses forms cavities in the kidney which open into the pelvis. The 306 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tuberculosis. Tuberculosis. softening is here, as in the lungs, probably in large part due to the action of other organisms, and there is nearly always an accompanying purulent inflammation. Fre- quently miliary tubercles are formed around the periph- The tubercles rarely have any typical structure, but generally take the form of a round-cell infiltration with central caseation. Giant cells are generally present. Baumgarten has shown that the bacilli enter the tissue either through the capillaries of the glomeruli, or through the intertubular capillaries. Frequently the glomerulus forms the point of origin of the tubercle, and may be recognized in the centre of it even after caseation has taken place. According to Baumgarten the bacilli enter the fixed cells of the tissue here, and cause them to proliferate as in all other organs. Arnold also lays stress on the part that the epithelium plays in the formation of the tubercle, and thinks that most of the giant cells are formed from the epithelium. Both here and elsewhere we must differ from Baumgarten in his views that the first formation of the tubercle is always found in an aggre- gation of epithelioid cells. In the majority of cases the kidney tubercle is nothing more than a circumscribed area of infiltration with lymphoid cells, the centre under- going caseation, and it has seemed to us that the epithe- lium plays but a passive part. Tuberculosis of the lymph-glands is important, not only clinically in that the glands are frequently the seat of a primary tuberculosis, but it is also important in its connection with the history of the disease. The caseous inflammation of these glands formed the type of the scro- fulous, as opposed to the tuberculous, affections. It was not until the glandular affection was more carefully stud- ied, microscopically, and until, even in these so-called scro- fulous glands, miliary tubercles were found in connection with a caseous inflammation, that what we now regard as a typical tuberculosis was considered as at all related to this. The two principal forms under which tuberculosis appears-the inflammation with caseation of its products and the formation of miliary tubercles-can be seen bet- ter here than in perhaps any other part of the body. They are generally combined in the gland ; a caseous inflammation is often associated with a formation of miliary tubercles, and a formation of tubercles without any other change is perhaps never met with. A caseous inflammation of the gland, in which the tubercles play but a minor part, is the most frequent form of tubercu- losis here. In the early stages the gland is enlarged, hypersemic in places, its cut surface is smooth, and contains here and there small, irregular, white, opaque patches. The capsule of the gland even at this early stage is thickened, and immediately beneath the capsule we may find, here and there, a distinct tubercle. On microscopic examination the gland shows mostly nothing more than a hyperplasia of its tissue ; here and there some newly formed bands of fibrous tissue are seen, and on the edges of the caseous areas the cells are often changed into large, pale, slightly granular epithelioid cells. Among these well formed giant cells are often found. The case- ation increases in extent until the whole of the tissue is changed into a white opaque mass, which resembles the cut surface of a potato. On microscopic examination the caseation is seldom so complete as it appears to the naked eye, but thin bands of connective tissue will be found in it. This caseous material can soften and break down, forming a creamy mass inside of the gland, which by ulceration may rupture into some cavity, or in the case of the superficial glands, through the skin. The material from the gland may thus serve to spread the disease further. When it ruptures through the skin, frequently sinuous tracts covered with fungous granula- tions are left behind, which may heal, forming large ele- vated red cicatrices, which ulcerate again from slight causes. The miliary tubercles of the glands are chiefly formed in the periphery opposite the hilus. The follicles are princi- pally affected and the tubercles have the epithelioid type. The lymph-glands apparently offer very favorable con- ditions for the development of the bacilli. They may be found here in considerable quantities during the rapid advance of the process. When complete caseation has taken place their demonstration is a matter of great diffi- culty, and they may be sought for in vain. As many ks twenty sections may be examined, and not more than one ery of the diffuse caseation. In most cases this form of kidney tu- berculosis is accompanied by ulcer- ation and the formation of miliary tubercles in the pelvis and ureters. It is more frequent in males than in females, and generally forms part of a genito-urinary tuberculosis. The formation of miliary tubercles is much more common than this case- ous inflammation. They are always present here in cases of acute miliary tuberculosis, and often scattered tu- bercles are formed in the kidney just as they are in the liver when there is no general infection. They may be very numerous, or not more than one or two may be found in a single kidney, and are rarely dis- tinctly circumscribed either macro- or microscopically. Those on the cortex are often more conspicuous from the injection of the stellate veins around them. Frequently tri- angular-shaped portions of the kid- ney, with the apex of the triangle pointing toward the pelvis, will be found filled with them. These areas are similar in shape to infarctions. They are due to a large number of bacilli entering one of the arteries and being distributed over the tissue supplied by this, where they cause the formation of the tubercles. The shape of the tuber- cles is rarely round, but is more or less oblong, being similar in this to the small miliary abscesses. Fig. 4133.-Tuberculosis of the Kidney with Secondary Infection of the Pelvis, Ureter, and Bladder. (Natural size.) 307 Tuberculosis. Tuberculosis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. bacillus be found. Even when they are apparently not present, the caseous material is infectious to animals, and cultures may be made from it. Either the bacilli in such cases are present in such small numbers that they are overlooked in the microscopic examination, or they have passed into a stage (possibly spore formation) in which they cannot be stained. There is nothing, except the direct proof by inocula- tion, which so clearly shows the infectious nature of tu- berculosis as the way in which it advances from point to point in the body. Cohnheim showed that only by the supposition that there was something infectious about the process, could any explanation of this be given. It spreads from organ to organ, step by step, along certain definite tracts, and knowing the affection of one organ, we can say with a great deal of probability what other organs will be affected. Were the disease due simply to a dys- crasia, we should expect that in its distribution over the body it would follow no law, that an infection of the intestine could just as readily follow after a tubercu- lous ulcer of the skin as after a lung tuberculosis ; and that the inguinal glands would be as likely to be infected by an intestinal ulcer as the mesenteric. In a consideration now of the disease as a whole, we shall find that its gravity, its course, and its whole nature, depend upon a number of factors. The consideration of some of these will hardly come under an anatomical study of the disease, and will be but briefly touched upon. The principal factors influencing the disease are : 1. The power of resistance of the tissues of the individual. 2. The manner in which the bacilli enter the tissue, and their number. 3. The anatomical structure of the af- fected part. 4. The virulence of the virus. That some individuals have a much greater resistance than others to the action of the pathogenic organisms is a fact long well known. Not all exposed and unprotected individuals in an epidemic of small-pox acquire the disease, and the same thing is true of all the infectious diseases. In no other way can we explain many of the facts in regard to tuberculosis, and especially the differences in the char- acter of the tubercles. Moreover, it is known that this resistance of the tissues may be lowered by various means, and is to a certain extent dependent on the age of the individual. Not only is the disease more apt to appear, but it runs a more rapid course at certain ages than aLothers. A susceptibility to the action of the tu- bercle bacilli may be inherited. This condition of sus- ceptibility is shown in various other wTays, by a ten- dency to inflammations of the respiratory tract, and to lymphatic enlargements. If any meaning at all is to be attached to the term scrofula, it should be used as an ex- pression to denote this condition of susceptibility. We are totally unable to say upon what anatomical condition or alteration of the tissues this susceptibility depends. Formad, a few years since, thought he had found the anatomical condition in a narrowness of the lymphatic channels, which produced lymphatic obstruction on slight causes. In the rabbit and guinea-pig he found -these channels to be narrower than in other animals. His observations have never been confirmed, and there is nothing in the whole history of the disease to make it appear that this condition, even if it existed, could exert any influence on the disease. It is curious that we do not find these differences in individual susceptibility in the lower animals. In them, inoculation in the same way, with the same virus, will be followed, in different animals of the same species, with the same results. It is almost as regular as a chemical experiment. We see too much proof, however, in man, that this individual sus- ceptibility of the tissues exists, to deny it, even though we may not explain it. We may find a cavity in the apex of the lung, opening into a bronchus in one indi- vidual, with little or no involvement of the lung or lungs elsewhere ; while in another individual there is infection of the other parts of the same or the other lung. In both cases the bacilli are present in the walls of the cavity and in the sputum, and the means for infection are equally present in both. The resistance of the tissues is shown not only in the differences in regard to primary infection, but after the disease is established. It is probable that no individual possesses an absolute immunity. A ten- dency to connective-tissue formation in the tubercles is probably the expression of a greater resistance. This is seen not only in single organs, but sometimes in the pro- cess all over the body. The miliary tubercles, the diffuse tuberculous tissue, and the inflammations, all show this same tendency. That the tissues are in many cases able to overcome the action of the virus, and that the individ- ual may recover, is a fact possibly better appreciated by the pathologist than by the practitioner. One very fre- quently finds, especially in the lungs, traces of a tuber- culosis from which the individual has long since recov- ered. This is shown in the cicatrized and shrunken cavities, which often contain a chalky or calcareous sub- stance, and around these nodules stellate bands of con- nective tissue are found. The manner in which the bacilli enter the tissue of an organ or the body is also of importance. They may of course enter the body in a number of ways. They may enter by means of the respiratory tract and the lungs be attacked primarily ; or by the intestinal canal, with the production of a primary intestinal ulceration or casea- tion of the mesenteric glands ; or there may first be some tuberculous lesion of the skin, with an infection of other parts secondarily, through the blood or lymphatic ves- sels. It is also important, in the case of the individual organs, how the bacilli enter them. The only way that is possible is along passages or ducts which ramify through these organs, or by the blood- and lymph-vessels. In the lungs these three ways of invasion are often seen together. The process here is largely influenced by these different paths of infection. The caseous pneu- monia most often follows infection of one part of the lung from another part by means of the bronchi; still miliary tubercles are also so produced. The number of bacilli which enter an organ at the same time is also important. This probably plays a con- siderable role in the primary infections. Tissues which are able to resist a small number of bacilli have their re- sistance overcome when the number is large. Animals ordinarily insusceptible may be rendered tuberculous when they are inoculated with a large amount of a pure culture. It is probable that the diffuse caseation attack- ing at once a comparatively large surface of the lung, and spreading rapidly, is due to the large number of the ba- cilli which are carried at one time into the tissue. The fourth element on which differences in the pro- cess depend, viz., variations in the virulence of the virus, is a fact which can hardly be doubted, although not enough experiments have been made on the tubercle ba- cilli to enable us to say anything with certainty about it. Such differences in the virus of other infectious diseases certainly exist, and there are many facts in tuberculosis which make it seem probable that they are also present here. In most cases not only are the lungs the primary seat of tuberculosis, but the pathological changes which the disease produces here are so extensive and well marked that the term tuberculosis is, with most practitioners, one under which little else than pulmonary tuberculosis is un- derstood. In by far the majority of cases the death of the individual is due to the lung changes. When the lungs are primarily attacked the bacilli enter them from with- out by the bronchi. Secondarily, they can be conveyed to the lungs in a variety of ways. They can come from a focus in a distant part of the body by means of the blood-stream. They can enter by means of the lym- phatics from a tuberculous bronchial or mediastinal gland. An important way of entrance is found in the ulceration of caseous bronchial glands into the bronchi, which is usually followed by extensive and rapidly pro- gressing areas of caseous pneumonia, especially in the lower lobes. It does not seem to us probable that a pri- mary tuberculosis of the lungs can be produced by ba- cilli which have been taken into the tissues from the ali- mentary canal. They would be lodged either in the liver or in the mesenteric glands. When the lungs are secondarily invaded the changes in them are no less ex- 308 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tuberculosis. Tuberculosis. tensive than when they are primarily attacked, and the primary focus of the disease may be overlooked. How- ever the bacilli may enter the lungs, and whatever the nature of the lesions produced, the bronchi soon come in contact with the diseased part and the bacilli become mixed with the other bronchial contents. Then they may be carried along these into other parts of the same or the other lung, setting up wherever they go foci of the disease. Or they may be carried out of the lungs with the expectoration and carry the disease further. Just that sort of anatomical structure is met with in the lungs which especially favors the extension and rapid progress of the disease. In the first place, the bacilli can reach any part of the lung along the branching bronchi, and when areas of caseation are once established the circum- stances, in the ease with which other bacteria can reach the caseous mass, are most favorable for the softening and destruction of this, with the formation of a cavity. In the w'alls of the cavity the growing bacilli are freely supplied with oxygen, and in consequence of this a most active growth can take place. The numerous lymph- vessels also form a suitable means for the further con- veyance of the bacilli, and independently of these the micro-organisms, having entered the white corpuscles, can be conveyed short distances. The walls and the in- terior of the alveoli form a suitable locality for their further development. From the lungs the bacilli can be readily carried to other parts of the body. They are carried from the lungs with the sputum along the bronchi and trachea. The trachea is often affected, but far more often than this the larynx is the next organ in the order affected. The tuberculous processes here have already been fully treated in the article on affections of the larynx. One point to which Cohnheim has called attention is of importance, namely, that the posterior wall of the larynx is most often the seat of the ulcerations, and it is here that the sputum remains longest in contact with the mucous membrane. After the sputum has been conveyed from the air- passages a part of it is expectorated, but a part, and probably the largest part, of it is swallowed. Wherever the sputum comes in contact with mucous surfaces in- fection may follow. The tuberculous ulcerations of the pharynx, tongue, and lips, are due to this mode of infec- tion. The bacilli are not separated from the sputum and contained in the expired air. Micro-organisms in general are not lifted by currents of air from moist sur- faces, and in spite of the fact that the air expired through the nasal passages must have passed over surfaces teem- ing with bacilli, it does not contain any, and the mucous membrane of the nares is not the seat of any ulcerations. It is hardly possible to imagine any mucous membrane which would be a more favorable place for the develop- ment of the tubercular processes did the bacilli ordin- arily reach it. Tuberculosis of the nares is, however, sometimes seen ; in these cases the bacilli probably be- come mixed with the nasal secretions at night, when the individual is lying on the back. The sputum which is swallowed comes first in con- tact with the mucous membrane of the oesophagus, and then with that of the stomach. The oesophagus enjoys probably a greater immunity from tuberculosis than any other mucous surface in the body. The reason of this most probably is found in the fact that everything passes through the tube so quickly that the masses of sputum pass through as masses, and the bacilli are not separated out and deposited on the surface. Even should a few be so deposited, they are again swept away by the food or drink which is continually passing down the tube. In the stomach the conditions are also unfavorable for development; for the bacilli are exposed to the action of the gastric juice and this inhibits their action. Still, cases have been seen of tuberculous ulceration of both the oesophagus and the stomach. Cohnheim suggests that the gastric juice may exercise a permanent inhibitory action on the virus, and the intestinal lesions only ap- pear after the gastric juice has become enfeebled by the gastric catarrh which is often seen in tuberculosis. It has not, however, been found that the gastric juice has any marked effect on the bacilli when both pure cultures and sputum which contains bacilli have been exposed to its action. The small intestine offers a favorable soil for the ac- tion of the bacilli. They develop in the lymphatic tissue of the intestine, and the ulcers produced are most fre- quent in that portion of the intestine where this tissue is most abundant. It is probable that the intestinal con- tents remain longer in contact with the walls here than in the other parts of the small intestine. Infection of other organs follows easily from the process in the in- testine. The bacilli are carried by the lymphatics to the mesenteric glands, and produce tubercles and a caseous inflammation here. They may, as we have seen, pass Fig. 4134.-Miliary Tubercles and Tuberculous Lymphangoitis on the Peritoneum over a large Tuberculous Ulcer of the Ileum. (Natural size.) into the lymphatics without producing any intestinal lesions. There is always some formation of miliary tubercles on the surface of the peritoneum over the ulcers, when these reach any considerable size. In some cases there is a general infection of the peritoneal cavity from the same source, with the production of a miliary tuberculosis here. In other cases there is not a general infection of the cavity, but a formation of miliary tubercles in certain places. The most common seat of this limited tubercu- losis is in the recto-vaginal and recto-vesical fossa?. It is here that any sort of finely divided substances enter- ing the peritoneal cavity tend to collect, and, of course, any tubercle bacilli entering the cavity will be carried to this place also. Sometimes infection of the entire cavity may be prevented by the formation of adhesions between the loops of intestine and the abdominal wall. It seems difficult to explain why we at one time have a 309 Tuberculosis. Tuberculosis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. localized pelvic peritonitis, and at another an infection of the entire cavity, except by the assumption that in the one case there is less resistance of the tissue to the action of the bacilli than in the other. It might possibly be the case that fewer bacilli entered the cavity in the one case, but it is probable that in any case the number of bacilli which come from the intestine is small, and they are de- veloped in the cavity either free or in the tubercles. There are other ways in which the peritoneum can be infected. One of the most severe cases of peritoneal tuberculosis I have ever seen was in a young girl, in whom the source of the infection could clearly be traced to an enlarged and caseous mesenteric gland, the caseous material of which extended through the capsule. This case followed on typhoid fever, and the healed typhoid ulcers were found in the intestine, but neither here nor in any other place in the body, except the peritoneum and mesenteric glands, was there any trace of a tuberculous process. The bacilli can also be carried from the intestinal tract by the blood-vessels. Naturally they will be deposited in the liver, and their action is seen in the miliary tuber- culosis of this organ which always accompanies the in- testinal lesions. The spleen is also frequently affected, but not nearly so often as the liver. In some cases the infection of the bile-ducts, with the production of a typi- cal bile-duct tuberculosis, suggests another way in which the liver can become infected. The bacilli may enter the organ from the intestine along the bile-ducts. It is difficult for us to understand how such an organism as the tubercle bacillus, without any power of individual progression, can make its way from the intestine into the liver against gravity and against the bile-current. It could only take place by a growth of the bacilli along the walls of the duct. It is probable that this bile-duct tuber- culosis can be better explained by infection from bacilli brought from some other place in the liver, by means of the lymphatics which run along the bile-ducts. The fact that often the beginning of a bile-duct tuberculosis is found in the formation of tubercles around these duetts, speaks in favor of this. The following is the most fre- quent type of tuberculosis met with : an advanced tuber- culosis of one or both lungs, tubercular ulcerations of larynx and intestine, a circumscribed infection of the peritoneum, infection of the mesenteric glands and of the liver. The next most frequent form is the acute miliary tuber- culosis. How it differs in the clinical picture from the form we have been describing is well known. These dif- ferences in its clinical character are no more marked than are those in the anatomical changes. All over the body, in every organ, myriads of the finest nodules may be seen, and there is no recent formation of diffuse tuberculous tissue such as caseous inflammations. Still, we know from microscopical examination of these nodules that while some represent typical miliary tubercles with giant cells, others are nothing more than minute foci of tuber- culous inflammation. We know from the work of Pon- fick and Weigert, that these cases are due to the entry of the bacilli into the blood-current, either directly from a tubercular ulceration of a large vein, or indirectly from the thoracic duct. There is a difference in the character of the disease when large numbers of bacilli are at one time thrown into the blood-current, or when there is a successive entry of smaller numbers. Though in some cases all the organs of the body may be affected, some are much more apt to become so than others. The bacilli are rather rarely seen in the mucous membrane, and the muscles and skin have a great immunity. They must be carried into all organs by the blood, and these tissues have a greater resistance to their action than others. In almost all cases some few are formed in the endocardium, and here they are found especially in the conus arteriosus of the right side. The cases next in order of importance to these are those of disseminated miliary tuberculosis, in which, along with a more or less advanced tuberculosis of some organ in the body, generally the lungs, miliary tubercles are found in other organs. They are most frequently found in the liver, kidneys, and spleen, but never in the numbers in which they are present in the acute miliary tuberculosis, and generally they are larger. It is possible that in these cases a few bacilli enter the blood from the formation of miliary tubercles in the blood-vessels, or in some other way, and are deposited in those organs most favorably formed for the retention of solid particles. In other cases we can have a distinctly circumscribed miliary tuberculosis. We have already referred to the infection of the peritoneum which may follow" an affec- tion of the mesenteric glands, and in the same way we can have a miliary tuberculosis limited to the pleura or pericardium, from either the mediastinal or the bron- chial glands emptying their infectious material into these cavities. The gland first becomes firmly adherent to the membrane, and the ad- vancing caseation first penetrates the capsule of the gland and then breaks into the cavity. The tuberculosis of the genito-urinary tract is of importance in showing how the disease may ad- vance from point to point. Until a few years back it was generally held that the kidney was the pri- mary seat of the disease, Fig. 4135.-Tuberculosis of the Epididymis, following a Kidney and Bladder Tuberculosis. (Natural size.) and descending from this the other organs were at- tacked. Weigert was the first to show that this was not the most frequent mode of infection. As we have seen, there are two well-marked varieties of tuberculosis in the kidney, one being the formation of miliary tuber- cles and the other the nephro-phthisis. There can, of course, be but two ways in which the bacilli can enter the tissue-either they must come from the blood or from the urinary tract. The blood infection does not seem ordi- narily to produce the nephro-phthisis, and from the mili- ary tubercles there is rarely a further spread of the in- fection along the urinary tract. Weigert thinks that the diffuse tuberculous inflammation of the kidney is due to bacilli which enter through the pelvis. It seems to us that in many cases the nephro-phthisis is primary in the 310 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tuberculosis. Tuberculosis. kidney. The caseous masses open into the pelvis or calices of the kidney, and these may contain not only tubercular ulcers, but miliary tubercles as well. The ureters are also affected, but ulceration in them is not so common as in the pelvis. The next organ to be affected is the bladder. Tubercular ulceration of the mucous membrane is found here, its favorite seat being around the mouths of the ureters. In the female the disease stops here, but in the male it progresses further, and in- fection of the prostate, the vas deferens, and the testicle follows. In most of these cases there is a tubercular caseous inflammation of the tube, which gradually ex- tends from the prostate to the testicle. Ordinarily but one kidney is affected, but the other kidney and ureter may be involved and, as it appears, secondarily to the bladder infection. Frequently the course of infection seems to take a contrary direction, and a tuberculosis of the bladder and kidney follows a primary focus in the testicle or epididymis. It is as difficult to explain in this case how the bacilli get into the kidney from the bladder, as how they pass from the intestine into the liver along the bile-ducts. The fact that the pus organisms take this course in the production of pyle-nephritis does not help us much. These are not capable of independent motion, but the urine affords them a suitable soil for growth, and a growth of them may take place in the urine in the ureter and pelvis of the kidney. The tuber- cle bacilli, however, do not grow in the urine, nor does it seem to me very probable that there is a constant growth along the inner wall of the ureter which finally extends into the kidney. It seems more probable to me that, hav- ing gotten into the bladder, a few may in some way enter the ureter, and when this is filled with urine and the patient lying on his back, they might be carried into the kidney, not by gravity, but, if we suppose the ureter to be distended with urine, by the slight currents which the movements of the patient may cause. Or it is possible to suppose that they may be carried more directly from the testicle to the kidney by the lymphatics. However the matter is explained, it is certain that this upward course of infection in genito-urinary tuberculosis often does take place. This is shown by the fact that the nephro-phthisis is so much more common in men than in women, and the opportunity for primary renal infec- tion must be the same in each. In women the only chance for such a course of infection would be from a primary tuberculosis of the bladder, and it is known that this does not take place. Tuberculosis of the uterus cannot be considered a very uncommon affection. It usually follows a peritoneal tuberculosis, the bacilli finding a ready means of entry into the uterus by means of the Fallopian tubes. These are generally affected at the same time with the uterus, and are dilated and filled with caseous pus. The bacilli may pass along them producing no effect, and only exert their action on the uterus. The secretion from the uterus loaded with bacilli passes into tlie vagina and may pro- duce tubercular ulceration here. The vagina may also be infected from the perforation of a tubercular ulcer of the rectum. In one case I saw a typical tubercular ulcer in the posterior wall of the vagina, without any infection of the tubes or the uterus. There was a tubercular peri- tonitis, and the ulcer was probably caused by bacilli com- ing from this, but which had produced no effect on either the tubes or the uterus. In a certain number of cases the disease is undoubtedly primary in the uterus, and prob- ably results from the entry of bacilli during coitus. I have seen one such case, in which both a fresh peritoneal tuberculosis and an acute miliary tuberculosis resulted, the bacilli finding entrance to the peritoneal cavity along the Fallopian tubes, and into the blood-current by the open uterine veins. The source of infection is very difficult to trace in the cases of tubercular meningitis. We should expect to find the meninges affected in cases of general miliary tuber- culosis, and we do find the miliary tubercles here strung along the small arteries of the pia mater like rows of fine beads. We may, however, find a tuberculosis of the pia mater in which there is a combination between a diffuse caseous inflammation and a formation of miliary tuber- cles. This may follow a tuberculosis of the lungs or any other part of the body. Weigert has pointed out two ways in which the infection may take place : either from a tuberculosis of the nasal mucous membrane which pene- trates into the skull cavity through the cribriform plate of the ethmoid bone, or from a tuberculosis of the pleura, the virus entering the spinal canal along the lymphatics which accompany the intercostal nerves. Neither of these modes of infection seems to give a sufficient explanation. Tuberculosis of the nasal passages is the rarest form of the disease which we meet with. The frequency with which tuberculous spinal meningitis is found associated with the affection of the cerebral meninges, speaks in favor of the entry of the bacilli along the spinal nerves. The source of this infection may also be found in the blood, and some cases fall in the category of those in which infection takes place from the accidental entry of a few bacilli into the blood-current. From a single mili- ary tubercle so formed a general tubercular meningitis could result. In the study of the disease it must be borne in mind that there may be an extensive formation of tubercle bacilli Fig. 4136.-Pearly Nodules on the Pleural Surface of Pericardium of a Cow. natural size.) in such cavities as the pleura, peritoneum, or pericardium, the bacilli growing here in the fluids of these cavities just as they grow in pure cultures outside of the body. The result of their presence is then most often seen in the diffuse inflammations of these membranes. In this discussion of the manner in which the infection of different organs results many possible modes of infec- tion have not been considered. Thus infection of one serous cavity may follow the disease in another ; the in- fection taking place along the inter-communicating lym- phatics. Infection of the pleura may follow that of the peritoneum or pericardium, and vice versa. We cannot close this part of the subject without again laying stress on what must be considered the most important ideas which come from the recent studies of the disease : 1. That tuberculosis is an infectious disease, and the le- sions produced by its virus, the tubercle bacilli, may as- sume a great variety of forms. It may produce miliary tubercles, or a diffuse formation of tubercular tissue, or inflammations with a fibrinous, purulent, haemorrhagic exudation, or the inflammation may be formative, with the production of fibrous tissue. All these lesions, what- ever their character, have the common end of caseation. If one considers for a moment the infinite variety of le- sions which the disease syphilis-the similarity of some of the aspects of which to tuberculosis has often struck ob- 311 Tuberculosis. Tuberculosis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. servers-may produce, these different lesions of tubercu- losis will appear less strange. There is more difference between some of the skin lesions of syphilis and the old liver gummata, than there is between the tubercular in- flammations and the miliary tubercle. All of the differ- ent tubercular lesions may be explained by the varying resistance of the tissue, this depending in part upon its anatomical structure and, we think, also on indefinable acquired and inherited properties, upon the manner in which the bacilli enter the tissue, their numbers, and also upon the different degrees of virulence of the bacilli. The primary seat of tuberculosis most often is the lungs, the bacilli entering here with the inspired air. They may, however, and in some cases do, pass from the lungs into the bronchial glands without the production of any pulmonary lesions, and the lungs may only secondarily become infected from the ulceration of such a gland into one of the air-passages. Their introduction into the common these tuberculous affections of the bones are we know from the works of Volkman, Konig, and others. Strong evidence of their being primary is found in the frequent complete recovery of the patient after the re- moval of all the diseased portions. In many, perhaps the majority, of the cases this affection of the bones is preceded by a trauma. The inflammatory tissue so produced affords a favorable soil for the growth of the bacilli. In such cases, assuming the mode of infection to be from the blood, we would have to suppose a very rare conjunction of circumstances, viz., the entry of the bacilli into the blood at the time of, or shortly before, the trauma, for we cannot suppose that a bacillus could be carried around for an indefinite time by the blood until it finds a favorable spot to rest. We do not believe that these cases are primary. In the great majority of cases, after death, another focus of the disease is found either in a caseous lymph-gland or in a circumscribed pulmo- nary affection. Even when such a focus is not found, it may easily be overlooked, for too much attention is not given to the lymph- glands in post-mortem examinations, and even if they all be examined, a small focus in one of them could be easily overlooked. The pri- mary focus of the dis- ease often is of little or no importance to t h e individual. It is probable that from such a focus bacilli often reach other tissues whose re- sistance they are not able to over- come. No description o f tuberculosis would be com- plete without some considera- tion of the dis- ease as it appears in the lower ani- m a 1 s. This is important, not only because the changes pro- duced by the dis- ease in these ani- mals make more intelligible some of the lesions seen in. man, but also the dis- ease in these animals may be the source of infection in man. The animals differ very markedly in their sus- ceptibility to the disease ; while some have a greater sus- ceptibility than man, others have a complete, and some only a relative, immunity. The dog possesses such an immunity; inoculation "with small quantities of the bacilli is without result, but when a large number are injected infection takes place. The most susceptible animals, and those most often used in inoculation experi- ments, are rabbits and giunea-pigs. The disease here runs a different course from its usual type in man. An important part of the changes consists in a caseous in- flammation of the affected part. The tubercles which are formed are generally of the epithelioid type. The susceptibility of these animals to the virus, and the rel- ative scarcity of what was regarded as the essential lesion of the disease-the miliary tubercle -is the reason why in the first experiments which were performed after Villemin's discovery, doubt was felt as to the infectious- Fig. 4137.-Pearly Nodules Formed along a Band of Connective Tissue which Hung from the Diaphragm into the Peritoneal Cavity. (X nat- ural size.) Fig. 4138.-Tuberculous Cavities in Cow's Lung. natural size.) body by the food also plays an important part. They may pass through the intact mucous membrane of almost any part of the alimentary canal, and be carried into the next lymphatic glands, causing a primary tuberculosis here. The lymphatics of the neck may become infected by bacilli which have entered them from the mouth. The mesenteric glands may be the seat of infection from bacilli which have entered them from the intestine. It is possible that single bacilli may enter the blood-current without the production of local lesions. They might become enclosed in white blood-corpuscles and thus enter ; or it is possible to suppose that they might pass through the lymphatic glands, and thus gain entry through the thoracic duct. The cases of primary tuber- culosis of the bones are explained in this way. How 312 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tuberculosis. Tuberculosis. ness of the disease. A doubt which, strange to say, does not seem to be fully eradicated from some minds. In some cases inert substances seemed to produce the dis- ease, because the experiments were not performed with rigid precautions and there was opportunity given for in- fection either locally, at the point of inoculation, or in some other way. In other cases where true virus was used, the disease produced was not recognized as tuber- culosis on account of the absence of miliary tubercles. Infection of the different organs may be followed from point to point as in man, and an acute general miliary tu- berculosis may be produced by the injection of pure cultures of the tu- bercle bacilli into the blood. We do not find the same resistance of the tissues as in man, and the entry of the bacilli into an organ is surely fol- lowed by tubercu- lous lesions. One of the most interesting forms of the disease is the bovine tuberculo- sis. This is inter- esting from the doubt that was thrown on the identity of the most manifest le- sion, the pearly nodules, with tu- berculosis. The anatomical struct- ure of the tissues, and the tendency which inflamma- tory processes have in these ani- mals, explain in part the difference in the lesions as compared with those in man. In cattle there is a much greater ten- dency to calcare- o u s infiltration than there is in man, and in the caseous material there is nearly al- ways extensive de- posits of lime-salts. The most essential lesion of the dis- ease is the forma- tion of the masses of tubercles or tu- berculous tissue know n as the pearly nodules. These have led to the disease being designated the pearl disease, or Perl-sucht. They are formed on serous sur- faces, especially on the surface of the lung. They are hard, firm nodules which project from the surface, some- times singly and as large as a pea, or even a walnut, and sometimes connected together, forming immense irregular masses. The single nodules may be smooth or irregular on the surface ; the irregularities in the latter case show their composition of smaller nodules closely joined to- gether. In some cases a number will be strung along a band of connective tissue, as the uterine hydatids are strung along the chorion villi. In some cases so many of these will be arranged in this way as to resemble a bunch of grapes. The nodules may be attached to the pleura by a broad surface of attachment, or by a fine thin pedicle. On cutting into one of the large masses its composition, by the joining together of many small nodules, maybe seen. In some cases the connection between them is so loose that they can be separated from one another. The single nodules are about the size of No. 5 shot. A caseous, or often a calcareous, centre may be seen in each. Micro- scopic examina- tion shows a much greater formation of fibrous tissue than is found in the miliary tuber- cles of man. Very small miliary tu- bercles, with giant cells and an ex- quisite reticular tissue, may be found, but more often the nodule is composed of a dif- fuse formation of tubercular tissue in which giant cells are irregular- ly scattered. We may have masses o f conglomerate tubercles formed in man which closely resemble these pearly nod- ules. We have seen one case where, with a pul- monary tuberculo- sis, there was an infection of the pleura, which was covered with nod- ular masses, some as large as a pea. O n microscopic examination they were found to be conglomerate tu- bercles with a great deal of fi- brous - tissue for- mation. The tuberculo- sis of the lymph- glands in cattle also plays a promi- nent part. The glands become enormously e n - larged, and the same combination of miliary tuber- cles, diffuse tuber- culous tissue, and caseation is met with here as in man. There is, however, a much greater formation of fibrous tissue, and lime-salts are deposited in the caseous mass, converting it into a hard, calcareous, yellow mass. These lymph-glands may reach an enormous size. The lesions which the disease produces in the lungs are of great importance. To un- derstand them it is necessary to consider those differences in structure which the cow's lung presents in comparison with the human lung. The formation of the lobules of the lung is much more definite than in man. The lobules Fig. 4139.-Tuberculous Ulcer of the Trachea of a Cow. (Natural size.) 313 Tuberculosis. Tuberculosis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. are separated from one another by loose connective tis- sue, they can be dissected apart, and are placed along the bronchi in much the same way that the lobules of the liver are placed along the branches of the hepatic vein. The lymphatics run in this interlobular tissue. A bron- chiole enters each lobule and divides, giving off branches which pass to the different parts. Other methods of in- fection than that through the bronchi are rare ; miliary tubercles scattered here and there in the tissue are some- times seen, but the whole process seems to be, in the ma- jority of cases, a tuberculous broncho-pneumonia. In the affected lobules one often finds these tubercular foci scattered along the small branches of the intra-lobular bronchioles and following their divisions, so that the ap- pearance of minute bunches of grapes is seen. These small areas of caseous pneumonia increase in size and join together until caseous masses, some of which fill the entire lobule, are formed. After the caseous masses are so formed they do not seem to undergo a gradual mary foci were, and cavities occupying the entire lobule are formed. The caseous material is much firmer and denser than in man, and on crushing it between the fin- gers small calcareous masses can be felt. In some cases it is expelled, and the cavities are lined with a firm, tough granulation tissue which is either perfectly smooth or contains here and there caseous points. Often in such a cavity, hard caseous masses as large as a pea will project from the walls wdiere the process of sequestration has not been complete. Frequently two or more distinct small cavities are found in a single lobule. The cavities rarely exceed the limits of the lobule, but in some cases several join together; but the cavities so formed are never so large as some found in the human lung. The remark- able tendency to the formation of connective tissue which we find here, seems to limit both the extent and the rapidity of the advance of the process. Along with these changes in the lung a tubercular ulceration of the bronchi is very often seen. This af- fects principally the larger bronchi and the trachea. The ulcers which are formed in the latter are frequently of enormous size, and filled with masses of exuberant granulations, between which caseous masses are en- closed. This granulation tissue may contain giant and epithelioid cells, or it may be the ordinary type of such tissue. In addition to these very large ulcers, smaller and more superficial ones are often seen, and caseous inflammation of the submucous tissue which has not yet ulcerated. The wyhole process in the lungs may run its course without any formation of miliary tuber- cles, but be confined to caseous inflammation and the formation of tubercular tissue. Whatever form it as- sumes, the formation of connective tissue plays a much more prominent part than it does in man, and here we see again how the action of the tubercle virus may be modified by the nature of the tissues. In the liver and other organs large tubercles, sur- rounded by a firm zone of connective tissue, are often seen. The caseation in the middle is more like that of the gumma than the tubercle, and in this caseous mass small yellowish calcareous particles are found. Another interesting form of tuberculosis is that of the intestines of sucking pigs. In these cases there is a tuberculosis of the udder and mamma of the mother, and the milk contains large numbers of bacilli. The en- tire mucous membrane of the large intestine in these cases is converted into a caseous mass, and beneath this tuberculous tissue and giant cells are found. The dis- ease was for a long time considered to be one of the forms of dysentery. IF. T. Councilman. TUBERCULOSIS: SYMPTOMATOLOGY AND TREATMENT. Tuberculosis is, originally, always a local disease, and only late in its course, as a rule, and rarely, does constitutional infection occur, and a general tuberculosis result. When the constitutional infection is produced by a comparatively small number of bacilli, there is the deposit of tubercles, in varying numbers, throughout the body. This constitutes a general tuber- culosis. If the constitutional infection results from the discharge of a large number of the bacilli into the circu- lation, or possibly when the organisms undergo multipli- cation in the blood, miliary tubercles are found in large numbers in many organs, and the affection is known as general miliary tuberculosis. This pursues a rapid course and terminates early in death. The constitutional symptoms, occurring in the usual forms of the disease, are entirely secondary to the local process, and are produced directly or indirectly by it. The clinical manifestations of the general form of the disease, and especially of general miliary tuberculosis, properly speaking, are alone to be considered as the characteristic constitutional phenomena of tuberculosis ; and yet these forms are so infrequent comparatively that their symptomatology is perhaps less important and de- serves less careful consideration than the general symp- toms occurring as the result of local tubercular pro- cesses. The clinical history of each of the local forms of tuberculosis is treated under its respective head, with Fig. 4140.-Tubercles in the Liver of a Cow. (Natural size.) breaking down and expulsion from the lung, but they become sequestered. They are gradually separated from the surrounding tissue by the formation of a vas- cular granulation tissue around them, and finally they lie in a cavity formed by such tissue. Often the lung will contain innumerable small caseous masses like this, which can be squeezed from the bronchus leading into the lob- ule. The membrane formed around them is peculiar. In many cases it is composed of a typical tubercular tissue, is rich in connective tissue which has more or less of a reticular arrangement, and contains both giant and epi- thelioid cells. In other cases it does not seem to differ from any other granulation tissue. When the caseous masses are not completely separated the boundary between it and the caseous mass is a perfectly sharp one. In a single lobule there may be a number of these caseous masses each no larger than a bean. By the advance of the caseation these become united, just as the small pri- 314 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tuberculosis. Tuberculosis. the diseases of the organs affected, and only the general constitutional phenomena of the disease and general mil- iary tuberculosis are here to be considered. It is very difficult, in a disease of this nature, to con- sider the general symptomatology of the affection in- dependent of the local process ; for the local symptoms form a very large and important part of the clinical his- tory, and determine so completely the nature, extent, and severity of the general manifestations. Yet, as tuber- culosis is so general in its distribution, and constitutes so distinctly one of the general morbid processes, its gen- eral symptomatology deserves a special consideration, independent of the site of the local process. As one would be led to expect from this standpoint, it is found that, throughout all the varied local aspects of the disease, as presented in tuberculosis of the lungs, joints, bones, glands, kidneys, brain, or genital organs, the constitutional symptoms present the most marked uniformity, varying rather in degree than in nature. This is true in all of the stages of the affection, whether late or early in its course, excepting in those rare instan- ces when the local process produces very early death from the involvement of the functions of some vital or- gan. In the majority of cases, as tuberculosis usually affects the internal organs, it has existed for a considerable pe- riod of time, and often, perhaps, in a latent condition, for years before the characteristic local or constitutional symptoms appear. Some recent writers have even urged that not only are the cases of primary bone and joint tuberculosis that appear in early life, but also those rare cases occurring in middle life, in reality all inherited forms of the disease, that have remained latent until some change in the local or general condition has created more favorable opportunities for their extension. Perhaps properly included under the head of the gen- eral symptomatology of tuberculosis are the symptoms so frequently preceding the development of this disease. We find a large class of persons who have inherited or acquired a peculiar delicacy of constitution and liability to a low grade of chronic inflammations. These chronic inflammations are often really tubercular in character, although not necessarily so. Such persons show a spe- cial susceptibility to all forms of noxious influences. They are more prone to various forms of disease and have less resisting power. They readily develop catarrhal in- flammations of the mucous membranes, and especially those lining the air-passages. They are peculiarly liable to severe colds that are very slow in their resolution. They are pale, feeble, and poorly nourished. Early in life they are subject to enlargement of the lymphatic glands, especially of the cervical lymph glands, which often become cheesy, break down, and suppurate. This is in fact, only a form of tuberculosis affecting the lymph glands ; but we speak of such persons often as scrofu- lous. These individuals are also more liable to tubercu- losis of other organs, and such is the history of many cases before the development of the genuine disease. Although tuberculosis is usually one of the most in- sidious of diseases in its development, and often has ex- isted a long time before any marked or characteristic symptoms have manifested themselves, yet, on the other hand, it may develop suddenly, and rapidly proceed to an early and fatal termination. No organs or tissues of the body are exempt from its ravages. The site of the primary affection seems to depend largely upon the rela- tive exposure to infection of different organs and upon the condition of local vitality of the tissues. The com- parative exemption from the process which some tissues possess, and the peculiar liability to it shown by others, depend apparently more upon their relative exposure to infection than upon any constant or great difference in their susceptibility to the disease. There are, however, some exceptions to this rule, as, for example, the skin. The primary affection is, in the large majority of cases, in the lungs or lymphatic glands. It may, however, be primary in the peritoneum, the genito-urinary tract, the bones, joints, skin, or nervous system. Throwing aside, then, for the moment, all the local manifestations of the disease, we find that there is a char- acteristic train of general symptoms that ultimately stamp more or less clearly the local process as tubercular in nature, and that they are very uniform in their occur- rence. Irrespective of the site of the original point of infec- tion, and often long before there are symptoms pointing to the location of the disease, there are manifested cer- tain symptoms of a general constitutional impairment, in- sufficient in themselves to render the diagnosis possible. These may make themselves apparent to the friends of the patient before he is himself aware of their presence. There appears to be a gradual lowering of the standard of general nutrition, the weight diminishes in most cases very notably, and there is impairment of muscular strength and endurance. The patient is unable to per- form so much labor as usual without increased fatigue. Anaemia is commonly prominent, and with this de- velops all the long train of symptoms usually accom- panying it. Insomnia and various forms of neuralgia are frequent symptoms. There is disorder of the func- tions of the alimentary tract-impaired appetite and di- gestion, constipation, etc. In fact so frequently do diges- tive disorders precede or accompany the development of tuberculosis that they have been considered by many excellent observers as forming one of the most impor- tant set of predisposing causes of pulmonary tuber- culosis. It seems probable, however, that in some cases at least, they form a part of the early manifestation of the general constitutional disorder incident to the develop- ment of the local tubercular process, and are really the result of the disease rather than predisposing causes of it. Persons susceptible to this disease often show7 much less resisting power to all sorts of exposure, and greatly diminished powder of endurance. The date at which the local symptoms first become apparent, as compared with the degree of the constitutional involvement, depends largely upon the nature and function of the tissue primarily involved, and upon the susceptibility of the individual. Unlike most other forms of disease produc- ing a general depression of vitality, there is usually in this no corresponding depression of the spirits or in- volvement of the mental faculties. These often remain almost intact, sometimes even to the end, and excepting the nature and probable termination of their own malady, in regard to which they are ever sanguine, the patient's judgment and mental power may remain quite unim- paired. Following the anaemia and the gradual and progressive loss of muscular strength, there is an acceleration of the heart's action, and a corresponding increase in the num- ber of respirations. When the site of the local process is in the lungs these last symptoms are much more marked. Increase in the body temperature is also an early symptom, and constitutes a good criterion to judge of the rapidity of the progress of the local disease. The fever usually assumes the hectic type, being attended by evening exacerbations and profuse sweating. These febrile symptoms, sometimes preceded by slight chills occurring before marked local symptoms have presented themselves, may be mistaken for malarial manifestations. The absence of any splenic enlargement, remittent type of the temperature in place of the intermittent type of malarial fever, and the occurrence of the pyrexia after mid-day, in phthisis, instead of before mid-day, as is the rule in intermittent fever, are differential points when taken in connection with the local symptoms and phys- ical signs. Chills may occur without any succeeding pyrexia. In some cases more or less marked rigors occur with the chills. Cold sweats, independent of these febrile manifestations, and occurring at night, are fre- quently present, especially in pulmonary tuberculosis. Sometimes the fever shows very marked intermissions, and the temperature during the very early hours of the morning may be subnormal, even when in the afternoon it reaches 102° F. or 103° F. In such cases it reaches the lowest point usually about 4 a.m., when it may not be more than 96° F. After this time it gradually rises and reaches the normal temperature, or slightly more 315 Tu berculosis. Tuberculosis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. than this, about 9 a.m. Such a temperature curve as this is almost pathognomonic of tuberculosis. In some cases marked dyspnoea occurs, independent of any very extensive involvement of the lungs, or great elevation of the temperature. This is probably due to the action on the nerve-centres of some chemical poison, resulting from the life processes of the tubercle bacillus. Pain is not usually a marked symptom of tuberculosis in any of its forms, excepting when the brain or me- ninges are involved, then it constitutes a very constant and characteristic phenomenon of the disease/ Disorders of menstruation are frequent events early in this disease. At first the menstrual flow is scanty, and later it ceases entirely. The patients often ascribe their other troubles to the checking of menstruation, and think that if the menstrual flow was re-established they would disappear. As the disease advances all the signs and symptoms of the constitutional impairment become more marked. The emaciation may become extreme. There is complete loss of muscular power, the anaemia is profound, the heart's action is greatly accelerated, the pulse being 120 or more per minute. The respirations are correspondingly in- creased, and often accompanied by dyspnoea, and the ele- vation of temperature is greater, reaching perhaps 104° or 105° F. in the afternoon or evening. The stomach often becomes intolerant of food, and vomiting may become a marked symptom. Profuse diarrhoea frequently appears with or without an intestinal tuberculosis. As the result of the severe anaemia occurring late in the disease, marked oedema may appear in the lower ex- tremities. This, beginning in the feet and around the ankles, extends upward, involving the legs and thighs. Sometimes it is much more marked in one extremity than in the other, and then it is usually found to be associated with thrombosis of the femoral vein, which is one of the occasional events in this disease. Thrombosis may occur in both femoral veins. General anasarca rarely appears, and when present is usually due to coincident renal disease. Bed-sores may develop wherever there is slight press- ure, as the emaciation may become so extreme that but little intervenes between the skin and bones. The bed- sores are especially frequent over the sacrum, nates, heels, and elbows, and often greatly increase the suffering of the patient. Sometimes furuncles and abscesses also develop in various parts of the body; the cough may become extremely harassing, and the condition of the patient, epecially when the mind is unaffected, is truly deplorable, and the suffering is intense. In the later stages of the disease the insomnia often be- comes very marked, there may be loss of mental power and memory, and a more or less active delirium. This is not the history of all cases, for sometimes the patients retain their consciousness and buoyancy of spirits to the very end. They may have but little suffer- ing, but they grow weaker and weaker ; they gradually pass away, the moment when life becomes extinct being almost imperceptible. A general miliary tuberculosis or tubercular meningi- tis, or some intercurrent complication may, however, quickly hasten the fatal termination. The constitutional symptoms, we see on reviewing them, are, for the most part, those incident to an affec- tion accompanied by great disturbance of nutrition and a continued elevation of temperature. This disturbance of nutrition is, in part, to be ascribed to the action of mod- erate fever, long continued, but probably, to a far greater extent, to the action of a chemical poison resulting from the life processes of the tubercle bacilli. This latter view has received great support in an experimental way from observations in which it has been shown that there is a progressive loss of weight and strength, with anorexia, gastric irritability, etc., produced in various animals by the daily injections of increasing quantities of an alco- holic extract of the sputum from cases of pulmonary tu- berculosis. The symptoms produced are proportionate to the amount of the extract employed, and finally, if the injections are continued, death results. The symptoms arising from the local process in the lungs, bones, joints, etc., in the various forms of tubercu- losis, will be found described under other headings in this Handbook. Some of these general symptoms are much more fre- quent and characteristic in tuberculosis of one organ than in that of others, but yet they may be present in any form of the disease. Many of them are found most fre- quently in pulmonary tuberculosis, which is the most common, and is usually regarded as the most typical, form of tuberculosis. But little need be said in regard to the course and du- ration of tuberculosis. It is essentially chronic in nat- ure, and the rapidity of its course and the termination depend largely upon the site of the local process and the nature of the conditions. A large proportion of the cases are self-limited and tend toward recovery. Acute Miliary Tuberculosis.-In acute miliary tu- berculosis there are deposited large numbers of miliary tubercles throughout the body. Some one organ is usu- ally more involved than any other, and in this the pro- cess is primary, and is generally much older. The age of the tubercles in the other organs may be apparently about the same. Any organ may be the site of the orig- inal local process. Acute miliary tuberculosis occurs after a primary pulmonary tuberculosis most frequently, but it may occur after a primary tuberculosis in the lymphatic glands, in the bones or joints, or in the genito- urinary tract. Rarely there are cases where no tuber- cular process can be found which seems to antedate the general infection. Still it seems improbable that an acute miliary tuberculosis ever occurs as a purely primary affection. The nature of this affection is often obscure, and the disease is so little characteristic that its diagnosis may be very difficult. This is especially true of those cases where the primary local affection has not given rise to any characteristic symptoms, so that the disease com- mences abruptly with symptoms similar to those of an acute infectious disease. In these cases the clinical his- tory resembles especially that of typhoid fever, and it is often mistaken for this. In other cases when, preceding the development of the acute general symptoms, there have been the manifestations of a local process in the lungs, or disease of the hip-joint, or caries of the verte- bra, or tuberculosis of the lymphatic glands, combined with the indefinite but often characteristic symptoms of impairment of general health-such as loss of weight and physical strength, anaemia, disturbances of the alimentary canal, impaired appetite and digestion, constipation, and perhaps neuralgia and insomnia-if such a history can be obtained it aids greatly in characterizing the disease. Whatever be the nature of the symptoms in the prodro- mal or the invasive period of the disease, when once fully established the clinical history of all cases denotes an acute febrile disease. The pyrexia is usually marked, the temperature often reaching 105° or 106° F. in the after- noon. There are usually marked remissions in the morn- ing. These remissions may be attended by more or less profuse perspiration. In some cases the temperature re- mains rather low throughout the disease. The pulse is rapid, ranging from 120 to 140 beats per minute. The pulse wave is small, and its character denotes great pros- tration. The respirations are, as a rule, very rapid-out of proportion to the extent of the pyrexia. They vary between 30 and 60 per minute, and are sometimes accom- panied by marked dyspnoea. Cough is usually more or less prominent, but may not be very troublesome. It is often not more severe than is present in typhoid fever, and is usually quite out of proportion to the extensive lesions frequently present in the lungs after death. The expectoration varies and may be almost wanting. It usually consists of a frothy, glairy mucus, or muco-pus, streaked perhaps with a little blood. Haemophthisis is an occasional but not frequent event in this disease. Diarrhoea is sometimes present and persistent. This may be due to an intestinal tuberculosis, or it may be independent of it. The spleen, too, is sometimes enlarged. 316 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tuberculosis. Tuberculosis. It may be absolutely impossible to differentiate these cases from those of enteric fever. Pain is not a promi- nent symptom, and is often completely wanting. There is complete anorexia, and there may also be gastric irri- tability. When the meninges are involved the cephalal- gia is intense ; there is rigidity of the back of the neck, vomiting, delirium, various ocular disturbances such as strabismus, ptosis, blindness, etc. The ophthalmoscope shows a choked disk, and sometimes a tubercular retini- tis. Sometimes there is more or less active delirium when the meninges are not involved. Emaciation is often very rapid. The prostration is marked very early, and the patient may sink into a typhoidal condition. There are then a rapid, feeble pulse, rapid, superficial respirations, a high temperature, a low muttering delirium, coma-vigil, car- phologia, subsultus tendinum, incontinence of urine and faeces, sordes on the teeth, dry, dark-coated, cracked tongue, etc. The disease pursues an invariably fatal course, and terminates in a period varying between two and eight weeks. Characteristic physical signs in this disease are want- ing. If the tubercles are equally disseminated through both lungs, they do not produce any appreciable modifi- cation of the physical signs obtained in health by per- cussion, or change in voice or respiratory signs. There may be at most only some dry and moist bronchial rales heard here and there over both lungs, but nothing more. The diagnosis must be made by exclusion. In an acute febrile disease, when the respirations are rapid, accom- panied by cough, and perhaps by dyspnoea, without any physical signs to denote an affection of the lungs, except- ing perhaps a few rales, the suspicion of the existence of miliary tuberculosis should be at once aroused. If the rales are localized at both apices, and there is a fam- ily history of tuberculosis, or a previous history of im- paired health in the patient, the diagnosis has great additional proof. Typhoid and remittent fevers must be excluded in making the differential diagnosis of acute miliary tuber- culosis. Treatment of Tuberculosis.-Only the general principles of the treatment of tuberculosis will be pre- sented here, the details of treatment being left for con- sideration in the various local forms of the disease. For the formulation of a rational system of therapeu- tics in tuberculosis, there must be first a clear concep- tion of its pathology. This, of course, may be said of all morbid affections, but it is peculiarly true in this one. Tuberculosis is originally a local infectious or para- sitic disease. Preceding the development of this local process there is usually, and perhaps always, a depressed condition of general vitality, or of the local vitality of the organs or tissues affected. This condition, if gen- eral, is loosely spoken of as the tubercular diathesis. The relation of this local or general condition to the tu- bercular process, and its influence upon treatment, will be better understood after referring briefly to some points in regard to the transmission of the infectious diseases. It has been shown experimentally that in the case of many infectious diseases of animals (and this is probably true of all), that all individuals, however susceptible the species or individual may be, yet possess a certain de- gree of immunity to every disease to which they may be subject. This susceptibility varies with different indi- viduals, and with the same individual at different times,, and is largely dependent upon the intensity of virulence of the virus employed, the amount of the virus used, and the conditions and surroundings of the individual experimented upon. It has been found, in the case of certain of these diseases, that the other conditions being the same, the effect produced is directly proportionate to the amount of the virus used. If a very small amount is introduced subcutaneously, no effect follows the in- oculation ; if a somewhat larger amount is introduced, a local disturbance at the point of inoculation follows, and if a still larger amount is used, characteristic phe- nomena of the disease are produced. In other words, the natural resistance of the individual to the disease in question must be first overcome by the size of the dose of the virus. We may represent this graphically by sup- posing that x - the normal resistance of an individual to a given disease, y = amount of virus sufficient to pro- duce the disease. These are both variable quantities ; x varies with the individual and with time, condition, etc.; y varies with the individual susceptibility and with the intensity of the virus. It will be readily seen that im- munity or increased susceptibility, or their equivalents, may be produced by variations in either x or y. The insusceptibility to any disease may be so great that under natural conditions the intensity of exposure to infection, or, in other words, the dose of the virus received, is not great enough to overcome this insusceptibility, and such individuals possess practically absolute immunity to the disease. Some persons have such an immunity to small- pox ; but there can be no doubt that in such individuals this immunity could be overcome artificially, if it were possible to increase indefinitely the dose of the virus. Now, in a local parasitic disease, such as tuberculosis originally is, it becomes evident at once that any influ- ence which diminishes the resistance of any organ or tis- sue that is exposed to infection, whether this influence is a local or general one, by just so much contributes to the production of the disease. The depreciated condition of general health, or diathe- sis, that usually precedes the development of tuberculosis, may be congenital or acquired, and it is because of the frequent development of tuberculosis, in some form, in those persons who have had transmitted to them at birth this condition, where there is a weak resisting power, that the disease has been so long considered hereditary. It is hardly necessary to add that a belief in the heredi- tary nature of the disease rests upon no sufficient founda- tion. But aside from this general condition of depressed vi- tality, that so often precedes the development of this dis- ease, there may also be produced by various causes a local depression of vitality in some tissues exposed to infection that has the same effect. It is the combination of these two sets of conditions, general and local, that offer s the best opportunities for the development of the tubercle bacillus. As an example of the development of tubercu- losis under such conditions, we may instance the occur- rence of tubercular joint disease in children after trau- matism, when the depreciated state of general health pre-exists. The traumatism produces the local depres- sion, which determines the site of the tubercular process. The tubercle bacillus is the active cause of this disease, and is the only active cause. If introduced in large enough numbers this will produce the disease indepen- dently of any other influence; but under natural condi- tions, if no local or general depression of nutrition exists, the intensity of exposure to infection, or the number of tu- bercle bacilli received at any given time, is insufficient to overcome the natural insusceptibility. When, how- ever, the natural resisting power to the disease is lessened from any cause, the dose of tubercle bacilli that before proved insufficient, now results in the production of the disease. Further than this, the same conditions exist later on in the disease, and influence in the same manner the exten- sion of the tubercular process. If the tissues possess a certain degree of vigor, and if the standard of nutrition is brought up to a certain level, they resist the multipli- cation of the tubercle bacilli and the extension of the tu- bercular process. This then becomes stationary or retro- gressive. If, on the other hand, the vitality of the tissue is low and the conditions are favorable for the develop- ment of the tubercle bacilli, they And little resistance to their multiplication and the disease rapidly extends. That this is exactly what occurs again and again, is shown clearly enough by the conditions found after death. In nearly fifty per cent, of the autopsies in hospital cases there are found after death the evidence of a tubercular process in some part of the body that has existed at some time in life. Probably not more than twenty per cent, of deaths result directly from this disease, and in 317 Tuberculosis. Tuberculosis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the other thirty per cent., or more than half of the cases of tubercular disease, the process has remained strictly localized, and in many instances has long since become stationary or retrogressive. In most of these cases the individuals have probably never been conscious of the existence of any disease. But at some time in life, as the result of some depressing influences, conditions favorable to the development of the tubercle bacilli have been pro- duced, the patients have been exposed to infection, and a local tuberculosis has resulted. Lhter the conditions have changed, the local or general state of nutrition has improved, and with this came a corresponding increase in the resisting power of the tissues ; they no longer afforded a favorable soil for the growth of the germs, and the disease ceased to extend. Keeping in mind these two etiological factors in tuber- culosis, first, the tubercle bacillus, and, second, the con- ditions that render the tissues a favorable site for their development, the principles of treatment become at once clearly defined. If either of these factors can be re- moved we can treat the disease radically. As regards the tubercle bacillus, it becomes at once apparent that in all forms of internal tuberculosis, when the diseased tissues cannot be removed surgically, treatment directed specially toward the parasite (i.e., germicidal treatment in the ordinary sense) is futile. From the nature of the pathological changes that occur in this disease, and from the position of the bacillus in the diseased tissues, it be- comes evident that no germicidal agent can be brought directly in contact with the organism, and we may dis- miss at once from our thoughts any idea of accomplish- ing any direct result by any form of antiseptic or ger- micidal treatment, whether it comes from the internal administration of germicidal agents or antiseptic sprays, or inhalations, or injections, or gaseous enemata. Any apparent results that are obtained by these means are in- direct at best, and such methods fall far short of accom- plishing the object for which they are intended. If we look to the other side, however, the prospect be- comes at once bright. We find the treatment based upon known facts in regard to the pathological anatomy and pathogenesis of this disease, to be in perfect accord with clinical experience. Any method of treatment that tends to improve the conditions of general nutrition tends, by just so much as it increases the resisting power of the tissues, to limit and check the extension of the disease. Further, any method of treatment that raises the local vigor of the organs or tissues affected, tends in the same way to increase the resisting power of the tis- sues, and so tends to check and limit the extension of the tubercular process. All medicinal methods of treatment that have withstood a long and severe test of clinical ex- perience come under one of these heads. The treatment is thus narrowed down to those meas- ures, for the most part hygienic in nature, which aim to bring up the standard of general nutrition to the highest possible point. In conjunction with such means may be sometimes used those that influence in the same way es- pecially the vitality of the organ affected.. From this standpoint, inasmuch as the predisposition may be inherited or acquired, the question of prophy- laxis is a most important one. For it is manifest that the chances of the patient predisposed to tuberculosis are vastly better before than after he has become infected with the exciting cause of tubercular changes. If we are dealing in any case with an inherited or acquired diathe- sis, the object of prophylaxis is to place the patient in sur- roundings free from infective matter, in a-tubercular sur- roundings, and then to remove if possible the diathesis. As regards the prevention of infection : Recognizing the many avenues of infection and the fact that, although it is probable (Cheyne, Ziegler) that the parasite does not live any stage of its existence outside of the body of ani- mals, yet the spores are capable of withstanding success- fully for a considerable time conditions averse to their development; recognizing these facts, consideration must be given to the following points : The sputum of phthi- sical patients should be at all times thoroughly disinfect- ed, germicidal solutions in glycerine and water should be constantly standing in the receptacles for expectora- tion. All handkerchiefs contaminated with such infec- tive matter should be placed in a solution of mercury bi- chloride (1 to 1,000) before being washed. All cloths and rags so contaminated should be burned, and all clothes containing infective matter from tubercular ulcers of skin or intestinal discharges from cases of tubercular en- teritis, etc., should be treated in like manner. The attend- ant should not occupy the same bed as his patient, nor should he live continuously in one room if it can be pos- sibly avoided. In the case of husband and wife this rule should be certainly enforced. There is strong evidence to support the belief that tuberculosis is sometimes com- municated per coitus through the genital organs. Infants should not be suckled by tuberculous nurses, nor should they sleep with tuberculous parents. Rooms occupied constantly by very sick patients should be occasionally fumigated. This disease, there is now no doubt, is often transmitted by the agency of milk from tuberculous cattle, and also quite likely by eating the flesh of diseased cattle or of hogs, and perhaps of fowls. Walley 1 says, that in the abattoirs into which his occupation takes him, scarcely a day passes that he does not see tuberculous cattle in the herds. To remove the diathesis, and to limit the extension of the tubercular process when once established, the meas- ures of treatment may be considered under the following heads: Atmosphere and climate, food, exercise and oc- cupation, baths, and drugs. Atmosphere. The importance of fresh air in the maintenance of health will not be disputed. Parkes2 says the average mortality increases with increase in population, and the main cause of this is impurity of air. lie also,3 in speaking of the marked diminution in death- rate from lung affections in the British army since 1846, gives reasons for saying that this diminution is undoubt- edly due to less frequent overcrowding in the barracks. The necessary amount of air-space to each individual is given between 1,000 and 1,200 cubic feet, in hospitals about 1,400 cubic feet, depending more or less upon the frequency of change of air in ventilation. For the proper standard to be maintained in an allotted space of 1,000 cubic feet, it is necessary for the air to be changed at least three times per hour ; the minimum amount of fresh air being 3,000 cubic feet per capita per hour. Where this amount of space is not obtainable the air must be changed more frequently, the important question of ventilation being to move the air as frequently as necessary, and at the same time to cause as little draught as possible. The bad effects of overcrowding are seen even at elevated stations in the mountains. Parkes (Op. cit., p. 429) says that, in the Swiss Alps, the women in some stations suffer greatly from tuberculosis, and scrofula is very common. The cause is that, being employed in em- broidery, they work in low, ill-ventilated rooms and in constrained positions-whereas the men who live outdoors are exempt. Another important point in relation to the atmosphere is the relative amount of moisture which it contains. This varies, as a rule, with the temperature. The amount of relative humidity that can be borne with the greatest comfort is between sixty per cent, and sev- enty-five per cent. Weber4 gives the ratio for very dry air as less than fifty-five per cent., and of moderately moist air as between seventy-five per cent, and ninety per cent. A high temperature can best be borne when the relative humidity is low, because the evaporation from the skin is freer than under the opposite condition ; and a low temperature is more easily borne with relatively low degree of moisture, because there is less heat lost by con- duction in dry air. There is more tendency to haemop- tysis when there is a sudden increase in relative hu- midity (Weber); one of the characteristics of mountain air, according to Weber,5 is its dryness and comparative absence of mist. To this is due the greater diather- mancy of air than at lower levels, and as a result the high temperature during the day and the low temperature of air at night. The climate and atmosphere cannot be considered separately. Another element which should be spokeu of here is the movement of the air in checking or 318 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tuberculosis. Tuberculosis. producing evaporation from the skin and from the lungs. A cold wind abstracts heat in proportion to its velocity (Parkes), a hot wind by evaporation, its power in this re- spect being in proportion to its humidity. In selecting a climate for phthisis patients the frequency and force of winds must be considered. Temperature should be considered in connection with humidity and movement of air. In choosing a climate the mean annual tempera- ture gives but little information. The diurnal range of temperature is very important. It should not be too great. One of the most important considerations, in ordering a change of climate, is the pressure of the atmosphere. The effect of rarefied air upon the respiratory system is to in- crease the frequency of respirations from ten to fifteen per minute (Parkes), which after a time return to normal (Bagshawe)/ and to increase the size of the chest 1 to 3 inches (Williams). This, however, is denied by Parkes (Op. cit., p. 428) and by Alcock.1 The effects begin to be felt at an elevation of 2,800 to 3,000 feet. The influ- ences upon the circulatory system are quickened pulse, from fifteen to twenty beats in the minute, and steadily increasing force of the heart's action. At 6,000 feet there is increased evaporation from skin and lungs, swelling of superficial vessels, and occasionally bleeding from nose or lungs (Parkes). Influence of cold is stimulating and causes feeling of buoyancy, there is increased appetite and digestive powers, and increased nervous and muscu- lar tone. A suggestion is made which is worthy of no- tice, by Creighton,8 based upon the results of experiments made by Paul Bert upon the blood of animals living upon elevated plateaus in Peru. Bert found that there was an increase in absorbing power of this blood for oxygen to one and a half time, there being an absolute increase in the quantity of haemoglobin in such blood. Creighton suggests that this increase makes up for the diminution in supply of oxygen due to decrease in amplitude of res- pirations, and finds in these facts a probable explanation of the benefit of these localities for cases of anaemia. The climate formerly sought in cases of phthisis was a warm, moist climate at about the sea-level, but the advice now generally given, and which is justified by experience, is to seek a climate which is cool and dry -a mountain climate. The question is one of a differ- ence in altitude rather than of latitude. The beneficial effect of mountain air in the cure of tuberculosis is un- questioned, but just what particular element this benefit is to be ascribed to is not determined. Weber9 gives the physical features of mountain air a^ follows : 1. Purity and aseptic nature. 2. Dryness of air and soil, and com- parative absence of mist. 3. Coolness of air and warmth of sun temperature. 4. Rarity of atmosphere. 5. In- tensity of light. 6. Stillness of air in winter. 7. Large amount of ozone. Creighton (Op. cit.) says that in the Andes phthisis is practically unknown, although the or- dinary exciting causes, such as industrial occupation, sed- entary habits and the like, are the same as at lower levels. On the other hand, Alcock10 says there can be no more pernicious error than to suppose that the air of the higher Alps is in any way a specific for advanced phthisis. In considering the advisability of a change of climate in tu- berculosis it is well, before sending a patient a great dis- tance from home, to test his recuperative powers near by; if he shows increase in weight and diminution in cough (should the case be one of pulmonary disease), it is prob- able that he will be improved by a more decided change in climate. The most important contra-indications against a change to a higher level are : 1. Great advance in the disease. 2. Advanced age of patient. 3. Febrile rise of temperature. 4. Albuminuria. 5. Continued loss of weight. 6. Sleep- lessness and irritable nervous system. 7. Co-existence of cardiac disease. 8. Bagshawe says that when the lar- ynx is affected mountain climate is directly unsuitable. The treatment by the differentiation of air (air under either a positive or a negative pressure) has been applied principally to cases in which the pulmonary organs are the seat of the local process, and the benefits obtained are chiefly local; but secondarily, the effects upon the sys- tem in general are of value. One is the increase of the vital capacity of the lungs, in some cases amounting to 1,000 c.c. increase in residual air.11 But the benefits are small as compared with those obtainable from a change to a mountain climate, which are not limited to the effects of altered atmospheric pressure alone. The subject of dietetics becomes of great importance as soon as the main line of treatment is directed against the underlying tendency to tuberculosis, and towrard in- creasing the resisting power to the disease. Just what prominence should be given to the different classes of foods in the dietary has not yet been determined defi- nitely-opinions differ ; but the majority incline to the belief that a nitrogenous diet mainly is the most rational one. The tendency to waste of tissue, and the enormous waste which in most instances does occur, would seem to indicate the importance of increasing the nitrogenous principles. Parkes says (Op. cit., p.. 193), whatever be the final source of motion, heat, etc., the direction given is by the nitrogenous structures ; also (p. 196), nitrogen- ized elements regulate the absorption and utilization of oxygen. Convinced of the importance of food in phthi- sis, Debove first proposed the method of over-feeding, or " stuffing." He considers that the absence of appetite is no indication as to the amount of food that can be digest- ed and absorbed. In this method, after lavage of the stomach in cases where there is catarrh of that viscus, food in a concentrated form is introduced by a tube, if the anorexia is a prominent symptom. The results which he and others have obtained fully justify this mode of feed- ing. Even in cases of considerable anorexia with chronic gastric catarrh, there was much increase in weight after a course of this treatment. The amount of nitrogen and carbon in the daily diet for ordinary work in a healthy man is thus given by Moleschott: N., 317 grains ; C., 4,750 grains. The dietary in any case should be based upon this as the normal standard. As food is so important in therapeutics in this disease, it should have special consid- eration from the medical adviser, and should be in a great measure under his supervision as to the quantity and as to the frequency of meals. Food in small quantities fre- quently repeated is more easily digested and absorbed than when given in larger quantities at longer intervals. The question whether or not the patient shows much el- vation of temperature is an all-important one ; the case, when pyrexia is shown, should be treated as any case of fever in respect of diet. The condition also of the kid- neys should have close attention. When albuminuria is present the diet should be restricted accordingly. Of course, all cases of gastric or intestinal indigestion should be treated as under other conditions. The importance of exercise, and especially exercise in the open air, at sufficiently frequent intervals and in prescribed degree, is not disputed. The special forms of exercise to be taken depend upon the seat of local disease in a measure. In pulmonary troubles the daily morning and evening employment of pulmonary gym- nastic exercises is of great advantage. Mountain climb- ing is a kind of exercise which is much praised for the benefits derived therefrom. In any hygienic course of treatment baths and the care of the skin should receive as much attention as any other part of the treatment. As Brunton says, the three great functions of man, generally speaking, are : 1 The devel- opment of tissue change. 2. The supply of sufficient aliment. 3. The removal of waste. The latter is of as much importance as either of the others. We take general hygienic treatment to be of the first importance in any case of tuberculosis, whatever the seat of the local process, and we consider the local treatment as occupying a subordinate place ; as being at best only adjuvant to the hygienic treatment. This is found to be the case even in tuberculosis of the skin, where, if in any situation, the local process can be easily reached by local remedies.12 In connection with all of the methods of hygienic treatment , by which we attempt to bring up the standard of general nutrition to the highest possible point and in- crease the vigor, so that the tissues may withstand and limit the extension of the disease, or throw off the sus- 319 Tuberculosis. Tumors. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ceptibility to it, there remains only to be added in a medi- cinal way such measures as aid in accomplishing the purpose, and in relieving the symptoms that arise from time to time as the result of the disease. Under the second head the treatment must be purely symptomatic, and depends upon the site of the local process. Under the first head the measures resolve themselves into a simple tonic regime in which the different bitter tonics, iron and cod-liver oil form the most important part. Of these iron and cod-liver oil act for the most part as food to the system, and replace the great loss resulting from the disease. All the methods of surgical treatment, such as come into play in the various forms of bone, joint, and gland tuberculosis, are not to be considered here. Suffice it to say that in a general way, inasmuch as this is a local parasitic disease, any focus of disease that can be removed at not too great a cost, diminishes by so much the chances of general infection, and removes a certain amount of diseased tissue and a certain number of tuber- cle bacilli, that otherwise must be overcome by the tissues before recovery can take place. In general miliary tu- berculosis, when the system is attacked at every point by the innumerable army of tubercle bacilli which have gained entrance to the general blood- or lymph-currents, the only hope is that, by supporting and symptomatic treatment, we may relieve in some degree the sufferings of the patient and somewhat prolong life. The final fatal result is inevitable. Hermann M. Biggs. 1 Edinburgh Medical Journal, vol. xxxiii., p. 1083. 2 Practical Hygiene, p. 105. 3 Ibid., p. 607. 4 Ziemssen's Handbuch Therap., vol. iv., p. 15. 6 Medical Times and Gazette, London, 1885, vol. i., pp. 337 et seq. e British Medical Journal, 1883, vol. ii., p. 159. 7 Lancet, 1887, vol. i., p. 333. 8 British Medical Journal, 1887, vol. i„ p. 822. 8 Medical Times and Gazette, 1885, vol. i., pp. 337 et seq. 10 Lancet, 1887, vol. i., p. 333. 11 Ziemssen's Handbuch Gen. Therap., English Translation, vol. hi., p. 456. 12 Valias : American Journal of the Medical Sciences, June, 1888. TUMORS, DIAGNOSIS AND TREATMENT OF. The classification of tumors used in the following pages is essentially that of Councilman, which will be found in a preceding volume, under the heading Growths, Patho- logical. I shall discuss the subject under the following heads : cular cyst, and meningocele. Of these the three latter are of the nature of hernial projections. Hygroma (superficial bursa) occurs as the result of ir- ritation, usually at the known anatomical site of a serous sac. It takes the shape of the cavity affected. It may appear suddenly from severe irritation,;but usu- ally is of slow evolution. It is unilocular, varies in size and consistency according to the relations oetween its wall and its contents, is translucent, of indolent growth, and remains stationary for a long period. The sac at first is thin, but after a long time may become thickened by subacute inflammation. The contents are purely ser- ous. Fluctuation is distinct. The skin is not necessarily involved, but may be thickened as a result of the original irritation, as is often seen in housemaid's knee. Bursae between muscles behave precisely as do those situated in the subcutaneous tissue ; they are rarely so large, how- ever, and may communicate with a neighboring joint, in which case the swelling is reducible. An hygroma may inflame and suppurate, in which case the ordinary his- tory of abscess supervenes. Anatomical site, fluctuation, transparency, and puncture are to be relied on mainly in forming a diagnosis. Articular cysts are rare. They are projections ex- ternally of the synovial membrane of a joint. The knee, elbow, and wrist are most frequently affected. The communication with the joint may, after a certain time, be obliterated, the cyst remaining. Such tumors are small, reducible, the tension varying with the posi- tion of the articulation, and are translucent if subcutane- ous. They are firmly attached by their under surfaces, in this respect differing from superficial burste. The synovial sheaths of tendons are subject to chronic effusions, which may ^either be circumscribed (ganglion) or involve the entire sheath. This latter form is rarely seen, except in the hand and forearm. It may extend under the annular ligament of the wrist, forming a swell- ing in the palm and preventing full extension of the fingers affected. Fluctuation between the palm and forearm is distinct. Transparency may exist. The contents of such a cyst are a clear, thin jelly, and in rare cases rice-like masses of fibrin may be present. These latter, when they exist, may give rise to a friction-sound which is characteristic. The malady is of slow growth and painless ; the skin is not involved. The circumscribed form of ganglion occurs frequently on the back of the wrist and instep, more often in the former situation, arising from the extensor tendons. It is possibly a hernial protrusion of the synovial mem- brane through the fibrous sheath. Such a cyst is hard, round, translucent, movable to a greater extent trans- versely than in the axis of the limb, situated under the skin, which is not involved, indolent (it may make its ap- pearance quickly, but remains stationary), and irreduci- ble. The fluid in these cysts is thicker than that con- tained in the diffused swellings. Meningocele is a hernia of the membranes of the brain, presenting the characters of a cyst. A portion of brain may be contained in the sac, constituting meningo- encephalocele. The protrusion occurs in the line of normal suture, is congenital, soft, rounded, partly re- ducible, covered by thin skin, which, from interference with the circulation, may appear bluish, simulating nae- vus, may pulsate, and 'will become tense when the pa- tient (child) cries, or makes a strong effort. The most common sites are in the middle line over the occipital bone ; at the root of the nose, and at the inner angle of the orbit, it is not uncommon. The connection with the interior of the skull may become obliterated. Pulsation is rarely present, except when the tumor is largely com- posed of brain-tissue. Reduction may be accompanied by convulsions or other nervous disturbances. After re- duction an opening is felt in the subjacent bone. Inter- nal hydrocephalus almost invariably accompanies the affection under consideration. In some very rare in- stances the hernia has occurred through a bone, and not in the line of suture. Should the tumor consist entirely of brain-substance, I. Cysts. II. Fibroma. III. Myxoma. IV. Glioma. V. Lipoma. VI. Osteoma. VII. Enchondroma. VIII. Lymphoma. IX. Angioma. X. Lymph-angioma. XI. Sarcoma. XII. Neuroma. XIII. Papilloma. XIV. Adenoma. XV. Epithelial Carcinoma. XVI. Glandular Carcinoma. Tumors which consist of con- nective tissue and are derived from tissues belonging to the connective-tissue group. They conform to physiological types. Tumors composed of connective tissue, but distinguished by an excess of cells over the formed material; in this conforming to the type of embryonic tis- sues. Cysts.-A sac filled with fluid more or less thick is called a cyst. Cysts may exist singly or in combination with other growths. The sac wall may be thin and diaphanous, or very thick and rigid, and in rare cases it may even be- come calcified. There is great variation also in the nat- ure of the cyst contents. Exudation Cysts, formed from Pre-existing Cavities.-Any of the natural serous sacs of the body may, by excessive exudation, become cystic, or, from defect in the enclosing tissues, may project beyond their natural limits as cysts. The most common are hydrocele, bursa, ganglion, arti- 320 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tuberculosis. Tumors. encephalocele fluctuation is wanting, while pulsation is distinct. Under no circumstances should a hasty diagnosis be risked. Hernia of the membranes from the spinal canal is en- titled spina bifida. There is absence of the spinous process and laminae of one or more vertebrae corre- sponding to the pedicle of the tumor. The tumor is congenital, variable in size, globular, soft, fluctuating, reducible, covered by thin skin, some- times discolored from obstruction to circulation, very rarely pulsating, and the tension may be increased by crying. The protrusion occurs in the middle line, and is sometimes reduced by holding the child head down- ward, so that the fluid may gravitate from the sac, which is felt to be adherent to the bony rim of the affect- ed vertebra. Obliteration of the canal in the pedicle may occur. Spina bifida is most frequent in the lumbo- sacral region. As is the case with cerebral meningocele, manipulation of the tumor may give rise to nervous dis- turbance. The spinal cord and nerves may be included in the sac. The cyst contains, ordinarily, cephalo-rachidian fluid. Hamatocele.-Extravasation of blood may occur into a serous sac, and is almost always the result of violence. It occurs, of course, in the locality where a serous mem- brane is known to exist, takes the shape of the cavity af- fected and also the size ; the tension will vary with the amount of blood extravasated ; it occurs suddenly after a traumatism, and moves with ease in the surround- ing parts. Even when subcutaneous, it is not translu- cent, but presents a bluish discoloration. A feeling of weight and pain is present; fluctuation is distinct. When coagulation of the blood occurs, pressure on the tumor yields a fine crepitation similar to that obtained by rubbing starch between the fingers. The effusion may remain for a long time indolent, and may by its presence cause irritation and thickening of the sac so as to resemble a fibrous tumor. Such a case fell under my notice some years ago, where the sac wall was more than one inch thick, and of stony hardness. The watery part of the contents may be absorbed and the fibrin re- main as a hard mass, resembling a fibrous tumor; the history, however, will give a clue to its nature. Suppu- ration is rare. In consequence of disease (purpura) or constitutional dee (haemophilia), blood may be poured into a serous sac without precedent traumatism sufficient to impress .he mind of the patient. ILematocele of the tunica Vaginalis may occur as the result of rupture of vessels in "a Ise membranes, and may be mistaken for hydrocele of the tunica vaginalis). There is rarely, however, lifficulty in reaching a diagnosis, as the slow formation, ransparency, fluctuation, irreducibility, absence of im- pulse on coughing, and lastly, withdrawal of contents by lypodermic needle, sufficiently characterize hydrocele. Glandular Retention-Cysts.-Cysts formed by gland secretion, which, owing to obstruction of the normally patent excretory canal, is retained. At first the contents of the cyst are composed of gland secretion only, but soon a modification of the wall takes place which may produce a great change in its secret- ing function, and, of course, therefore, a corresponding change in the imprisoned substance. Follicular cysts. The well-known sebaceous tumor, or wen, occurs as the result of secretion retained in the sweat-glands. It may be congenital, or may origin- ate at any age. It is found wherever sweat-glands exist. It is most common in the scalp. The normal duct is often to be seen upon its summit as a dark spot, which is nothing more than retained sebum dirtied, filling and obstructing the excretory channel. The skin is adhe- rent to the tumor where traversed by the duct, and may be more or less raised according to the size of the cyst. Consistence firm. The tumor may project deeply into the subcutaneous tissue, touching the skin at one point, or may lie in the deep layer of the derma itself. Growth is slow, and having attained a certain size the tumor re- mains indolent. The cyst contents are fat, epidermic debris, cholesterine, and water in variable quantity, rarely enough, however, to give fluctuation. Lobulation is rare. On the cranium, by pressure, the tumor may cause partial absorption of bone. Ulceration of the skin over the growth sometimes takes place, simulating epi- thelioma ; the patient's history will clear up the diag- nosis. The tumors are occasionally multiple. Sebaceous cysts are occasionally found unconnected with the skin, resting deeply in the subcutaneous tissue ; they arc extremely rare. By cleaning out the opening of the excretory duct it may be possible to obtain a small quantity of the con- tents of the cyst, when the diagnosis will become estab- lished. Mucous Cysts, Cystic Polypi.-The mucous glands may become transformed into cysts from occlusion of the ex- cretory canal. Their most common site is about the nares, mouth, and uterine neck; these last rarely attain to any size, and will not be considered here. The main characteristics of mucous cysts are : Shape, spherical, or nearly so. When growing in a narrow cavity it will increase in the direction of least re- sistance. Dimensions : it attracts attention by reason of its locality, when of moderate size. Consistence soft, elastic. Translucency marked. Color, white or pinkish. Mobility, movable on subjacent structures. Painless, ex- cept from pressure on neighboring structures. May in- terfere with respiration if in the nose, with swallowing if in the mouth. If in the nose, excess of secretion results from irritation of pressure. A ranula is often simply a mucous cyst. Cystic polypus of the antrum of Highmore may fill the entire cavity, and has probably been mistaken for dropsy of the antrum. Obstruction occurring in the large excretory canals (e.g., Steno's), is rarely productive of a cyst, but is quick- ly followed by inflammatory trouble in the gland itself, for which aid is sought. The mammary gland forms an exception to this rule. Here a cyst sometimes develops from obstruction during lactation, milk is retained, the watery matter is absorbed, and there remains a cheesy substance which may pro- duce no symptoms, or possibly may suppurate, when it is accompanied by the usual inflammatory symptoms. The vulvo-vaginal gland, in rare instances, has become cystic in consequence of obstruction of the duct; far more often, however, destructive inflammation with the for- mation of abscess results. Hydro nephrosis may occur from obstruction to the flow of urine, but inflammation, sooner or later, sets in. Retention-cysts other than those already mentioned commence in the small ducts and capillary tubes ; they from the first tend to assume a spherical shape, and are usually unilocular. The wall is often formed of gland tissue, more especially if the pathological process have begun deeply in the gland. The contents are usually limpid or viscid, and occasionally bloody, as the result of violence. The function of the affected gland is not interfered with, unless the main excretory canal be pressed upon. It is always of slow growth and painless, except from pressure upon the neighboring parts. The cyst is often very tense, in rare cases so much so as to render fluctuation, which is as a rule present, indis- tinct. Translucency is present if the tumor be super- ficial, unless blood be effused into the sac. The skin is not discolored. Motion occurs with ease in adjacent structures. The tumor may suppurate. Cholesterine is very often present in the contained fluid. Cysts of New Formation.-Cysts maybe formed in nor- mal or pathological tissue by softening, a mucous or colloid degeneration. Cysts arising in fatty tumors con- tain oil, those formed in fibromata or enchondromata contain serous fluid. Here they are accidental forma- tions, having no bearing on the prognosis or treatment. Cystic degeneration is especially frequent in connec- tion with sarcoma and carcinoma, and it may mask the presence of any coexistent solid growth. Thus a solid sarcoma may project into a cyst and become perceptible only after evacuation of the surrounding fluid. The 321 Tumors. Tumors. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. course of such a tumor would be that of sarcoma or car- cinoma, the cystic condition being but an accident. The presence of a foreign body may give rise to the forma- tion of a cyst, as also may any continuous irritation, the most familiar example of which is the bursa which forms under a corn. Cystic formations in connective tissue take place by a method not yet very clear. The congenital cyst of the neck is an example of a persistent branchial fissure, a foetal condition. This tumor may, and does sometimes, attain large size ; it is painless, translucent, and fluctuating ; is covered by healthy skin, is rarely multilocular, and gives a sensation of hardness along the line of junction be- tween two loculi ; its growth is slow ; it is often noticed first about puberty. Dermoid cysts. The lining membrane of these cysts is skin with the usual appendages, sweat-glands, hair, etc. The contents consist of epithelium, cholesterine, fat, etc., together with more or less fluid. These growths are located where, during fcetal life, fis- sures exist, and it is usually accepted that, an inclusion of the external germinal layer having taken place, it adheres in the abnormal situation, and grows with the perform- ance of its function the same as though properly placed. The cysts are, of course, congenital, and usually escape notice on the part of the parents or nurse. They in- crease very slowly during the early years, but a decided increase occurs more often about the age of puberty. Their usual seat is about the head and neck, in the sub- cutaneous tissue, along the line of one of the branchial fissures, although they are found elsewhere, notably in the ovary. Much the most frequent seat is near the outer half of the eyebrow, which corresponds to the su- perior fissure formed by the anterior cerebral vertebra, which becomes the forehead above, and the first bran- chial arc, which forms the jaws, nose, lips, etc., below. The mobility of these growths will vary with the nat- ure of the surrounding parts; and not infrequently they adhere to the frontal bone. Their shape is ovoid or spherical; the sac is firm ; if the contents are oily or very soft, fluctuation is present; bone or cartilage within the cyst, when present, grows from the wall and can be felt ; translucency is only exceptionally present; the skin over the tumor is unchanged, and very rarely ad- herent. Fibroma.-Fibroid tumor occurs in two forms, soft and firm. Soft fibroma, generally round or lobulated, is made up of oedematous, tough, white connective tissue, and may contain cyst-like cavities ; on section the fluid drains away. The color of the section is w'hite, the con- sistence is soft, whence the name. The most frequent seat is the cutis, and the growth may attain great size. Cutis pendula, soft warts, and fibroma molluscum be- long to this class. The surface is covered by the papil- lary layer, and when pendulous the tumor may be very oedematous in its lowest part, giving translucency. The tumors are often multiple. They may be congenital, but more frequently they occur during middle life, especially those situated about the genitals. Not uncommonly they are found growing from the submucous tissue of the nose, larynx, posterior nares, and pharynx, vagina, or uterus, as polypi, and they are then pedunculated. They may undergo chalky degeneration or may contain fat, cartilage, etc. Occasionally they are pigmented, as seen in mothers' marks and moles. Heredity has been no- ticed as a cause. They are of slow growth, and are some- times combined with sarcoma elements, and then take on a corresponding development. They are not painful ex- cept as a result of pressure. Congenital tumors develop most commonly on the face. Hair and sweat-glands may exist on their surface. Firm fibroid tumors may occur in all parts of the body. They are exceedingly hard, rounded or lobulated, tuberous growths. The cut surface is white or pinkish, and shows interlacing and circular fibres, the latter being found around the nerves and vessels (Billroth). Micro- scopic examination shows spindle cells. Thin-walled vessels permeate the tissue, allowing haemorrhage. Cystic cavities are not unusual. Sometimes vessels exist as a cavernous system. Fibroma of the uterus will not be here considered. Fibroids are most commonly found in connection with the bones, periosteum, and nerves. They may be single or multiple. When growing from bone they are often sarcomatous. When connected with nerves, the fila- ments of the latter are stretched over the tumor. In the prostate, fibroma occurs as a tumor within the gland. It has been observed as an irregular, lobulated, pedun- culated tumor of the tongue (Despres). When near a cavity it tends to become pedunculated. Naso-pharyn- geal fibromata occur in the young males by preference, and are found growing from the basilar process of the sphenoid bone. Fibromata grow slowly, and are painless unless they press on neighboring parts, and may attain great size. If near bones they cause displacement and absorption ; they develop from the thirtieth to the fiftieth year of age, and are rare in youth and infrequent after middle life. In youth, sarcoma elements are apt to appear, and the tumors are multiple rather than single ; the growth is central; fibro-neuroma is rarely single. Superficial ul- ceration may occur, or even gangrene, if the fibroma projects into a cavity. Calcification may occur as a re- trograde metamorphosis ; fibroma is usually incapsulated. It is a local growth, unless joined with sarcoma, when it takes on the behavior of the latter growth. Fatty Tumors.-Fatty tumors appear as outgrowths and as circumscribed masses-the fatty tumors proper, lipomata. The former are all ill-defined, non-incapsulated masses of the fat normally present in subcutaneous tissue, but here present in undue quantity. No good cause is known for such increase. They rarely appear before the fortieth year. The large, pendulous, double chin is an example of such a growth. They appear to accom- pany a general deposit of fat throughout the body. Lipoma occurs in the form of a well-defined collection of fat, having a distinct capsule, round or oval in shape, and divided by connective-tissue septa into lobes of greater or less size. Rarely it exists as a thin sheet " en nappe." An example of this kind was observed by me in which the growth, shaped like a thin placenta, encir- cled two-thirds of the arm. It projects in the direction of least pressure, and rarely causes an absorption of neighboring parts. If situated near a cavity it becomes pendulous and pedunculated, and the same is observed if the tumor adhere to the skin in its incipiency. There is scarcely a limit to the dimensions of a fatty tumor. Microscopically it resembles ordinary adipose tissue, the fat-vesicles being somewhat larger, however. On cooling, crystals of margarine become evident. The consistence will vary with the amount of connective tissue present: if there is much of the latter the growth is hard (stea- toma); if little, it is soft. Subcutaneous lipomata are usually soft; those more deeply situated are harder. These growths may appear wherever there is cellular tissue; invading localities, however, which are normally supplied with fat. The subcutaneous tissue of the trunk is the seat of election. While their occurrence on the ex- tremities is rare, Follin has noticed one on the finger, Liston one on the nose, and Nelaton one on the upper jaw ; one has been seen on the lower jaw by Jobert (de Lamballe), and one under the mucous membrane of the tongue by Langier. When situated upon the buttock (of the negro) they are very apt to become pendulous. Irri- tation and pressure seem capable of developing these growths ; they are not infrequent on the back of the neck where it is pressed upon by the band of the shirt; on the shoulder, where the sleeve joins the waist of the Tinder- garment ; on the right hip, as the result of pressure from the frequent carrying of a market-basket, etc. A sym- metrical disposition of lipomata on opposite sides of the body has been observed. Large tumors are usually sin- gle ; when multiple, they are small. If the tumor have attained any size, the skin over it is apt to be thickened. The septa already referred to as dividing the tumor into lobes are attached to the skin when the growth is situated in the subcutaneous tissue ; they can usually be 322 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tumors, Tumors, brought into view by grasping the mass of the tumor firmly so as to stretch the skin, after slapping or rubbing it with a rough towel, when the connective-tissue inser- tions will be lined in white. Another method is to render the skin tense and then move the tumor ; the skin will be drawn upon along the lines of the septa. By rubbing the lobules together a soft, indistinct crackling may sometimes be produced which, near the wrist, might be confounded with the rubbing of the rice-like bodies present in some ganglions. Lipomata are very movable, the firm ones less so than the soft; they have been known to change their position by force of gravity. One fell under my notice some time ago which, having first appeared near the mastoid process, was finally removed from over the clavicle. It was one inch in diameter, somewhat flat, very soft, and, of course, not adherent to the skin. Large veins are sometimes seen on the surface of the growth ; it is nourished by one or two arteries which enter its deep surface. The removal of a fatty tumor rarely gives rise to much bleeding. Telangiectatic tissue has been seen in some portion of a lipoma. Very soft tumors may present a quasi-translucent appearance. Unless a nerve be pressed upon, no pain is present. These growths may be congenital, in which case they do not increase after birth. They appear rarely in childhood or old age, more often in individuals from thirty to fifty years of age. Hereditary predisposition does not seem to be a probable factor in the causation. Growth is slow. Secondary changes are rare, the most frequent being cystic degeneration, probably from at- trition of the lobules, the contents of the cyst being oily. These growths are never infectious. Ulceration may take place, but such an occurrence should not inter- fere with a correct diagnosis. Nelaton has observed a rapid increase in the size of a lipoma after suppression of the menses. In a case referred to me for microscopic examination by Dr. H. P. C. Wilson, there was marked turgescence coincident with each menstrual period. After imperfect removal, the portion of the tumor re- maining will continue to grow. As a means of differ- entiating between cyst, soft cancer, and fatty tumor, Nelaton calls attention to the fact that, a needle being in- troduced into the growth, any attempt to circumduct the point will be resisted by the fibrous septa of a lipoma. Enchondroma.-Cartilaginous tumors occur as round- ish, nodular growths, with well-defined borders, incap- sulated in nearly all cases by a tough fibro-cellular mem- brane. They are hard and resisting, and an elastic recoil is noticed when they are compressed ; degenerative changes, cystic, calcareous, etc., may modify this pecu- liarity. The surface of an enchondroma is usually smooth or tabulated, and the size attained by the mass may be great ; in this case large subcutaneous veins are seen. These tumors rarely occur except in connection with the osseous system, of which they appear to be the special offspring. Occasionally, however, they grow in the mamma, testicle, or one of the salivary glands, and in one or two cases they have been found connected with the sheath of a tendon. Of bones, the phalanges of the fingers are most often affected ; more rarely, those of the foot ; the femur, pelvis, rib, and scapula with diminish- ing frequency. About the skull and face such tumors are very rare, but when they do occur in this situation the upper jaw is most often the seat of the disease. On the hand and foot the tumors may be multiple, else- where they are more often single. Enchondroma com- mences in youth before puberty. When found in adult life it is a periosteal growth. The ends of long bones near the epiphyses are particularly liable to be the seat of an enchondroma, and it is also apt to develop in the pelvis in the neighborhood of the pubic and sacro-iliac ar- ticulations. When the tumor occurs in bone, compact osseous tissue replaces the periosteum and enucleation is often easy. However near the ends of tang bones tumors may occur, the articular surfaces are unaffected. Epiphys- eal exostoses which commence as cartilaginous growths will be treated of in the next section. It is very un- usual to find the growths on the fingers almost trauslu- cent. Occurrence of the tumors in parent and child has been noticed. The determining cause may be an in- jury- Growth occurs concentrically ; in rare cases, secondary tumors appear around the primary local infection. These tumors are of slow growth and sometimes may remain stationary ; rapid increase suggests sarcoma. Calcification and true ossification are more frequent when the site of the tumor is the periosteum. Mucous softening is not uncommon, in which case fluctuation may be present. Ossification and growth may occur in different parts of the same tumor ; at the same time, ul- ceration from extreme tension of the skin may occur, and central softening with ulceration outward has been seen. Enchondroma causes injury by its size, position, and degenerations. It is so rarely infectious as to suggest enchondro-sarcoma in the cases reported. The health of the patient is usually good. Cartilaginous formations are common in combination with malignant growths, and in such companionship they sink into insignificance as compared with their associate. Enchondroma pushes neighboring tissues aside, and by friction a bursa is sometimes formed. Unless a nerve is pressed upon, pain is absent. Hydatids of bone have been mistaken for enchondroma. Cartilaginous tumors on section are bluish or yellowish white generally, but as vascular connective tissue is always present to a greater or less extent, so the color will vary greatly. Sometimes typical cartilage-cells are found on microscopic examina- tion ; at other times, stellate cells are seen embedded in a soft basement-substance, mucus-like in character. Osteoma.-Osseous tumors occur in two forms, the spongy and the eburnated, corresponding to the ordinary divisions of bone into compact and cancellated. Of these two forms the spongy is the most common. It occurs on long bones (tibia, fibula, humerus, and femur, especially), usually in relation with the epiphy- sis. It commences as an outgrowth of cartilage, ossifi- cation taking place pari passu with growth, a layer of cartilage covering the surface. Epiphyseal exostoses occur, of course, before the twenty-fourth year and cease growing with general ossification of the skeleton. Oste- oma spongiosum contains marrow, and, even when not upon an epiphysis, appears in youth. Osteoma eburnosum contains the usual Haversian sys- tem of blood-vessels, etc. It occurs on the skull, face, scapula, and flat bones generally, is usually of small size, and is seen prior to middle life. Osteomata are seen more often in males than in females; no good cause is assigned for their presence. A tendency to the production of osteomata has been observed, as the following example which fell under my notice will il- lustrate : W. H , eleven years of age. Is healthy and active, has had measles, but no other infantile diseases. Is the fifth of eight children, and none of the others is affected. Lungs and heart healthy. No history of rickets, syphilis, or scrofula. At age of four lumps about the knees were noticed. Osseous tumors were symmetrically situated, as follows : On the parietal bones, the spines of the scapulae, lower ends of radii and ulnae, both upper and lower extremities of tibiae and fibulae, and inner and outer aspects of the lower end of each femur. Except about the knee these exostoses were small ; here, however, they were as large as small apples. The motions of wrist, ankle, and knee were perfect. Osteomata are of slow growth, rarely attain large size, are painless, and cause inconvenience only by pressure on neighboring parts. Follin has seen gangrene of the foot from interference with the posterior tibial vessels ; Breschet, luxation of the lower jaw by a bony growth from the upper jaw. The shape is usually rounded, and the surface more or less smooth. The growths are, of course, hard and non-elastic. If they grow from the epi- physis they are pedunculated. They are multiple as often as single. If the surface-temperature is elevated, the tu- mor is sarcomatous. Inflammation followed by caries or necrosis is sometimes observed. When they are situated within the pelvis, parturition 323 Tumors. Tumors. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. may be interfered with. When commencing in the diploe of the skull, the tumor may project inward toward the brain, giving rise to cerebral symptoms. Ossification of muscles or tendons sometimes occurs and may cause partial or complete anchylosis of a joint. They have been formed in the structure of a muscle as a result of habitual pressure. Epiphyseal exostoses are often surmounted by a bursa, giving a sense of fluctua- tion ; such bursae almost always communicate with the adjacent joint, and practically, even if not anatomically, are pockets of the articular synovial membrane. The diagnosis of osteoma is often facilitated by the use of a fine exploring needle. Myxoma.-Myxoma is a tumor composed largely of mucous tissue. It is commonly joined with another form of tissue, as in myxoma fibrosum, myxoma cartilagino- sum, myxo-sarcoma. Uncombined with sarcoma it is a local growth, does not recur after extirpation, or give rise to general infec- tion. It occurs usually before middle life, rarely in early childhood, however, and may grow with moderate ra- pidity, exhibiting a tendency to approach the surface and to become pendulous if in the subcutaneous tissue. Great rapidity of increase suggests a combination with sarcoma. The most frequent seats of the tumor are the subcutaneous and intermuscular tissues, the labia, and the parotid gland. Of the osseous structures the upper jaw is commonly invaded; of glands, the mamma, testicle, and thyroid. The shape of myxoma is rounded, rarely lobulated ; it is of moderate size, translucent, and of a soft and gelatinous consistency. The possible combina- tion of myxoma with other growths must be kept in mind, as modifying the consistency. From tension the skin over the tumor may be reddened or show an arbo- rescent injection. The growth is generally incapsulated, but is sometimes diffuse, especially when located in the mamma or testicle ; it is usually single, except when oc- curring on the sheaths of nerves where multiple tumors have been observed. The neighboring lymphatics are unaffected. Angioma.-The term angioma is applied to a tumor composed almost entirely of vessels held together by a small amount of connective tissue. The simple division into capillary, arterial, and venous, suffices for clinical study. Lymph-angioma will be considered later. Popularly such tumors are known as naevus, mother's mark, or erectile tumor. They appear to result from the dilatation of vessels already in existence, coincident with which thinning of the vessel-walls is observed ; these phenomena have led observers to seek a cause in paraly- sis of the vaso-motor nerves. Porta 1 records a case fol- lowing injury. Capillary angioma appears as a discolor- ation of the skin, more or less red, but little if at all elevated above the surrounding surface. The color is bright scarlet or purple, depending upon the relative proportion of arterial and venous blood. Angioma be- gins almost always with dilatation of the capillaries, the veins or arteries being subsequently involved. Arterial angioma is, next to capillary, the most frequent, venous the most rare. Most of these growths are present at birth and, even if not noticed for some time, questioning usually elicits the fact that some discoloration of the skin had always been present. Inquiry should be made concerning this point more particularly in the case of deeper growths, for thereby the diagnosis is greatly facilitated. The female is more often affected than the male, Lebert and Porta giving sixty- two per cent, as the proportion of tumors requiring treat- ment. No cause can be assigned for the presence of the angiomata. They may remain stationary, grow, or dis- appear. Growth may be slow or fast, and may involve the skin only, or deeper structures, or both. The arterial variety is accompanied by enlargement of the afferent trunks and, later, by dilatation of the veins, probably pas- sive, until aneurism by anastomosis, in rare cases, may re- sult. Such dilatation of the afferent trunks is not present in venous angioma, which is made up of veins enlarged so as to form sacs filled with slowly moving blood. In ex- ceptional cases, from excessive enlargement of the ves- seis, absorption takes place and a so-called cavernous an gioma is formed. Disappearance of the growth may take place, and is effected as a result of inflammation, thrombosis, ulcera- tion, or, as in a few reported cases, of gangrene. Spon- taneous cure occurs most commonly, however, by a low grade of inflammatory action in the vessel-walls, leading to connective-tissue proliferation, contraction, and grad- ual obliteration of blood-channels. Cystic degeneration may occur from occlusion of vessels at certain points, the intervening channels, variously dilated, containing fluid more or less resembling blood, according as resorp- tion of the coloring matter has or has not taken place. Cysts so formed may increase to a certain size. A large proportion of naevi disappear in the early years of life. Naevus does not return after complete extirpation ; a portion of the growth not removed may, however, con- tinue to increase as if no operation had been attempted. General infection is not observed. The vast majority of erectile tumors occur in the skin and subjacent connec- tive tissue; next in frequency, the mucous membrane and submucous tissue are affected. The mucous mem- brane at the entrance of a natural cavity, as that of the lips, is especially prone to this diseased action. The head is the most frequent seat of the affection as compared with the rest of the body. Of 107 tumors of the head 18 oc- cupied the hairy scalp, 89 the face (Porta). When in the orbit they merit special attention, as will be referred to later. Pain is rarely present unless an important organ, as the eye, be involved. The surface of a naevus varies in color according to the blood circulating through its vessels as well as to its depth beneath the skin. Arterial tumors are more va- riable than venous ones-they may be progressive or may retrograde ; when large, they may pulsate and give rise to a blowing sound. Venous tumors are more stable, and usually congenital. Incomplete reduction may be ef- fected by pressure. The tension of a tumor may be affected by crying or other effort. Erectile tumors are sometimes incapsulated, and usually single, though the reverse has been observed by Cruveilhier. When deeply situated the diagnosis is difficult or impossible. In the area surrounding a tumor enlarged arteries or veins are sometimes seen ; the presence of the former usually indi- cates a growing tumor. Of internal organs, the liver appears to be more often affected than any other. It is a fact worthy of note that a growing angioma will, during an intercurrent disease, remain stationary, and even to a great extent disappear. Coincident with return to health renewal of growth in the blood-tumor is observed. Lymphatic angioma is very rare. It differs from or- dinary angioma in being composed of dilated lymphatics, the contained fluid being lymph, It is seldom, if ever, seen as a well-defined tumor, but occurs as a diffused swelling in connection with elephantiasis. Adenoma.-This term is applied to tuberous new for- mations in which the glandular tissue is the chief ele- ment. Simple hypertrophy of a gland, such as is seen some- times without known cause in the female breast, and which consists in an increase or enlargement of cells, is not included in this term ; neither is the increase of one organ in order to compensate for the atrophy or destruc- tion of its fellow, as, for example, the kidney. Microscopically, adenoma resembles the glandular tis- sue, of which it is the outgrowth. Pure adenoma is com- paratively rare, there being generally present increase of connective tissue, with a clinical history of sarcoma. These tumors begin as excrescences from, or sometimes in the immediate neighborhood of, but rarely within, a parent gland. Neither sex is specially affected. Adenoma occurs in early rather than in late years, and is rare after the age of forty-five. The breast is apt to be affected in women between the ages of twenty and thirty years, and in males from puberty to thirty years of age the naso- pharyngeal mucous membrane is more commonly the seat of this form of new-growtb. 324 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tn mors. Tumors, In the breast imperfect lactation or traumatism is often held to be the determining cause, but this is more than doubtful; for the origin of these tumors in other situa- tions no cause is known. The tumor is usually noticed for the first time acci- dentally, or the patient may not have been aware of its presence until so informed by the surgeon. Growth is slow and painless, unless in the vicinity of sensitive parts. For years, or even permanently, there may be no in- crease, and spontaneous decrease in size has been ob- served. Rapid increase without inflammation indicates sarcom- atous growth, and calls for appropriate treatment. Fatty, mucous, and especially colloid degeneration, is common. Cysts are of very frequent occurrence, and unless deeply situated can usually be recognized. Haem- orrhage may take place into the cyst as a result of vio- lence. On section the tumor is grayish pink or gray, streaked more or less with blood-vessels. A mottled appearance, with haemorrhagic spots, is seen only when great connec- tive-tissue increase is present. Adenoma is benign, does not return after extirpation, does not affect the neigh- boring lymphatics, nor reproduce itself in distant parts of the body. There is often a tendency to assume the nature of carcinoma or sarcoma, in which case the re- spective characteristics of these growths are added to and supplant those of the original tumor. The mamma, parotid and thyroid glands, and the mucous membranes are the more common seats of these tumors. The surface of the tumor is geherally smooth and lobed ; its substance is elastic to the touch and resil- ient if cystic fluctuation is present; it is incapsulated, and movable upon surrounding parts. Adenoma is sin- gle rather than multiple. The neighboring parts are simply pushed aside and do not become involved in the new-growth. Adenoma, while resembling normal gland tissue, never performs the functions of glands. An increase of size, however, may be observed at the menstrual period when the tumor exists in connection with the mamma, or during mastication if it is connected with the parotid gland. Pain suggests rapid growth ; in other words, degenera- tion. When near a cavity, adenoma becomes pedunculated and is almost always oedematous. Adenomata vary according to locality; this subject will be referred to again. Neuroma.-Neuroma is a tumor growing from a nerve. Microscopically it consists of connective tissue and nerve-elements in varying proportion. A division is usually made into : 1, Tumors in which the white sub- stance of Schwann is present ; 2, tumors in which the white substance of Schwann is not present. Such a classification is, however, needless clinically, where it is well to consider the growth as a fibroma involving more or less the nerve-fibres. These tumors are most common in middle life between the ages of thirty and fifty years ; males are more often affected than females, in the pro- portion of 26 to 19 (Paget). Traumatism has been as- signed as a cause in some cases, but ordinarily no cause can be assigned. It is sometimes congenital ; growth is very slow, but the spontaneous disappearance of a neu- roma is almost unknown. In common with other fi- bromata, cystic degeneration is observed, the contained fluid being usually serous and colored by a varying admixture of blood. Sarcomatous degeneration is like- wise observed and is to be suspected when rapid increase in size has occurred. Local recurrence after removal raises a like suspicion. Neighboring parts are displaced, not invaded, by the growth ; adhesions are very excep- tional, the neighboring glands are not enlarged, and local or general infection is not observed. The skin is mova- ble over the growth. Neuroma occurs usually as a sin- gle tumor, but may be multiple. R. W. Smith records a case in which as many as two thousand were counted on one patient, and Follin saw an "incalculable num- ber ; " more pain is apt to be experienced when there is only one growth than when there are several. The spinal nerves are the favorite seat, next the sympathetic system, most rarely the cranial nerves. It is scarcely necessary to call attention to the fact that a neuroma, if situated over the known course of a nerve, is movable across its long axis, and is more or less fixed by whatever tends to stretch and render tense the nervous cord. The shape is round or oval, the surface is smooth, and the tumor is well defined and of small size ; large tumors have been observed in exceptional cases only. On section the color is white, and a well-defined capsule is found. Sensory disturbances are the most prominent symptoms, and may be of various sorts, such as numbness, formication, shoot- ing or tearing pains, etc. The pain may be paroxysmal or continuous, may come on suddenly or gradually, may appear idiopathically or require an exciting cause, may cause trifling inconvenience or render life a miserable burden. Pain may be so severe as to induce epilepti- form convulsions. Complete freedom from discomfort between the paroxysms is observed. The older the neu- roma the more severe the pain. During a paroxysm, swelling of the tumor has been observed. Pressure on a nerve-trunk above the tumor may arrest an attack. Pain is referred generally to the peripheral parts sup- plied by the affected nerve-trunks ; this is especially the case after an amputation. The parts supplied by the affected nerve may be cold, badly nourished, etc. Re- flex symptoms, such as are seen after injuries of nerves, have been observed. Changes in the weather may in- duce pain. Commencing aneurism has been mistaken for neuroma, as have also other tumors pressing on nerve- trunks. Follin describes a condition occurring in males of mid- dle age characterized by the presence of many neuro- mata. In this affection the general symptoms domi- nate the local; various functional disturbances appear, followed by a state of marasmus and death. The dura- tion of the disease is about six months. The diagnosis is difficult until the tumors can be felt along the course of the superficial nerves. There are two forms of neuroma occurring near the skin, viz., subcutaneous painful tubercle and plexiform neuroma. The former is more frequent in women, and is seen as a tubercle not larger than a pea in the subcuta- neous connective tissue ; it is always solitary and is very painful. The plexiform neuroma is always subcutane- ous and presents the appearance of a fibrous net-work with irregular swellings. Depaul observed one example on the neck of a child, Verneuil another on the prepuce, accompanied by an intense local neuralgia. Lymphoma.-Tumors to which the above term is ap- plied resemble, microscopically, lymphatic glands, to which connective tissue is added in varying quantities. They are most common in youth, very rarely appearing after the twentieth year, and, when not induced by inflam- matory lymph transmitted through the lymphatics, are considered, usually, to be exponents of struma. Bad ventilation and nutrition are predisposing causes. The mulatto is more subject to these growths than is either the white man or the negro. In shape they are oval or round, smooth, firm, elastic, incapsulated, and movable in the surrounding tissues at first, though later they may form adhesions. They grow from the lymphatic glands, and are therefore found where such glands usually exist. In the neck they are most common ; then they occur in the axillary, inguinal, ab- dominal, and bronchial regions with diminishing fre- quency. They are more often multiple than single, and, when removing an apparently solitary one, the surgeon will frequently bring into view a number of small tu- mors whose increase is only a matter of time. Growth is slow and, a certain size being attained, the tumors may remain indolent for years, when either suppura- tion or absorption, with gradual disappearance, may oc- cur. Rapid growth and invasion of neighboring parts, with enlargement of the spleen, excess of white ele- ments in the blood, and marasmus, are occasionally ob- served. To such growths the term lympho-sarcoma is ap- plied, although the microscope may not distinguish them 325 Tumors. Tumors. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. from the more benign form. Large size is not often at- tained, yet, when the growths are numerous, serious, and even fatal, effects may result from their presence. When inflammation and suppuration occur, the his- tory changes to that of chronic abscess. Leucocythfemia to a slight degree is present in many cases, enlargement of the spleen only in the more severe, and death may occur without this latter complication being present. Lymphomata are found in the intestines and other in- ternal organs, but need not require the attention of the surgeon. The growth of a lymphoma in the small bowel has been known to induce intussusception. Chronic enlarge- ment of the tonsils resembles lymphoma from irritation, and usually results from chronic inflammation of the pharynx. Sarcoma.-About no class of tumor has more knowl- edge been gained during the past few years than about sarcoma, and yet with equal truth it may be said that of no class of tumor is there so much yet to be learned. The pathological histology of sarcoma is being most thoroughly investigated, but the knowledge of the symp- toms of the various forms of cell-growth is in a com- paratively embryonic state. The question of recurrence, especially with change in the minute anatomy of the sec- ondary formations, is for the present, at least, unsettled, yet it is one which, in view of its importance and singular characteristics, it behooves us most earnestly to study. A sarcoma is a tumor of the connective tissue, in which the anatomical elements, while capable of nu- merical increase, do not go on to complete tissue for- mation, but retain their embryonic characteristics to a greater or less extent. Microscopically such a growth is seen to consist of a basement-substance, cells, and blood-vessels. Sarcomata are named according to the character, num- ber, and arrangements of the cellular elements. Thus, they are termed the small-celled, the spindle-celled, the oval-celled, the giant-celled or myeloid, and the stellate- celled. While such a classification is accepted and used as the best available, it must be remembered that rarely, if ever, does a sarcoma consist of cells of one type, but that different parts of the neoplasm present elements differing from each other in form, and probably also in mode of growth and propagation. It can easily be understood how, in the growth of a be- nign tumor, failure of the bioplasm to reach adult life and form tissue at any point will leave that portion of the tumor in an embryonic condition, i.e., sarcomatous ; and this is very common. Such growths are spoken of as osteo-sarcoma, chondro-sarcoma, taking their names from the tissues with which the sarcoma is associated rather than from the specific form of the bioplasm elements. Sarcoma is a growth preferably of the first half of life, differing thereby markedly from carcinoma, ■which is an affection of middle life and later years. Up to the age of ten years examples of this affection are not very frequent; thence to the fortieth year it is comparatively common ; rarely is it seen in old age. The two sexes are about equally liable. The influence of heredity is not yet determined. So far, testimony in the affirmative does not seem to preponderate. Strong, vigorous, other- wise healthy individuals are more liable to be affected than the weak and feeble. Local irritation by blows or otherwise is generally invoked as determining cause, ap- parently with good reason in many instances. The follow- ing case is an example in point: M. L , aged fifteen, fell, striking the right shin against the curb-stone ; a swelling at once appeared ; this tumefaction never dis- appeared. Three months after the injury slow growth was noticed ; three years later, rapid increase. The tumor measured twenty-four inches in circumference when I amputated the limb, four years after the original injury. The sarcoma originated in the periosteum, oval cells predominating. There was no family history of tumor. Cicatrices are sometimes the site of this growth. There is no tumor, however innocent, that may not have engrafted upon it a sarcoma with malignant character- istics. In considering the mode of invasion, a distinc- tion must be made between primary and secondary growths, since the previous treatment and manner of re- currence offer valuable suggestions. Constitutional treatment by means of the iodides will clear up the diagnosis where syphilis is suspected ; while a recurrent tumor in the neighborhood of the scar of a previous operation assists in the diagnosis of sarcoma. Carcinoma, it may be observed, usually recurs in the cicatrix of a former operation. The rate of growth varies greatly ; it may be slow or fast, or, after a period of torpidity, exceedingly rapid increase maybe observed. Practically it may be said that the reverse of this never occurs, and, indeed, from the absence of stroma, theoreti- cally it would seem impossible. Here, again, the com- parison made with carcinoma is suggestive. The soft varieties of sarcoma, i.e., round-celled, grow more rapidly than their harder brethren the spindle-celled ; to this, however, there are exceptions, as when a growth, having been sequestrated by surrounding parts, finally pierces the obstruction and grows in unrestrained luxuriance. Sudden increase in size may take place from extravasa- tion of blood within the neoplasm. Involvement of the skin and surface-ulceration result in the natural course of the tumor-growth, and maybe the occasion of profuse haemorrhage. In the softer forms these ulcerations give occasion to protrusion of substance, fungus, while the firmer varieties, under like circumstances, will develop good granulations with eversion of the cutaneous edges. Ulceration from within outward is rare, being more apt to occur in cysto-sarcoma with intra-cystic growths. The most strikingly malignant as well as very benign tumors are found in this class of growths. Extirpation may cure, or general infection may cause death in a few months after the first appearance of the tumor. The local recurrence of sarcoma has been already referred to ; namely, that it returns near, rather than in, the cicatrix of a previous operation. Very rarely are the neighbor- ing lymphatic glands enlarged, unless by intercurrent inflammation ; general infection appears to take place through the medium of the veins, and secondary growths occur therefore in the lungs by preference. No opinion can be expressed as to how soon local return or general infection may be expected ; in most cases, suffice it to say that soft growths justify a more unfavorable prognosis than firm ones. Of degenerative changes, softening in various forms, colloid, mucoid, and cystic, is most common ; cicatricial shrinkage probably never occurs. The influence on the organism depends largely on the organ affected. Pain is exceptional ; an investing cap- sule is usually present, especially in the firm varieties. Diffuse sarcoma has been observed in the mamma and testicle more often than elsewhere. As sarcoma is a connective-tissue formation, it may be looked for in the derivatives of the middle germinal layer of the embryo, though it may be found arising from con- nective tissue wherever present. The fasciae of the ex- tremities and the intermuscular connective tissue, to- gether with the osseous system, are especially favored by these growths. The ends of long bones, like the tibia and humerus, are often affected, and the sheaths of nerves not rarely. Of glands the mamma is the most often involved. The character of the tumor bears relation to the soil from which it springs. Myeloid tumors arise from the ends of the long bones and from the lower jaw, spindle- celled from fascia and sheaths of nerves, but there are many exceptions to this. Periosteal growths are more or less surrounded by bone, whatever their size. New formation of gland-elements is usual in adeno-sarcoma. Sarcomata of special regions will be more fully referred to later. In shape these tumors are rounded or lobular, usually sharply bounded ; if they are near the skin, cutaneous discoloration from injection may be present. The con- sistence varies greatly according as an osseous, medul- lary, or cysto-sarcoma is under observation. In vascular sarcomata, change in consistence is noticed according to 326 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tumors. Tumors. patient's recent movements ; thus rest for a night after exercise, a railway journey, etc., will always cause a cer- tain shrinkage and consequent hardening. Clinically this sign has stood me in good stead on more than one occasion. Sarcomata may attain great size, especially when oc- curring on the extremities, or secondarily, in the chest. The surface-temperature of osteoid and soft growths is above normal. Translucency is present to a greater or less degree in cystic and colloid degeneration. Melan- otic growths justify an especially bad prognosis. Sar- comata are movable unless attached to bone, the harder varieties especially so, whether in or with neighboring parts will depend upon their anatomical site. As vessels always exist, various degrees of vascularity may be pres- ent (S. telangiectodes) ; growths commencing in the me- dullary portion of the bones often pulsate-the so-called aneurism of bone. Sarcomata usually begin as single growths. Epithelial Carcinoma or Epithelioma.-Epithe- lioma usually commences in the neighborhood of one of the natural openings of the body, mouth, nose, anus, and usually on the mucous rather than the cutaneous surface ; if upon the skin, a sweat-gland may be the start- ing-point. A scab is often first noticed, which may be picked off only to form again upon a surface almost nor- mal, and the patient is somewhat surprised that it reforms at all ; after a variable time the surface beneath the scab is found to be moist and, the scab ceasing to form, a chronic ulcer remains. Away from a muco-cutaneous border a papilloma is apt to be a starting-point for epithelioma, the surface be- coming more and more fissured and cracked, then a little blood will occasionally ooze, and finally the papilloma is replaced by an ulceration, the appearance presented re- sembling thqt noticed after scabbing. In both cases the cause can usually be directly traced to some frequently recurring irritation, the elements of the growth resembling the surface from which they pri- marily originate, pavement epithelium characterizing those about the lip, columnar those about the rectum and anus. The denuded surface slowly extends superficially as well as deeply, becomes indurated, and the secretion ac- quires the odor met with in open carcinoma generally. By this time the induration has extended far beyond the ulcerated area, and neighboring tissues and organs are matted together. Ulceration is progressive and contin- uous, death taking place in uncomplicated cases by grad- ual wasting. Complications, however, are many, the growth often interfering with normal functions-swal- lowing, for instance, when the tongue is the seat of dis- ease ; a large blood-vessel may be opened by ulceration, or septic pneumonia may follow implication of the air- passages, etc. Epithelioma, in common with other carcinomata, is generalized by wny of the lymphatic channels, hence the glands receiving lymph from the diseased area become early infected ; just how soon this may be expected is uncertain, but no diagnosis, much less prognosis, is com- plete without the knowledge derived from an investiga- tion of these structures. Epithelioma is met with late in life, the cervix uteri and the mouth being the chosen lo- calities in the female and male respectively. Secondary ulcerations spring from infected lymphatics. Sensibility is not changed in the early stage of the growth ; when, however, the infiltrated area is great and ulceration ex- tensive, great pain is experienced. About the mouth tertiary syphilitic lesions may simulate epithelioma, and more than once I have seen epithelioma engrafted, as it were, on a syphilitic scar. Glandular Carcinoma.-Carcinoma is at present be- lieved by most observers to arise from the germinal layer producing epithelium ; hence it is not to be expected as a primary tumor in bone, muscle, etc., the derivatives of another layer. Any portion of the body may, however, be involved in a growing carcinoma, so that the recogni- tion of the starting-point of the primary tumor becomes of great importance. Carcinoma is but little, if at all, painful in its incipiency, unless sensory nerves should be involved, and it is not at all unusual for the presence of the growth to be discovered by accident. Not infre- quently I have been consulted by women on the subject of mammary carcinoma associated with involvement of the corresponding axillary or supra-clavicular glands, who had discovered merely by chance that they were the subject of tumor formation. Later in the life of the tu- mor, pain becomes a most distressing factor, variously described as shooting, darting, or boring. The harder varieties of carcinoma are more painful than the softer ; indeed, a decided clinical distinction in many ways exists between them. Females are more often affected than males, and the mamma is the organ most frequently in- volved. Hard carcinoma-scirrhus-does not attain great bulk, and may diminish in size, hence th*e term, atrophic, is occasionally proper. Soft carcinoma may attain large size, not, however, attaining the bulk of certain sar- comata. The surface is irregularly bossed or knobbed, varying much, but not smooth and uniform ; cysts from obstruc- tion of normal canals may be recognized in some part of the tumor. Adhesion to the skin may occur early, and is common in scirrhus. Here the color of the skin is not at once changed, but if any alteration is present it will be lighter than normal ; later, the skin may redden. Softer forms than scirrhus are sometimes accompanied by hyperaemia of the skin, giving rise to a distinct pink flush w'hich fades under pressure of the finger. Rapid growth is indicated by such a condition. A brawny state of the skin over a carcinoma, without change of color, results from lymphatic engorgement, and justifies a most unfavorable prognosis. The pre- sence of small nodules, like grains of shot, in the skin in the vicinity of a large growth, indicates a large area of infiltration, and may contra-indicate operative measures. Brawniness commences as a faint parchment induration in the deep layer of the skin, with ill-defined edges, and does not retrogress ; carcinoma en cuirasse is an ad- vanced stage of this condition. Scirrhus may be of stony hardness, encephaloid the reverse, and many intermediate grades between these extremes exist ; the first class impress the examining hand as being very heavy, not so the latter. As in- volvement of neighboring structures is one of the most marked characteristics of carcinoma, mobility of the tumor will vary with the anatomy of the part of the body affected. The growth can be moved with ease upon or among adjacent parts, and rendering adjacent parts tense, will immobilize the growth ; mobility is to be sought for in the direction of the length of, not across, neighboring vessels, nerves, muscles, etc. Mobility is to be also sought for by attempting to raise the tumor from its bed. Implication of lymph-channels occurs sooner or later, and is indicated not only by skin infiltration already men- tioned, but also, and with far greater frequency, by car- cinomatous infiltration of the glands receiving lymph from the diseased area. The glands are thus trans- formed into tumors similar to the primary one. The lymphatic glands, in relation with the new-growth, are to be always carefully examined, and if it should appear that a few only are affected, and these capable of being removed with the parent tumor, an operation may be undertaken ; but, on the other hand, when the glandular infection has extended so widely that not all the second- ary tumors can be removed, an operation is inexpedient, since pain and inconvenience only will result, and the progress of the malady will not be materially interfered with. In stout persons glands but moderately enlarged may sometimes not be felt through the skin; this is notably the case in the axilla. Carcinoma occurs -with decidedly greater frequency in persons over forty years of age. The question of hereditary transmission of carcinoma has been much discussed. While carcinoma may not be transmitted as such, yet, as peculiarities of tissue are transmitted from parent to child, it would be expected that similar peculiarities of nutrition or degeneration, 327 Tumors. Tumors, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. or similar tumor formation, might occur. Broca's well- known instances are very convincing. Carcinoma and tuberculosis frequently have been noted in companion- ship. Injury has been followed by carcinoma sufficiently often to be accepted as a determining cause ; and the same may be said of a not very intense, but habitual, ir- ritation. In the mamma the induration remaining from previous abscess has been considered a cause of malig- nant disease. I have been unable to verify this assertion from recorded observations. The rate of growth in carcinoma varies greatly, the tumor sometimes destroying life in a few months, some- times lasting for years. When the tumor is located in one of the internal organs, the growth is progressive and not slow; when upon the surface, as in atrophic mam- mary carcinoma* superficial ulceration and cicatrization of the skin may alternate in different parts of the growth for years. It may be stated generally that the harder the tumor the slower the progress, and the softer the tumor the more rapid is the advance. Ulceration on the cutane- ous surface may occur as a deep excavation, with hard, irregular sides, the edges being involved with the tumor, thickened, and everted, the discharge being ill-smelling and profuse, usually somewhat bloody; such an ulcer does not heal. A superficial form of ulceration is met with, commencing as a crack in thinned, infiltrated, and discolored skin ; it extends as a hard, pink, raw area, not at all, or but little, depressed below the adjacent surface ; the discharge is scanty, and healing may take place, re- sulting in a tender, thin cicatrix, showing the blood- vessels. The cancerous cachexia of older writers may be taken as an indication of metastatic growths and gen- eral carcinosis. Carcinoma exhibits very markedly the tendency to recur in situ after removal by operation, due to the fact that tissue in the vicinity of the primary growth is infiltrated with carcinoma cells ; unless the infiltrated area is re- moved with the original tumor, return of the growth is certain ; and the necessity for free extirpation is there- fore apparent. Cysts are observed in association with carcinoma, and may be the result of occlusion of a natural channel by the new growth, or of degeneration of the new growth itself. Rupture of a vessel and extravasation of blood is rare. Diagnosis of Tumors.-Three elements enter always into the diagnosis of a tumor : 1. The history of the patient prior to coming under ob- servation. 2. The condition of the patient when under observa- tion. 3. The intellectual work on the part of the sufgeon by which, from these two, an opinion is deduced. 1. History of the Patient-Hereditary Predisposition.- Much attention has been given to heredity in the study of growths, yet there are other matters of so much greater importance from a diagnostic stand-point, that brief reference only is here needed. There seems to be little doubt of the fact that, as the stature, features, col- oring, etc., of the child resemble the parent, so may the various tissues equally resemble and equally be subject to a similar form of hypertrophy or degeneration. Es- pecially does this appear to be the case with carcinomata. Sarcomata are of too recent recognition to permit of the expression of an opinion, yet there seems to be no rea- son why an exception should be made in their favor. Certain of the simple tissue-tumors, enchondroma, oste- oma, etc., have been observed in children whose parents were similarly affected. Age.-Age has a most important bearing on the sub- ject in hand, since, as the different tissues grow with varied rapidity at different periods of life, so is there a tendency found to the development of tumors similar histologically to the tissue whose period of most rapid increase it is. Sarcoma is seen rather in early life, car- cinoma in middle and advanced life. Enchondroma and osteoma are found when the growth of the skeleton is most active ; lipoma at the time when subcutaneous fat is deposited ; dermoid cysts and certain adenomata at .the time of puberty. Certain tumors, found at or shortly after birth, are termed congenital, and correspond generally to defective development during foetal life. They are found by preference in the line of bone suture ; these are enceph- alocele and spina bifida. Angiomata are often congeni- tal. Race.-It may be well to note the fact that negroes are more liable than whites to scrofulous adenitis, while epi- thelioma is exceedingly rare among them. Fibroma of the uterus and lobe of the ear is common among negroes, while keloid transformations of old scars is not unusual. (See paper by author in " Trans, of Amer. Surg. Soc.") Occupation.-The persistent use of any part of the body in the pursuit of an occupation may be followed by a charactistic tumor-for example, house-maids' knee, and the papilla of the plasterer. Determining cause.-Continuous irritation, as men- tioned in the last section, may be followed by a tumor, and any growth is generally referred by the patient or friends to some known injury. Careful interrogation will, however, in the majority of cases, show that this opinion is unfounded. The following example illus- trates how a single blow may be followed by unfortunate results ; Mrs. * received a violent blow in the mamma from the handle of a parasol. Within five minutes she was seen by Dr. C. Johnston ; the breast was bruised, but contained no tumor. In the course of some months a tumor formed deep in the gland at the seat of the in- jury, and was removed by Dr. Johnston. Recurrence of the growth took place, and it was again removed. The tumor returned once more, and the patient died of general carcinosis. Microscopical examination of the growth showed a schirrous carcinoma. As the breast was carefully examined at the time the blow was received and no tumor found, I am forced to conclude that the carcinoma resulted from the blow of the parasol handle. Any continuous irritation may be followed by a simple tumor, as mentioned in the previous section, while the occurrence of an epithelioma of the mouth, in some part which is habitually in relation with a broken tooth or other rough surface, as the stem of a pipe, is very fre- quently seen. Diagnostic signs drawn from the history of the tumor itself.-The commencement, course, duration, evolution of symptoms, and result of previous treatment of any growth, must all be taken into consideration. The simple tissue-tumors are of the slowest growth, and may remain for years without causing inconven- ience ; they may slowly attain great size. The most rap- idly growing tumors are the sarcomata. They may ap- pear with almost the rapidity of an abscess, and in such a case are soft, and give to the hand a sensation of fluctua- tion (false fluctuation). Intermediate between these ex- tremes are the carcinomata. In still another class of cases, a tumor which has ex- isted for years begins suddenly to increase ; a sarcoma- tous life has become engrafted upon a previous benign existence. The size which may have been attained prior to ulcera- tion is to be taken into consideration. The sarcomata may be of large size before ulceration takes place, but in the carcinomata this occurs earlier and while they are still comparatively small. Benign growths ulcerate only in consequence of some local accident, as position, attri- tion, etc. The evolution of the symptoms throws great light on the histology of a tumor, but unfortunately the source of information-the patient and friends-is not always such that the data given can be regarded as thoroughly reliable. Thus a tumor in the groin, which at one time had had distinct pulsation, would lead to a suspicion of aneurism, while the subjective sensation of pulsation would rather suggest abscess. Again, pain in the back, weakness, and distaste for exercise, followed by a lump * Personal communication to author. 328 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tumors. Tumors, in the groin, would lead the surgeon to suspect caries of the vertebrae rather than a tumor of new formation. In doubtful cases great assistance in forming a correct diagnosis may be rendered by a knowledge of the result of previous treatment. If a soft, rapidly increasing tumor, after a week's poulticing, is freely opened, and only blood issues, the diagnosis may easily be made. A testicle enlarges rapidly, but resumes its size under large doses of iodide of potassium ; again the diagnosis is made by treatment alone. A patient suffers from an enlargement in the scrotum, a trocar is introduced, serum flows, the patient is re- lieved, and a diagnosis made without trouble. 2. The Patient under Observation.-Morbid phenomena actually existing when the patient is seen are of two kinds : A. Physiological, Functional, or Subjective. B. Anatomical, or Objective. A. Functional Disturbances.-The symptoms falling under the head of general surgery need not be here dis- cussed, yet few tumors, when of any size, are unaccom- panied by distinct changes in certain bodily functions. Circulation.-Vascular change offers valuable sugges- tions in tumors of the neck, axilla, and groin, and is to be sought for at some point removed from the growth ; oedema indicates interference with return of blood to the heart, from involvement of, or pressure on, the venous channels. Feebleness or extinction of pulse points to like arterial implication. Capillary engorgement, espe- cially about the face, is one of the earliest signs of press- ure on the jugulars, either internal or external, and, taken in connection with the size of the tumor, aids the sur- geon in diagnosticating its deep or superficial origin. Respiratory System.-Pressure on the trachea, either lateral or substernal, may interfere with breathing, while implication of the laryngeal nerves may cause change in the tones of the voice, or even aphonia. In the latter case laryngoscopic examination will be required. Digestive System.-The extremities of the alimentary canal are often the seat of new formations. Difficult mastication results either from the presence of a tumor of large size, or from a small extension of one behind the ramus of the jaw. Occlusion of the parotid duct from pressure causes dryness of one side of the mouth, and the patient habitually masticates on the other. Inflamma- tory affections interfere with mastication by reason of the pain which the act excites, rather than by the pro- duction of actual inability. Regurgitation of food with but little effort, immedi- ately after swallowing, should direct attention to the oesophagus. Constipation caused by the presence of a tumor is gradual in its development, and usually passes unnoticed until frequent and bloody stools appear, when the patient will remember that previously constipation existed. The diarrhoea and bloody stools indicate almost certainly degeneration of the growth, and considered in connection with the length of time that the malady has been present, will be of assistance to the surgeon in de- ciding between carcinoma and other growths, ulceration occurring more rapidly in carcinoma. Incontinence of faeces occurs more often as a result of nerve disease than of new-growths. The character of the discharges, puru- lent, bloody, like a pipe-stem or ribbon, and finally com- plete rectal obstruction, are all to be noted. Pain is very commonly present in rectal diseases, and will be referred to later. Nervous System.-Motor disturbances to the extent of complete paralysis are exceedingly rare, as is also loss of sensation to the same degree. Pain, on the other hand, is comparatively frequent, and is rarely absent, in rapidly growing tumors, while in those of slow growth it is not so often met with. It may be felt in the tumor, or re- ferred to the peripheral distribution of the nerve impli- cated, as is seen so often in neuromas of stumps. It may be intermittent or continuous, idiopathic or felt when the growth is handled only, and is characterized by such terms as shooting, boring, etc. The lancinating pain of carcinoma is well known, as is also the pulsating pain of an acute abscess. In sarcoma occurring near an articulation, the patient defines the pain early in the disease as dull, but later as bursting ; tins I have noticed in several instances. Functional disturbance of a nerve related to a rapidly growing tumor, implies implication in the growth ; of one related to a slowly increasing tumor, may imply pressure only. Sudden cessation of acute pain might suggest circumscribed suppuration. Noctur- nal pains are suggestive of syphilis. A distinction should always be drawn between move- ments which cannot be executed, and those which are not executed owing to pain. Motion in the course of a long bone indicates solution of continuity from intersti- tial new formation. Examination of the Tumor itself. Shape.-In general, tumors tend to assume a more or less spherical shape, and the more rapid their growth the less easily are their limits defined ; as increase takes place in the direction of least pressure, so their form is modified by surrounding parts. Bones, bands of fascia, muscles, all may produce fission and lobulation. The lobulated form of lipoma is ■well known. Tumors projecting into cavities are usually pedunculated if they grow from the soft tissues, but when they originate in the osseous boundaries of a cavity pedunculation is far more rare. The size of a tumor is to be considered in connection with its age and the condition of its surface, whether ulcerated or not. Benign growths increase slowly, and are inconvenient from their ■weight or by producing deformity ; should ulceration be present, it is the result of irritation. Cer- tain pendulous growths, such as a fatty tumor of the buttock, may ulcerate at the most dependent portion simply from congestion caused by position. Of malignant neoplasms the sarcomata grow with the greatest rapidity, and may attain a large size prior to the occurrence of ulceration. Carcinomata, on the other hand, growr more slowly, and may ulcerate when they are still of moderate size, as is so often seen in the female breast. Epithelioma usually commences with ulceration. Malignant growths involve the skin, which gives way, producing a ragged ulcer with raised edges ; benign growths cause ulceration of the skin by pressure, with- out involvement, the resulting sore having thin, dis- colored, and undermined edges. The pendulous fatty tumor of the buttock is an exception to this rule, but in such cases a consideration of the previous history w'ill prevent error. Rapid change of shape without decrease in size should excite suspicion of malignancy ; the sudden occurrence of outgrowths more or less spherical is rarely seen ex- cept in rapidly growing sarcomata, or cystic formations. The existence of oedema will suggest inflammation. Color.-The skin covering a tumor may be quite white from cicatricial contraction or oedema ; bright red, in impending ulceration, as in acute abscess; black, in cases of gangrene and melanotic tumors. Again, the tu- mor may lie so close to the skin that its proper color will show through, as seen in angiomata and very vascular sarcomata. In certain cavities, such as the nose, mouth, rectum, etc., tumors are subject to direct observation. Temperature.-Inflammatory troubles are always, of course, accompanied by elevation of temperature, but cer- tain new formations also exhibit the same phenomenon ; thus, in osteo-sarcoma, there is present an increased tem- perature to the extent of from 1° to 2° C., as compared with the corresponding (unaffected) region on the oppo- site side of the body. Further observation may show, and it is not unlikely, that all rapidly growing tumors are accompanied by elevation of temperature. Translucency.-Translucency bears direct relation to the walls of the tumor, its contents, and its color. Thin- walled cysts with limpid contents, as hydrocele, transmit light freely, and all gradations exist from that to abso- lute opacity. To examine the translucency of a tumor it must project from the body, so that light may be applied on one side and the eye of the observer on the other. The method of procedure which I adopt is as follows : A Fergusson speculum, at the free end of which is held a lamp or candle, is placed against the tumor, and at the 329 Tumors. Tumors. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. opposite side of the growth is placed another speculum through which the surgeon looks ; if now a black cloth be spread over the tumor so as to cover it, except w'here in contact with the specula, the amount of translucency present may be well appreciated. The coverings of a tumor should be tightly stretched when translucency is sought for. Certain solid growths, such as lipoma and myxoma, occasionally allow the pas- sage of light. In the negro opacity is the rule, owing to the pig- mented epidermis, but even here most hydroceles trans- mit an appreciable quantity of light. Consistence.-Probably no sense is so important to the surgeon as that of touch ; properly educated, it is a magi- cian's wand, so often does it reveal the obscure; it is necessary only to cite the hand of the blind to indicate the perfection which may, and should, be attained by one anxious to gain surgical success. To judge of the consistence of a growth both hands should be used, applied on opposite sides if possible, as far asunder as the size of the tumor will admit; after this the various points of the surface may be explored with the fingers. It is a good general rule to estimate a tumor's consistence with as many fingers at a time as may be applied to its surface. The bony and calcified tumors will be found to be very hard and inelastic ; the cartilaginous as hard, but with a certain resiliency ; then the fibromas and scirrhous tu- mors, less hard, etc. Variations will be often found in different parts of the same growth. Fluctuation, when frank, indicates a cyst with fluid contents, whether of primary or secondary formation ; but rapidly growing, soft, vascular tumors give to the fingers a sensation so nearly identical as to be worthily called false fluctuation. True fluctuation can be ap- preciated in all directions, but this is not the case with false fluctuation ; true fluctuation is better ap- preciated when the adjacent parts are relaxed; the false, when adjacent parts are tense. Muscles, when pressed laterally, give a sensation very like fluctuation ; tumors occurring on the extremities should be examined in a line corresponding to the long axis of the limb. Soft vascular growths will give different sensations to the fingers according as they are irritated or remain undis- turbed for a short time, in consequence of the varying amount of blood which they contain ; it is therefore al- ways well to examine doubtful cases a second time after twenty-four hours have elapsed, causing the patient meantime to exercise or remain in bed, as the indications may suggest. Certain parts of the body, as the testicle or the pulp of finger, fluctuate in a state of health. Oc- casionally a tumor lies near to the surface of the body at one point, so as to afford room for one finger only ; fluctuation is then obtained by pressing sharply and holding the finger in position, so as to receive the recoil of the fluid termed " shock of return ; " in such a case, by placing the whole palm of the hand on the skin near the tumor, and giving a smart tap with a finger of the other hand at the most superficial part of the growth, a vibratile thrill will usually be felt if fluid is present. Examination through natural openings should never be neglected where it is possible. Acupuncture by means of a fine trocar and cannula, with or without aspiration, or by means of a grooved needle, will facilitate a diag- nosis in some cases of deep-seated tumor, more especially in cysts and very vascular sarcomata, from which last the blood will often issue in a jet. A needle will often be of service in determining the relation of a growth to adjacent bone. It is profitable, in many cases of superficial tumor, to remove a piece and subject it to microscopic examina- tion, for thereby the diagnosis is rendered certain. For removing small pieces from deep growths a special har- poon has been devised. Mobility.-The quantity and quality of motion capable of being imparted to a tumor, affords valuable informa- tion as to its seat and limits. The tumor is to be grasped so that it, and not the super- ficial structures alone, will move with the examining hand. Attempts should be made to raise the tumor from its bed, to move it in the direction of adjacent muscles, vessels, and nerves, as well as across their course. The patient should be made to execute appropriate move- ments, that it may be seen in what manner muscular rigidity affects the mobility of the tumor. If attach- ment to a bone is suspected, the bone should be steadied and the growth moved ; connection between the two w ill be apparent if motion is transmitted. A tumor situated upon an extremity, unless it be ad- herent to the bone, can always be moved laterally. Herniae are generally reducible in part or wholly, as sometimes are also purulent collections-for example, psoas abscess. Partial reduction of the contents, with more or less rapid refilling, is seen in angiomas and very vascular sarcomas, as well as in aneurisms ; of these sarcomata refill most rapidly, angiomata swell slowly, while aneurisms pulsate. If a tumor is lobulated its different parts may move upon each other, and so give a false sense of motility. The motion which may be im- parted to a tumor, whether it moves in or with the sur- rounding tissues, very plainly indicates displacement or involvement of adjacent parts, and so assists in the dif- ferentiation between benign and malignant growths. Anaesthesia.-Anaesthetics are useful aids to diagnosis by allaying pain.and muscular contraction. Some per- sons automatically, as it wTere, resist manipulation by the surgeon, contracting their muscles and firmly fixing a tumor ; a growth situated upon or near a nerve may be so painful that the patient is actually unable to bear handling. With children anaesthesia is very useful ; and it offers the only certain means of recognizing the so- called phantom tumor occasionally seen in hysterical women. Pulsation is most distinct in aneurism ordinarily, but it may be transmitted to a tumor resting on an artery ; in such a case the impulse is not distensile, and may be made to disappear by raising or moving the growth away from the vessel, while pressure on the vessel abolishes pulsation, the size and volume of the tumor being un- affected. A pulsating tumor of bone is a sarcoma. Abnormal sounds are occasionally present on ausculta- tion or percussion, while others are appreciated by touch. The parchment crackle of bone thinned and distended by a central growth is an example of this latter class. The blowing sound heard in aneurismal dilatations is well heard in very vascular sarcomas. Resonance on percussion in inguinal tumors would suggest hernia. The relation of a tumor to an adjacent cavity must be carefully investigated, whether it be a hernia, or whether, the tumor commencing in the vicinity, the cavity be not involved secondarily. Especially is this of moment in tu- mors about the cranium and spine. Due regard must be paid to normal openings and parts which have united late in foetal, or early in extra-uterine, life, such as the cra- nial suture or the inguinal canal. It is necessary alw'ays to search for tumors elsewhere than in the locality indicated by the patient, as a means of learning whether there is constitutional infection or not. Especially is it obligatory to examine the lymphatic glands through which the lymph from the affected dis- trict passes. Sarcomas rarely are reproduced in lymphatic glands, while with carcinomata the reverse holds good. In the case of a sarcoma the lungs should be carefully inves- tigated. 3. The Intellectual Work on the part of the sur- geon, by which the evidence obtained is sifted and an opinion formed. This is, after all, the most difficult part of diagnosis, and it is quite impossible to lay down rules for it. Certain general directions only can be given. The surgeon occupies a judicial position, health and dis- ease plead before him, and an unbiassed mind is essential to a truthful decision. No hasty examination is to be made, no detail is too small for consideration and com- ment. Above all, the surgeon must remember that the patient is a sufferer, perhaps certainly diseased, and that patience and kindness should be united with firmness on his part. The patient's story should be first heard, and 330 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tumors. Tumors. then the physical examination is to be proceeded with. It does not suflice to examine the seat of disease only, but the corresponding region on the other side of the body is always to be exposed and investigated. It is my habit to expose the diseased area as well as the uninjured side whenever practicable, and then to in- terrogate my patient, observing meanwhile his actions, attitude, etc. ; then I examine by touch, hearing, etc., and finally explore by puncture, incision, or aspiration, if deemed expedient. A diagnosis may sometimes be reached immediately, the symptoms being direct and positive; more often, however, the indirect method, or that by exclusion, must be resorted to ; this means that, having obtained all the data, the surgeon eliminates, one after another, the pos- sible diseases in the order of least probability, the last one being, of course, the most probable. Treatment of Tumors.-The treatment of a tumor is necessarily preceded by a diagnosis and a choice of operation. No operation is to be undertaken lightly, but the patient's secretions are to be examined and regu- lated, and the patient generally prepared as for any other surgical procedure. The medical treatment of tumors can be dismissed with the statement that, with the exception of cases of gummata, drugs given by the mouth do not appear to be of use. Electricity has, up to the present time, except as a cautery, not taken the place of the knife. Apostoli's method of treating uterine myomata is still sub judice, and need not be held to invalidate the preceding state- ment. Cysts, if simply tapped, almost invariably refill, and it becomes necessary to modify the internal surface so that adhesion between opposite sides shall take place, and permanent obliteration be thereby secured; this can be done by injections of iodine, carbolic acid, etc., or by free opening and stitching of the sac to the skin, granulation resulting. A thick-walled cyst may be dis- sected out, but when the wall is thin it may be well to fill the sac with some material which solidifies at the temperature of the body, thus transforming the cyst into a solid, and then dissection becomes easy. When a cyst is not in relation with important structures, the lining membrane may be scraped and a cure obtained by sub- sequent drainage. Compound ganglion is best treated by free incision, curetting, and subsequent drainage. It is scarcely necessary to say that the principles of anti- septic surgery are to be rigorously carried out in the treatment of tumors. Angioma may be treated by ligature en masse, by ex- cision, by ignipuncture, electricity, or Paquelin's cau- tery, or by injection of some coagulating fluid-Liq. ferri subsulph. This last method is very dangerous unless pressure is made all around the tumor, thus averting the chance of a clot being carried to the heart. Ignipuncture or injection is followed by but little scars, a matter of importance on exposed portions of the body. Removal by knife is the most effective, rapid, and least painful (under anaesthesia) treatment for non-ma- lignant tumors. Each growth is to be considered by itself, and general directions only can be laid down here. The incision through the skin is to be very free and in the direction best calculated to expose the tumor ; at the same time, if possible, the known course of large nerves and vessels should not be crossed. Where the oppor- tunity offers the incision should be so made that a por- tion of it corresponds to the lowest part of the tumor, thus affording exit for drainage. The free wound in the skin permits the tumor to rise from its bed and renders subsequent dissection superficial. The knife should be carried close to, and with the edge directed toward, the growth. The knife edge should be always in view, and the structures should be recognized before they are di- vided. Vessels may be divided between two ligatures, but nerves can usually be avoided ; if, however, a large nerve is divided during the course of the operation, the ends should be sutured before the wound is closed and dressed. The treatment of malignant, differs from that of sim- pie, tumors, inasmuch as the surgeon, having made a di- agnosis, at once considers: 1st. Can I remove this growth together with adjacent infected tissue, so that recurrence shall not take place ? 2d. If this is impossible, can I give to my patient by operation a period of relief, with a prospect of the growth not returning ? Malignant tumors are in their incipiency local ; after a certain time there is local and general infection ; a cure can only be hoped for when complete removal is effected. The necessity for correct diagnosis and early radical ex- tirpation is plain. So important is an early diagnosis, that very often exploration by incision for purposes of diagnosis is proper. The first question above can probably be answered af- firmatively, if the tumor is small, recent, so situated that the surrounding tissue can be freely removed with it, and if there is no sign of distant infection by way of the lymphatics or blood-vessels. The second question can be answered affirmatively, when the primary tumor is so situated that the incisions for its removal shall pass through probably non-infected tissue, where there is no apparent constitutional impli- cation, and where, while adjacent lymphatic glands may be enlarged, such enlargement is restricted to a few glands which are freely movable in the surrounding connective tissue. In any case, the operation for the removal of the tumor must not immediately destroy the patient; such a statement one would think needless, but I believe it is justified by certain surgical (?) pro- cedures which have been reported during the past few years. If it is impossible to cut out the primary tumor thor- oughly, if the adjacent lymphatics are so extensively adherent as to render it impossible to remove them, or if there is general constitutional infection with growths elsewhere in the body, no operation looking toward cure is to be thought of. I have seen an open cancer curetted with the result of greatly relieving the pain and lessen- ing the discharge, but this of course is palliative, not curative. It is scarcely necessary to say that when a primary tu- mor is removed, enlarged neighboring lymphatic glands must also be taken away. It may happen, when the primary growth is in the female breast, that axillary enlargements are obscured by fat; it is in my opinion necessary, when operating for malignant mammary growth, to open the axilla freely, to search for and remove enlarged glands. Tumors recurring in situ after extirpation of a malig- nant tumor, are also to be removed, unless general infec- tion (carcinosis) exists. The treatment of malignant disease by means of caus- tics is largely resorted to by ignorant and irregular prac- titioners. It has been my fortune to see numbers of people from whom had been removed so-called cancers, which were not cancers at all. It has been my fortune to examine several malignant tumors, the bearers of them declining operative measures at my hands, and subsequently, after having been subjected to caustics, my counsel has been sought. I have found evidence of great local tissue de- struction with advanced cicatrization, and in every case of carcinoma death has resulted from disease of the neighboring glands. I am forced to the opinion that malignant disease, accompanied by glandular enlarge- ment, is not cured by caustic treatment. So potent a remedy, probably, has a field of usefulness, but that field is not yet located. The histology of the tumors hitherto subjected to such treatment is not known, hence data are wanting upon which an opinion can be formed. The pain following the use of caustics has been always de- scribed to me as being far greater than that succeeding a modern-aseptic-operation under anaesthesia. I have destroyed a number of growths by means of caustics, but my experience is as yet too limited to warrant an ex- pression of opinion. To the sufferer from malignant disease too far advanced for operation, relief is to be given by regulating the various secretions, by cleanliness 331 Tuning-Forks. Turpentine. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. and antiseptics, and by such drugs as obtund pain, at the head of which stands opium and its derivatives. Louis McLane Tiffany. 1 Dell' angectasia, p. 6. Milano, 1861. TUNING-FORKS. The tuning-fork {Stimmgdbel, dia- pason) is usually seen in the form which gives it its name; it may be regarded as, essentially, a straight rod of metal-the material commonly used being tempered steel, though brass, bell-metal, or gun-metal are equally efficient-free at both ends, and supported in the middle by a handle or stem placed at right angles to the long axis of the rod. In the form in common use the two halves of the rod are bent upward parallel to each other and in a line with the long axis of the stem, and are called tines or branches ; these branches vibrate when set in motion in a direction transversely to their long axis, and must be adjusted so far apart that they shall not touch in the limit of their greatest audi- ble excursion. The fork is usually set in vi- bration by striking it upon some moderately hard substance ; by striking it with a hammer, either in the hand or attached to the stem of the fork by a spring handle; by inserting a rod between the tines at the base of the cleft between them and withdrawing it toward the tip, the tines approximating, as in many forks of French manufacture, and so being displaced outward by the passage of the rod ; by bowing, and by being actuated by an electro-magnet. The principal use of the tuning-fork in medi- cine up to the present time has been as a test of hearing power, though forks have been recently used in the investigation and treatment 6f dis- eases of the nervous system, both on account of the mechanical and the acoustic value of their vibrations. In 1878 Tt. Vigouroux investigated the effects of the tuning-fork upon hysterical patients in Charcot's wards. He used an enormous diapason, made to vibrate by a bow, and mounted on a large resonator- box ; with this he succeeded in causing muscular con- tractions and in putting an end to hemiansesthesia almost as rapidly as with the magnet or the electric spark, and in one instance the attacks of pain accompanying loco- motor ataxia were relieved by putting the legs of the patient into the resonator. In these experiments the vi- brations were transmitted by the air, and to localize their action the handle of the fork was tipped with a button of wood and applied directly over the affected nerve or muscle. Boudet used a small fork, giving four hundred and thirty-six vibrations in the second, connected with an electro-magnet, after the plan of Konig, and worked by a single battery cell; the apparatus rested on a tablet of wood, seventeen by seven centimetres in size, held by a handle ; to the edge of the tablet, at the point where the vibrations were strongest, a small copper peg, ten centimetres long, was screwed and capped with a disk not more than one centimetre in diameter; this appara- tus, applied to the supraorbital region of healthy subjects, produced a local analgesia, often a well-marked amesthe- sia, the time required varying from eight to twenty min- utes, according to the individual. Similar effects were obtained in other parts of the body ; they were more marked and rapid in proportion to the vicinity of sensitive nerve-branches, the thin- ness of the tissues, and the firmness of the surface on which the skin rested ; the greatest effect was produced on the forehead, the temples, the gums, the mastoid pro- cesses, or wherever the nerves are most easily pressed against a bony substratum. Applied to the points named, the fork produced vibrations of the skull in uni- son with its own, and with resultant sensations of either drowsiness or vertigo, which, as described, greatly re- sembled those produced by the constant electric current applied to the head. This application was found efficacious in relieving hemicrania, or even in cutting the attack short if taken in the beginning. In neuralgia the effect was more striking, the acute pain disappearing after a few minutes of application to the affected nerve, especially when, as in the case of the trigeminus, the point of exit from the bony canal could be acted on directly. The rapidity of vibration seems to be unessential. Vigouroux, in his experiments at the Salpetriere, suc- ceeded equally well with a wide range of pitch, the force of the vibrations seeming to be the essential feature in securing rapid and complete results ; the effect seem- ing to be that of a modified form of massage and analo- gous to that produced by the same means in plants, and evidenced by their accelerated growth. A confirmatory line of research in the human subject has been followed by J. Mortimer Granville, who de- scribes results obtained in the relief of pain by the " per- cuteur," a small hammer with rapid stroke analogous to the tetanomotor of Heidenhain. In the absence of any one fixed measure of the hearing power, the provision for which, by any one test, is in the nature of things impossible, the tuning-fork becomes of great value as a comparative test, especially as it provides a ready means for contrasting the hearing power for a given tone of constant musical value conveyed to the auditory nerve in two ways ; firstly, through the medium of the air and the sound-transmitting mechanism of the ear-aerial conduction ; and, secondly, through the medium of the bones of the head-bone con- duction, and also for testing the duration of perception of any given tone aerially conveyed and gradu- ally decreasing in intensity. For such uses in the ordinary course of clinical research the sim- plest apparatus is the best, and while there are advantages in using several forks of different pitch in many cases, for common use a sin- gle fork of about the average mean pitch of the human voice, C. (phil- harmonic) 562 v.s., or, better still, physical C. 512 v.s., without clamps and without hammer or other act- uating apparatus, is the best; while for control experiments a series of three or four forks with octave in- tervals, C. 256 v.s., C. 512 v.s., C. 1024 v.s., C. 2048 v.s., possesses cer- tain advantages and covers a suffi- cient portion of the scale of human audition to answer all demands of ordinary clinical tuning-fork tests. While, as compared with other instruments, the tuning-fork pos- sesses great freedom from confusing over-tones, and while there is a very wide interval between the lowest of them and the dominant or funda- mental tone of the fork, it is still important to be rid of them as far as is possible. To get the dominant, it is neces- sary either to use a resonator, which re-enforces the dominant tone only, to weight the tines of the fork at the tip, by metal clamps, for in- stance (Fig. 4142), or to fasten a metal ring encircling the bases of the tines at the nodal points (Bezold). In setting the fork in vibration, prominence may also be given either to the overtones or to the dominant by striking the fork upon or with a hard or soft substance ; it is important, there- fore, for comparative tests, that there should be uniform- ity in the make, material, and manner of actuating the forks-a matter much more difficult of achievement than at first appears. Fig. 4141. Fig. 4142. - Tuning-fork Provided with Adjusta- ble Clamps. One-half natural size. 332 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tuning-Forks. Turpentine. By adding weight of metal to the tips of the tines of a tuning-fork in such a manner as to afford an inclined plane, upward and outward, on the outer surface of each tine, two objects are attained: the effect of permanent clamps in damping the overtones is secured, and a means is provided for setting the fork in vibration with a fairly uniform degree of intensity, by drawing it through a wooden ring small enough to force the inner surfaces of the tines into contact, or through the fingers of the left band, the fork being firmly grasped by its stem in the right, and care being taken to practise a uniform speed of withdrawal of the fork as nearly as possible (see Fig. 4141). In testing duration of perception, aerially, in any given case, the influence of the residual sensation should be borne in mind, and the tone of the fork, in- stead of being allowed to be continually heard, should be frequently interrupted, either by removing; the fork from the neighborhood of the ear tested, or by removing it from the resonator, if one is used in the experiment. The same suggestion is of value in testing duration of hearing by bone conduction. The simplest method of comparing the perception of a tuning-fork tone by aerial and by bone conduction is to set the fork in vibration, with as little evidence of over- tones as possible, and hold it for a moment with the tips of the tines opposite the external meatus and at a fixed distance, one centimetre, for instance, away from it, and then immediately transfer the base of the stem of the fork to the mastoid process of the same ear, the fork being held at right angles to the plane of the mastoid surface and being pressed firmly upon the skin at a point over the centre of the mastoid prominence. The patient is asked to compare the apparent intensity of the tone in the two instances, and the experiment is then re- versed, and repeated, if necessary, several times, and with different forks of the series suggested ; the test is then made with the introduction of the element of time- duration of perception, comparatively-the precaution of interruption of the sensory impulse being observed. In testing the two ears in the same individual, aerially and by bone conduction, the fork set in vibration may be passed rapidly from one ear to the other, and then placed in contact with the head in the median line, suc- cessively on the forehead, the vertex, and the occiput, the patient being called upon to indicate the ear in which the tone is more loudly heard, care being taken to exer- cise as nearly as possible a uniform pressure, as the degree of compression of the soft tissues has a decided influence on the transmission of the vibrations of the fork to the cranial bones. The perception apparent by bone conduction is also influenced-aside from changes in the auditory apparatus which are the subjects of in- vestigation-by conditions of the cranial bones and of the superimposed soft parts ; the test with the tuning-fork, therefore, is of value principally as affording a tone of definite and constant pitch by means of which the per- ceptive power of the auditory nerve may be tested for that particular tone, without reference to the transmission of the tone, aerially, through the usual channel of com- munication, and as a test also of the changes in trans- mitting power of the sound-conducting mechanism of the middle ear. The use of the tuning-fork for the purposes above in- dicated is comparatively so recent that the conclusions to be drawn from it, except such as relate to the simpler propositions of determining loss or suspension of percep- tive power of the auditory nerve, are still a matter of active investigation and involve questions which must be studied from the direction of the domain of physics, as well as of medicine, to reach satisfactory conclusions. Clarence J. Blake. TURNIP, INDIAN. The corm of Arisama Triphyllum Torrey ; Order, Aracea (Jack in the Box, Wake Robin, Devil in the Pulpit, etc.). This well-known vernal flower, common all over the country in swamps, along brook-sides and in other damp and shady places, has a large, solid, roundish rhizome, to which it owes its most descriptive common name. This corm, containing abundance of starch, and pervaded by an intensely acrid juice that bites the tongue like Aconite or Ranunculus roots, was for- merly officinal in the United States, as Arum Maculatum ; a nearly related plant of similar properties is yet found in France {Arum Gouet, ou Pied de Veau, Codex Med.). Both have become obsolete in medicine. The acridity of Indian Turnip diminishes very much in drying, and is completely dissipated by age. The drug has been given in a number of chronic diseases of the chest and joints with reputed benefit. W. P. Bolles. TURPENTINE (Terebinthina, U. S. Ph., Ph. G. ; Thus Americanum, Br. Ph. ; Galipot, Codex Med., etc.). Turpentine is a generic name given to the natural com- binations of resin and volatile oil found in most species of conifers, the Pistacia- and Copaiba-trees, and others. While all these products, however, are properly spoken of as turpentines, Turpentine, when used alone without any qualifying adjective, means the oleo-resin of the common species of pine-in this country of Pinus Aus- tralis Michaux, P. Tada Linn., and other denizens of the great pine-forests of the Southern States ; in France and Germany of P. Pinaster Solander {P. Maritima Poir) ; in Northern Europe of P. BylvestrislAwa.in Austria of P. Laricio Poir, etc. American turpentine is collected on an enormous scale in North Carolina, Virginia, Florida, and in some other States. Deep gashes are cut in the trunks of the trees, near the ground, and hollowed out at the bottom so as to hold a pint or more of liquid, and above these slight cuts are made in the bark from which the Turpen- tine flows, and,running down, is collected in the " boxes," as the excavated gashes are called ; from these it is ladled out from time to time as the boxes fill, and fresh hacks are occasionally made in the bark above to keep up the flow. The freshly collected turpentine is then filled into barrels and carried to the still, where the oil is distilled off, being the spirit of turpentine, as it is commonly called, of commerce. It is yellow, soft or hard, according to age, of the well- known terebinthinous odor and taste. If soft enough, upon standing it separates into a clear and crystalline portion, the latter mostly abietic acid. As indicated already, turpentine consists of oil of turpentine and rosin. The oil {Oleum Terebinthina, U. S. Ph.), which is present in the proportion of from fif- teen to thirty per cent., is the type of a large number ; in fact, of most of the light essential oils. It is a "thin, colorless liquid, of a characteristic odor and taste, becom- ing stronger and less pleasant by age and exposure to air, and of a neutral or faintly acid reaction. Sp. gr., 0.885 to 0.870." Commercial oil of turpentine consists of several hydrocarbons, Ci0Hie, which can be separated by careful fractional distillation, each having a different boiling-point and different sp. gr., but presenting no other obvious differences. Rosin {Resina, U. S. Ph.), the res- ins left after evaporating the oil, varies considerably in its appearance, according to the extent of its preparation. If the water with which it was distilled has not been en- tirely boiled out, it is opaque and yellow, if it contains no water, it is clear ; if overheated, it is dark brown or black, if not, it is bright and clear. The quality required by the Pharmacopoeia is " a transparent, amber-colored substance, hard, brittle, with a glossy and shallow con- choidal fracture, and having a faintly terebinthinate odor and taste. Sp. gr., 1.070 to 1.080. It melts at about 135° C. (275° F.) and is soluble in alcohol, ether, and fixed or volatile oils." The abietic acid in the opaque "Thus" is a product of hydration of rosin, and may be produced in ordinary rosin by treating with diluted alcohol. Action and Uses.-The most active part of turpentine is its oil, which is one of the most irritating of its series. Applied to the skin arid prevented from evaporating, it quickly causes smarting and redness, and after a quarter of an hour or more is liable to destroy the surface and cause ulceration. In large doses, ten or fifteen grams, taken internally, it is a quick irritant, causing prompt ac- 333 Turpentine. Tynip. Membrane. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tion, but is unsafe. Used with suds or other vehicle, as a rectal injection, it is promptly rejected, and in conse- quence is a useful stimulating evacuant of the lower bowel. Oil of turpentine is readily absorbed in vapor by the lungs, as well as in its liquid condition by the stomach. It is excreted also by the lungs as well as by the skin and kidneys, the latter principally in the course of its elimina- tion ; it is, if in large quantity, an irritant to the whole urinary system, causing strangury, frequent micturition, haematuria, etc. The urine has a rather pleasant violet- like odor. Like all essential oils it is an antiseptic. In small doses (a few drops) it is stimulant and haemostatic, and frequently given with good effect in the haemorrhage of typhoid and phthisis, tn large amounts, two or three grams and upward, there are mental exhilaration, in- toxication ; and in poisonous doses dulness, coma, and convulsions, with muscular weakness and heart failure. Turpentine itself is not much employed in this country, but may be given for chronic diarrhoea, ulceration of the bowels, chronic rheumatic joints, sciatica, etc., as well as in leucorrhoea and gonorrhoea, under conditions indicating copaiba, over which it probably has no ad- vantages ; it may be made into pills and a gram or two be given at a time. The oil is frequently employed as an irritant application (turpentine stupe); a flannel pad wrung out from hot water, and freely sprinkled over the surface with oil of turpentine, acts the same as a mustard paper. It is also a very useful injection (fifteen grams, in a litre or less of warm soap-suds, and stirred in while being administered). Internally, as above indicated, it may be given in doses of from three to ten drops. Rosin is not very active, and is seldom employed externally. The following preparations are officinal. From the oil, Linimentum Cantharidis (cantharidis fifteen, percolate with enough oil of turpentine to make one hundred parts). Linimentum Terebinthina (resin cerate, sixty-five parts, dissolved in thirty-five of oil of turpentine), both very irritating applications. From rosin, Ceratum Re- sina (resin, thirty-five parts ; yellow wax, fifteen parts ; lard, fifty), and Emplastrum Resina, the surgeon's adhe- sive plaster, which consists of : Powdered resin, four- teen parts, Lead plaster, eighty parts, Yellow wax, six parts, melted together and spread upon cloth. Of these the first three are more often used in combination with vehicles to weaken them ; the latter is partly superseded of late years by the rubber adhesive plasters, of which that made by the formula of the late Dr. Martin is the least irritating. (See Caoutchouc.) Allied Plants.-The genus is the most important one of the coniferae, and comprises about seventy liv- ing species, distributed over the cooler regions of the earth (temperate and arctic zones). The turpentines and their oils are found in some degree in all species, and tar and pitch, the result of the destructive distillation of many kinds of wood in this country, are derived mostly from pine knots and logs. Both these products have been used in medicine, and tar is still officinal (Pix Liquida, U. S. Ph., Br. Ph.). By distillation tar yields a number of complex products, among them impure acetic (pyroligneous) acid, the so-called oil of tar (Oleum Picis Liquida, U. S. Ph.), and pitch. Tar is a good antiseptic; it has in general the properties of turpentine, but is less irritating, and has had times of great popularity as a medicine. But the best preparations are the syrup (Sy- rupus Picis Liquida, U. S. Ph.) and the oil of tar (Oleum Picis Liquida, U. S. Ph.). Dose of the syrup five or six grams; of the oil, ten drops. Larix Decidua Mill (L.Euro- paa D. C., etc.), the European larch, is the source of the nearly obsolete Venetian turpentine. The bark of larch is also officinal in some European countries. It contains larixnic acid. Picea (Abies') ercelsa Lk., the Norway spruce, is the source of genuine Burgundy pitch. Abies Balsamea Mill, our balsam fir, is the source of most of the Canada Turpentine or Canada Balsam, so much used in microscopic work. It is officinal'(Terebinthina Canaden- sis, U. S. Ph.). It collects in small blisters beneath the outer layers of the bark, and is collected by puncturing them. Abies Alba Lk., the silver fir of Europe, in the same way furnishes the Strasburg Turpentine. Callitris Quadrivalis Vent, yields Sandarac. Juniperus Sabina Linn., Savin Tops. Juniperus Virginiana Linn., Cedar Apples and Oil. Juniperus Oxycedrus Linn., Oil of Cade. Juniperus Communis Linn., Juniper Berries, Oil, etc. Allied Drugs.-The turpentines of the Pistacias, Chian Turpentine, Mastic, etc., as well as "Balsam of Copaiba," are nearly related in every way, excepting bo- tanically, to the coniferous turpentines. Terebene is an artificial derivative of Turpentine, of similar qualities, but milder. IF. P. Bolles. TYMPANIC MEMBRANE AND OSSICLES, ANAT- OMY OF THE. The tympanic membrane, membrana tympani, or drum-membrane, is composed of three layers ; viz., the external or dermoid layer, the middle or fi- brous, and the inner or mucous layer. The dermoid or skin layer of the membrana tympani is a continuation of the skin of the external auditory canal. In this layer, however, there are no hairs nor follicles, as are found elsewhere in the cutis of the audi- tory canal. In other respects it is true skin, but extreme- ly thin and transparent. The outer or skin layer of the membrana tympani is the only one of the three compo- nent layers of the drum-membrane which can be in- spected directly from without. When the auditory canal is illuminated and a normal membrana examined from without, several prominent features in it attract the observer's attention ; viz., its almost circular shape, and peculiar polish and color ; its vertical and horizontal inclinations ; the ridge formed in one of its radii by the handle of the hammer-bone ; the short process at the upper end of the latter ; the folds of the membrana ; the flaccid portion of the tympanic membrane, the portion above the short process of the hammer, the so-called Shrapnell's membrane; the white, tendinous periphery of the membrane ; and, finally, the bright, triangular reflection of light in the antero-inferior quadrant of the membrane, running from the lower end of the malleus, at the centre of the mem- brane, the umbo, toward the periphery. This re- flection is called the "pyr- amid of light" (see Fig. 4144). Generally a deli- cate plexus of vessels can be seen in the region of the folds and in the mem- brana flaccida, and one or two delicate arterioles can be traced downward along the manubrium of the malleus. For purposes of con- venient description, the membrana tympani is called circular in shape. Its form, however, varies between that of an ellipse and an irregu- lar oval, while in some cases, in which the lateral por- tions of the annulus tympanicus are especially curved outward, it assumes a heart shape. Strictly it may be considered an ellipse, the long diameter of which, amounting to nine or ten millimetres, runs from above and in front downward and backward, and the greatest transverse diameter of which runs from below and in front, upward and backward. The proportion between these diameters is 4.3'" : 4.0"' (Von Troeltsch and Hyrtl). Since the difference between them is so slight, and their inclinations so nearly vertical and horizontal, the outline of the tympanic membrane is considered circular, and is divided into quadrants by the horizontal and vertical diameters, which greatly aids in locating points to be de- scribed. Color.-The normal color of the membrana tympani is not constant, because it varies, just like the color of the teeth, with the individual. As the latter varies from a bluish to a yellowish white, so the drum-membrane varies, in a perfectly normal condition, from a bluish to a yellowish gray, the former being the commoner tint. Fig. 4143.-View of Outer Surface of Membrana Tympani. (Gruber.) A, malleus, manubrium ; B, lower end of manubrium; C. short process; D, posterior fold of the membrana. 334 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ^mp.'^embrane. This color is generally spoken of as a " pearl color," but, whatever color the tympanic membrane possesses, it is always modified by the physical conditions incident to stretching a nearly transparent membrane over a dark- ened cavity, which modification is not generally taken into account by observers. The color of the tympanic membrane is, furthermore, modified by the color it transmits from the tympanic cavity, the latter factor being modified by the varying degrees of tenuity of the membrana, as well as by the varying conditions and colors of the mucous lining and the contents of the tympanic cavity. That part of the tympanic membrane behind the lower end of the manu- brium, and over the promontory of the cochlea, is ren- dered yellowish gray by the rays of light reflected from this part of the inner wall of the tympanic cavity. The tympanic membrane owes its peculiar lustre to the delicate and shining epithelium of the skin-layer. The slightest maceration, exfoliation, or thickening of this delicate epithelium deprives the membrane of its beautiful gloss. The dermis of the membrana is thickest in children, and hence their membran(e rarely shine as brightly as those of adults. The Inclinations.-Another important feature attract- ing the eye of the observer is that the tympanic mem- brane, in its normal condition, is inclined outward in its vertical plane at an angle of forty-five degrees, and in its horizontal plane ten degrees toward the right on the right side and ten degrees toward the left on the left side. If the planes of both membranae be extended downward until they intersect, the angle they will then form will be equal to about one hundred and thirty de- grees to one hundred and thirty- five degrees. Of still greater im- portance than this, however, is the direction of the walls of the auditory canal from the plane of the membrana tympani. Thus if a perpendicular be drawn from the upper pole of the drum-head to the inferior wall of the auditory canal, it will strike the latter about six millimetres from the inferior pole of the membrane. A similar result will be obtained by drawing a perpendicular from the middle of the posterior periphery of the drum-membrane to the anterior wall of the auditory canal, from which it is manifest that the lower anterior part of the membrana is farther from the external opening of the canal than the posterior upper part is. The tympanic membrane is in- clined the most in very young children, being almost horizontal in the early years of life. As the osseous canal does not exist at this early period of life, the upper part of the membrana tympani lies very near the external meatus at this time. In some instances there is observed a physiological variation in the obliquity of the tympanic membrane, and a filling in of the segment of Rivinus (the region of the membrana flaccida) with osseous tissue. Hence on inspection there is found a large portion of the field at the fundus of the canal taken up by the upper wall of the canal, which seems to dip down to join the mem- brana tympani on a line with its folds. In such cases there is very little, or no membrana flaccida. This con- dition is observed in the feeble-minded, with other cra- nial defects in development. Moos and Steinbriigge ob- served in a cretin, with defective cranial development, a difference of 40° in the inferior angle of the membrana tympani, on each side. In such cases the difference may be from 10° to 50° greater than normal. The Handle of the Malleus.-Running from above downward and backward to the centre, or umbo, of the tympanic membrane is seen the ridge formed by the manubrium or handle of the hammer. This slightly elevated ridge, entirely opaque and decidedly whiter than the surrounding membrana tympani, is in the di- ameter which divides the tympanic membrane into two unequal parts, the anterior being the smaller and the posterior the larger. At the upper end of this ridge is the short process of the malleus, projecting sharply out- ward, somewhat above the general surface of the handle of the hammer. In general appearance it is not unlike a pimple with pale-yellowish contents. The lower end, or tip of the ridge, which curves slightly forward, is flatter, broader, and yellower than the rest of the outer covering of the manubrium. This is due to the fact that the bone at this point is spade-shaped, and also be- cause the radial fibres of the middle layer, the mem- brand propria, centre at this lower end of the handle. The lower end of the hammer draws the membrana tympani very markedly inward, and forms the depressed centre of the membrane called the umbo. The concavo- convex shape of the drum-head from the tip of the manubrium outward toward the periphery is due to the comparatively large number of circular fibres at a point between the umbo and periphery, which constrict, as it were, the radial fibres so as to form a kind of funnel. Pressure or traction applied to the cen- tre of a membrane stretched over a ring tends to draw the former into a conical shape, a vertical section of which is repre- sented by the line AUA' in Fig. 4145. But if a smaller concentric ring be placed at BC, in Fig. 4146, so as to resist the in- drawing force at U, the curve assumed by the membrane will be represented by the line AUA' in Fig. 4146, and the whole membrane will be drawn into a concavo- convex surface, the line AUA', Fig. 4146, representing on the right-hand side the curve of the tympanic membrane on its outer surface. The yellow spot at the end of the handle of the mal- leus, in the centre of the umbo, is a purely physiological condition. It is, in fact, part of the cartilaginous struct- ure at the end of the manubrium of the hammer. Trautmann 1 has concluded that: 1. Its physiological significance is the same as an epiphysis of a long bone. 2. The diagnostic value of the yellow spot is apparent in cases of thickening of the membrana tympani, as the former will disappear much sooner than the sharp edge of the malleus. 3. Opacities of the membrane with thickening change the color of the yellow spot. 4. When the malleus is twisted on its long axis the form of the spot will be altered. 5. If the spot does not move dur- ing alterations in the atmospheric pressure in the canal induced by the pneumatic speculum, it is fair to conclude that either anchylosis of the mal- leus or its adhesion to the inner wall of the drum-cavity has occurred. In the latter in- stance, the differential diagnosis is aided by the necessary foreshortening of the handle of the hammer. Folds of the Membrana Tympani.-From the short process of the manubrium of the malleus two delicate ridges may be seen, one passing forward, the other backward to the periphery. These are the so-called folds of the membrana tympani. They are formed by the pressure outward of the short process of the malleus, and constitute important topographical as well as diagnostic points in the tympanic membrane. Above these folds is the so-called membrane of Shrapnell, or the membrana flaccida. It owes its flaccidity to the small quantity of fibrous tissue entering into its composition, and to the loosely stretched cutaneous and mucous layers of the membrana tympani which here come together. In the upper part of this flaccid membrane there was once said to be a normal opening, the foramen Rivini, named after the supposed discoverer in 1717. Its existence finally was denied by Hyrtl, and his con- clusions are now universally accepted. Pyramid of Light.-The pyramid of light is the name applied to the beautiful triangular reflection of light emanating from the antero-inferior quadrant of the nor- mal adult membrana tympani. The apex of this trian- Fig. 4145. Fig. 4144. - The Normal Membrana Tympani. Fig. 4146. 335 Tympanic Mem- brane. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. gular reflection touches the tip of the manubrium of the malleus, and its base lies on, or near, the periphery of the tympanic membrane. It forms, with the handle of the hammer, an obtuse angle anteriorly, which becomes greater as the inclination of the membrana tympani to the auditory canal diminishes. Its average height is from 1.5 to 2 mm., and its average width at the base is from 1.5 to 2 mm. The causes of the formation of this pyramid of light, or its optics, have been variously de- scribed by a number of careful observers. From the most recent investigations,2 it is conclusively shown that there are three elements indispensable to the formation of the pyramid of light ; viz., a shining surface, the pe- culiar inclinations of the tympanic membrane, and its pe- culiar funnel or convolvulus-like shape. In these three conditions may be found the solution of three very im- portant questions, viz.: 1. Why do we see such, or any reflection from the tympanic membrane ? 2. Why do we see this one in the antero-inferior quadrant ? and, 3. Why is its shape pyramidal ? 1. We see a reflection because of the lustrous epithe- lium on the dermoid layer of the membrane. 2. The peculiar inclination of the tympanic membrane so places the latter that, by the modifications of its surface brought about by the traction inward at the umbo, or centre, the only possible spot from which light can be reflected is just where the pyramid of light is seen, as will be ex- plained further on. 3. The funnel-shape of the mem- brana tympani will explain the pyramidal shape of this reflection upon the physical laws of concavo-convex mir- rors. Not one of these conditions is sufficient of itself to produce a normal pyramid of light upon the tympanic membrane. That the lustre of the skin-layer is an im- portant factor in producing this peculiar reflection may be proven by syringing an ear in which this pyramid of light is visible. After a slight maceration and conse- quent dulling of the lustre of the outer surface of the membrana, the pyramid of light will have disappeared or become distorted. In order to prove that the peculiar inclinations of the membrana tympani toward the walls of the auditory canal have also their part in the production of the pyra- mid of light at the point where it is normally found, i.e., in the antero-inferior quadrant, it is necessary only to inspect a normal tympanic membrane during inflation by the Valsalvian or any other method. It will then be seen that the pyramid of light becomes altered in position re- specting the malleus. That this reflection can come only from the antero-in- ferior quadrant is shown by an experiment of Politzer, as follows: If the auditory canal be removed from the membrana tympani, so that the latter is attached only to the annulus tympanicus, and the membrane then be re- volved so that other parts of its surface successively as- sume the position of that from which the pyramidal re- flection formerly came, we shall perceive on each of these parts a reflection almost exactly like the original pyramid of light, excepting behind the manubrium, w'here, owing to the different curve of the membrane, the reflection in question will be somewhat different, both in shape and brilliancy. The third important condition in the formation of the pyramid of light is the funnel-shape of the membrana tympani, to which is due, according to Trautmann, the pyramidal shape of the reflection under consideration. The cause of the pyramidal shape of the " reflection of light" from the membrana may be thus stated : The normal tympanic membrane has quite a high de- gree of lustre, is inclined at an angle of 45° in its verti- cal plane, and in its horizontal plane it is inclined 10° toward the right on the right side and 10° toward the left on the left side. Furthermore, it is drawn inward so as to form a concavo-convex funnel (p. 335), the apex of which lies in the centre of the anterior part of the yellow spot at the lower end of the handle of the mal- leus. The angle at 'which the sides of this funnel meet is greater than a right angle, the depth of the funnel is equal to about 2 mm., and the distance from the apex to the periphery is 2.5 to 3 mm. anteriorly and 3 mm. posteriorly. But a reflection of light from the surface of the membrana tympani, were it flat, could not reach the eye of an observer, because the rays of light from without, on account of the inclination of the membrana tympani, would fall upon the plane surfaces of the same at a very acute angle, and since the angle of reflection is equal to the angle of incidence, the rays of light reflected from the planes of the membrane, having an angle of 45°, would strike the inferior wall of the external audi- tory meatus, and in consequence would be unable to reach the eye of an observer from without. The rela- tions, however, are different in a reflection from a con- cavo-convex tract. For, on account of the vertical in- clination of 45° in the membrana tympani, and of its horizontal inclination of 10°, and also because of its concavo-convex shape, the antero-inferior quadrant of the tympanic membrane is drawn at right angles to the illuminating point. Since, now, the illuminating body and the eye are in the same line in examining the ear, only the rays of light which fall perpendicularly upon the antero-inferior quadrant can reach the eye, since a'll other rays are reflected at such an angle that they strike the walls of the auditory canal ; therefore, the only re- flection of light seen by the observer comes from the antero-inferior quarter of the tympanic membrane, and constitutes the " py- ramid of light."3 Geometric Divisions of the Tympanic Membrane. -It has been suggested 4 to divide the membrana tympani into two grand tracts, the one above, the other below the folds of the drum-head (ae, ed, Fig. 4147). The upper tract is subdivided into three sectors; viz., aeb, bee, and ced, Fig. 4147. The sectors are bounded below by the folds of the membrana tympani, and above by the annulus tympani- cus and the segment of Rivinus, be. The middle sector, bee, is separated from the other two on each side by the two suspensory ligaments be, ec, of the handle of the ham- mer. Between the anterior suspensory ligament be and the anterior fold of the membrana tympani lies the ante- rior sector, and between the posterior suspensory liga- ment and the posterior fold of the membrana lies the posterior sector. The inferior division of the membrana tympani, viz., that portion below the folds, is divided into an anterior segment, beginning at the anterior fold and extending to the pyramid of lightt and the posterior segment, extending from the pyramid of light to the pos- terior fold of the membrana. It is said that the radial fibres in the tract of the pyra- mid of light of a normal membrane are shorter, and therefore tenser and more retracted, than those fibres which run directly backward and forward from the ma- nubrium. The tendinous ring {Annulus tendinosus).-Before considering the membrana propria, the structure from which the fibres of this middle layer of the tympanic membrane originate, demands a short description. This is the so-called tendinous ring of Arnold. It is a mass of fibrous tissue around the periphery of the membrana tympani, effecting the union between the latter and the inner edge of the external auditory canal. This tendin- ous ring is wanting at the segment of Rivinus (upper pole of the membrane). It is, furthermore, not always visible from without, even when present in its normal position around the periphery, close to the annulus tympanicus. The fibres of the membrana propria, the origin of which has just been explained, are not inserted directly into the bone of the manubrium, but into a cartilaginous groove which receives the manubrium and short pro- Fig. 4147. 336 Tympanic Mem- brane. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. cess.6 It presents in general the appearance of a deep groove, when seen from behind, after the removal of the malleus. Gruber has shown that this groove is closed at its upper end, so that it forms a cartilaginous cap, which covers in the short process on all sides; its lower end, on the contrary, is open behind, and it gradually becomes shallower or flatter, until lost in the substance of the membrana tympani. It extends from a little above the short process to a point half a millimetre be- low the spade-like end of the manubrium. The inner surface of this cartilaginous groove, which is in contact with the malleus, is lined by a very delicate layer of connective tissue, between which and the malleus there is found a small quantity of fluid resembling synovia. If this is so, there is here a kind of joint. Now and then cases are observed presenting, as it were, two short processes. Such an appearance is explainable as a re- sult of a luxation upward of the malleus out of this car- tilaginous groove. The upper one of the two is the true short process, in such instances. K61 licker 6 re- gards this hyaline cartilage as a remnant of foetal life, lie does not admit the presence of a normally developed, constant space between thisi cartilage and the malleus. Membrana Propria: the Middle, Fibrous Layer of the Tympanic Membrane.-This layer may be subdivided, into two distinct and very delicate layers, an outer one, composed entirely of radiate fibres, closely connected with the skin-layer of the membrana, and an inner layer composed entirely of circular fibres, in close relation with the mucous membrane composing the inner layer of the tympanic membrane. These are called the radial and circular layers of the membrana propria. The fibres of the first arise from the annulus tendinosus and the upper wall of the auditory canal, and are inserted into the han- dle of the hammer, centring for the most part at the um- bo. The fibres composing the circular layer arise partly from the annulus tendinosus, but the majority arise from the substance of the membrana tympani itself (Von Troeltsch). Some of them are inserted into the malleus. The circular fibres are most numerous a short distance from the periphery of the tympanic membrane. They are thickest in the upper third of the membrane, where they are twice as numerous as the radial fibres. The thickness of the circular layer at this point is 0.026"', while that of the radial layer is 0.018'" (Gerlach). The circular fibres are much less numerous at the middle third of the space between the malleus and peri- phery, and almost wanting at the centre of the mem- brana. A knowledge of the arrangement of these fibres is important when considering pathological changes which may have taken place in the tympanic membrane, and also in explanation of its peculiar concavo-convex shape. For, "if its radial fibres were not united by transverse ones, they would be stretched in a straight line. In point of fact, however, they maintain a curved shape, with the convexity toward the meatus. Hence we conclude, that the radial fibres are drawn toward one another by circular fibres, and that the latter are also made tense at the same time. There is, in fact, in the membrana tympani at rest, no other force competent to hold the radial fibres in a curved position, but the ten- sion of the circular fibres." 1 In addition to the two layers of the membrana propria, just described, there is still another layer composed of descending fibres (Gruber). They are external to the radial fibres, arise from the upper segment of the annulus tendinosus, and lying very close to one another, are inserted into the sides and median line of the cartilaginous groove of the malleus. The three layers of fibres entering into the composition of the membrana propria are lightly bound together by a very delicate connective tissue, but they cling very closely to the annulus tendinosus, cartilaginous groove, and the dermoid and mucous layers. There is also in the membrana tympani a set of fibres arranged in a peculiar way, and first described and named by Gruber-the dendritic {arborescent) fibrous struc- ture of the tympanic membrane. " They arise near the periphery, about in the middle of the posterior segment, pretty far apart, but as they proceed on their upward course in the posterior segment, they approach one another in order to divide again, at some distance from the manubrium of the malleus, into several branches, usually about three, which run in different directions, and are finally lost by intertwining with the fibres of the inembrana propria." 8 These fibres are not confined to the posterior segment, but traces of them are found throughout the membrana tympani. The function of these fibres is considered by Gruber to be, in all proba- bility, to relax the tympanic membrane, although it can- not be shown as yet that it is muscular. The membrana propria consists chiefly of connective tissue of that variety, half-way between the ordinary fibrillated and the homogeneous con- nective tissue of Reichert, as shown by Gerlach. The fibres are 0.004'" broad, and 0.002"' thick. Upon these ribbon-like fibres are found peculiar spindle - shaped corpus- cles, once supposed to be peculiar to the membrana tympani, and named the "corpuscles of the mem- brana tympani," or the "corpuscles of Von Troeltsch," after the ob- server who first called attention to them. They are, however, only the connec- tive-tissue corpuscles of Virchow. They are 0.002"' long, and about 0.005'" wide at their broadest part, with two or three processes. They are found under two forms, the spindle-shape and the stellate (Gruber). Internal or Mucous Layer of the Tympanic Membrane.- The internal layer of the membrana tympani is of mu- cous membrane, a continuation of that lining the tym- panic cavity. It is thickest at the periphery of the tym- panic membrane, growing thinner as it approaches the centre of the membrana tympani, where it is extremely delicate. On the inner surface of the layer various in- vestigators have found villous bodies (Politzer, Gerlach, Kessel). They resemble intestinal villi in appearance, and are usually found in delicate children. They are globu- lar or finger-shaped, the former being from 0.10'" to 0.12'" in diameter, and from 0.12'" to 0.14'" in length. The finger-shaped villi vary in length from 0.10'" to 0.12'", and in width from 0.06'" to 0.08'" (Gerlach and Gruber). As no nerves have ever been found in these bodies, and as they are connected to the mucous membrane by means of pedicles, they should be regarded as villi rather than as papillae (Gerlach). They are never found be- low the upper third of the malleus, nor are ever more numerous than eight. The finger-shaped ones are 0.02 mm. long, by 0.05 mm. in breadth, according to Moos,9 who asserts that they are prolongations or protrusions of the mucous membrane, covered by a single layer of ciliated cylinder epithelium, and contain one vascular loop. It is not yet decided whether they are constant in the foetus and new-born child or not. Fold of Mucous Membrane Enclosing the Chorda Tym- pani.-Near the upper boundary of the tympanic mem- brane the mucous membrane of its inner surface is re- flected over the chorda tympani, and back again to the drum-head. This duplicature is visible in some cases from without, as a grayish line, both before and behind the malleus. This fold or duplicature, being adherent to the neck of the malleus, is thus divided into an an- terior and posterior portion, and aids in the formation of the so-called pouches of the tympanic membrane (Von Troeltsch) which will be described later. Blood-vessels of the Membrana Tympani.-The tym- panic membrane is supplied by the tympanic branch of the inferior maxillary artery, and also by a short direct branch from the internal carotid artery, in the carotid canal. By the latter channel the membrana tympani may become engorged very quickly. Fig. 4148.-View of Inner Surface of Membrana Tympani. (Gruber.) A, Manubrium of the malleus ; 2?, the lower end of the manubrium; C, head of the malleus; D, body of the incus; E, short process of the incus; F, processus lenticularis of the in- cus ; G H, chorda tympani; I, inser- tion of the tensor tympani muscle. 337 Tympanic Mem- brane. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. There is in the tympanic membrane of the dog, the cat, the goat, and the rabbit, a series of vascular loops running from the periphery of the membrane tow'ard the malleus. A similar series of loops runs both posteriorly lines long, and can be removed with the malleus. After birth it unites with the under wall of the Glaserian fis- sure, and when the malleus is removed only a short piece of the former long process is found attached to it. This remnant attached to the malleus was all that was known of the former long bony process to the older anatomists, among whom was Folius, from whom this process has received the name of processus Folianus (Venice, 1645). In its entirety it has been called the processus Havii, after Rau or Ravius, who described it to his pupils. It has also been called the processus longus seu spinosus. It is united to the Glaserian fissure, in adults only, by a mass of ligamentous tissue which permits slight motion in any direction. The head and neck of the malleus pro- ject into the tympanic cavity, and are entirely free from the tympanic membrane. The rounded smooth head is directed anteriorly, and the surface which articulates with the incus is directed backward. The long diameter of its articular surface runs vertically ; the short diam- eter horizontally. In the direction of the former the ar- ticulating surface has been said to resemble a saddle, for the surface is divided a little below the middle by a hori- zontal ridge, and depressed on each side of it. This ar- ticulating surface is also concave in its short diameter, i.e., from without inward. If a shallow oval basin, the long diameter of which is considerably greater than its short diameter, be placed across a ridge and then bent downward, and at the same time slightly twisted on it- self, the cavity thus formed will fairly represent the ar- ticulating surface of the malleus. The neck of the mal- leus connects the head with the manubrium, or handle. It makes, with the head, an angle of about 135°, opening inward toward the drum cavity. There are three dis- tinct surfaces on the neck of the hammer ; a broad inner one turned toward the tympanic cavity, bounded in front by the process of Rau, or the long process of the mal- leus, and behind by the long, low, bony elevation for the insertion of the tendon of the tensor tympani muscle, and an anterior surface, lying above the ridge running from the short process to the long process, and extend- ing to the angle made by the head of the malleus with the neck, and separated from the posterior surface by a sig- moid ridge for the insertion of the ligamentum mallei ex- ternum of Helmholtz. The posterior surface lies between the aforesaid sigmoid ridge in front, the edge of the ar- ticulating surface of the malleus above, the low, long process behind, and a line drawn from the insertion of the tensor tympani to the short process below. Of all the surfaces of the neck the posterior one glides most gradually into the manubrium. The handle or manubrium of the malleus, that part of the ossicle inserted into the tympanic membrane, also has three surfaces, which may, in fact, be considered prolongations downward of those of the neck. Since all these surfaces gradually approach one another, and are united in the tip or point of the manubrium, the latter may be said to resemble a three-sided bayonet, one ridge of which passes from the short process directly down- ward to the tip, and consequently is turned toward the external auditory canal. The lower end or tip of the handle of the malleus is flattened into a small disk, one surface of which is turned toward the auditory canal. This spot is plainly visible as the pale, round centre of the umbo. The long axis of the handle of the hammer is convex posteriorly and inward, so that when viewed from with- out the manubrium appears concave on its anterior and outer surfaces. This is especially marked at the lower third on the anterior surface, so that the manubrium ap- pears curved decidedly forward near its lower end, in the place of the membrana tympani. Along the ridge of the manubrium, directed toward the external audi- tory canal, several small, node-like prominences are sometimes observed. These are purely physiological ; but their origin is obscure. The dimensions of the malleus are as follows : It is nearly 9 mm. long, its manubrium being from 4 mm. to 5 mm. in length, and its head 2.5 mm. thick. The lat- Fig. 4149.-Membrana Tympani of Dog. (C. H. Burnett.) This wood- cut is from a drawing of a chloride of gold preparation, made by the writer, a, a, Vacancy left by the handle of the hammer, or malleus ; b, b, b, b, vascular loops ; c, c, ordinary capillaries, not looped. and anteriorly from the malleus toward the periphery of the membrane (Fig. 4149). There is also a distribution of blood-vessels in the tym- panic membrane of the guinea-pig peculiar to it. It is arranged in the form of a net, with coarse quadrangular or hectagonal mesh. In man the vascular mesh is simi- lar to that of the guinea-pig, but much closer and with coarser vessels. The Ossicles of Hearing.-In the tympanic cavity of mammals there are three small bones : The malleus, or hammer ; the incus, or anvil; and the stapes, or stirrup. Anatomists of a later day have shown that the once so- called os orbiculare, or os Sylvii, does not exist as a sep- arate bone ; but that that which once received this name is the processus lenticularis of the long process of the in- cus, which fits into a corresponding depression in the head of the stapes. The malleus, or hammer, received its name from Vesa- lius, and is divided into a head, a neck, and a handle. Fig. 4150.-Malleus of the Right Side. A, from in front; B, from be- hind. (Magnified four diameters. Henle.) a, Head : b, short process; c, long process; d, manubrium ; e, articular surface ; f, the neck. At the junction of the handle with the neck are two im- portant processes, viz., the short process in its outer as- pect, and the process of Rau or Folins, which passes an- teriorly into the Glaserian fissure. In the foetus and the new-born child this process is about three and a half 338 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tympanic mem- brane. ter is the greatest diameter of any part of the bone. The long diameter of the articulating surface of the malleus is about 3 mm. ; the short diameter is between 1.5 mm. and 2 mm. In twenty cases examined by Urbantschitsch only five were found in which the malleus was equal in length on both sides. The malleus is held in position by four ligaments, viz. : The ligamentum mallei anterius, ligamentum mallei superius, ligamentum mallei externum, and the ligamentum mallei posterius. The ligamentum mallei anterius is a broad band of fibres, holding the processus Folianus against the spina tympanica major. This ligament may be said to arise from the spina tym- panica major and to be inserted along the neck of the malleus all the way from the processus Folianus to the head of the hammer. A portion of it also runs from the processus Folianus to the short process of the ham- mer below, and to the membrana tympani above, thereby aiding the division between the anterior and posterior pockets of the membrana tympani; another fold of the same ligament runs from the processus Folianus down- ward, with a free margin, as far as the line correspond- ing with the inserion of the tensor tympani muscle. This aids in making the limiting wall between the anterior pocket of the drum head and the tympanic cavity. The round ligamentum mallei superius descends ob- liquely downward and outward from the tegmen tym- pani to the head of the hammer. Its function is to pre- vent the malleus from being forced outward. The ligamentum mallei externum is a very important collection of satin-like, tendinous fibres, which radiate cess is above this axis-ligament, and all below the short process is below this axis, or fulcrum-line. The liga- mentum mallei anterius of Arnold was once described as a muscle, and called the laxator tympani major (Soemmer- ing). It is, however, only a ligament which originates from the spina angularis of the sphenoid, passes through the petro-tympanic fissure (Glaserian fissure), and is in- serted into the malleus. Under the name of ligamentum mallei posticum seu manubrii, the ligamentum mallei externum of Arnold, Lincke describes a ligament which passes from the upper edge of the end of the external auditory canal to the short process of the malleus, and occupies the position of a supposed muscle, once called the AI. laxator tympani minor, or M. mallei exterior seu Casserii. It is now universally acknowledged that mus cular fibres do not exist here (Henle). The Incus or Anvil.-The middle one of the three auditory ossicles is the incus or anvil. The name is de- rived from the shape of its upper half. This small bone is divided into a body and two processes, viz., a long and a short one. The latter is also called the horizontal pro- cess. It is held to the posterior and to the upper walls of the tympanic cavity by ligaments. This is an im- portant point in the mechanism of the ossicles. The longer process is also called the descending ramus of Fig. 4152.-Right Incus. (Magnified 4 diameters. Henle.) A, Inner surface; B, view in front; Aa and Be, body; b, short process; e, long process ; cl, processus lenticularis ; f, articular surface for the head of the malleus ; c, surface which lies in contact with wall of tympanic cavity. the incus (see Fig. 4152). It curves gradually outward and downward, assuming a slight sigmoid shape ; at its tip or lower end it curves rather sharply inward, to unite with the head of the stapes by means of the pro- cessus lenticularis. The narrowest part of the incus is at the middle of the body of the bone. Beneath this part it widens out again anteriorly into the important part which locks with the malleus in all its inward movements, and posteriorly into the descending ramus or long process. The articulation between the mal- leus and incus is a true joint, in which is found a meniscus (Riidinger). If this articulation is viewed on its outer surface, i.e., on that side toward the external auditory canal, it would seem that the incus quite over- lapped or embraced the head of the hammer. When viewed, however, from the tympanic side, it appears that the largest share in the joint belongs to the malleus. This is due to the peculiar structure of this joint, first pointed out and explained by Helmholtz in 1869 (Me- chanik der Gehorknochelchen, etc.). The greatest length of the incus is in a vertical line passing from the top of the body of the bone through the long process. It meas- ures 7 mm. The horizontal upper edge of the body measures 5 mm. Its greatest thickness, 2.5 mm., is at its articulating surface for the malleus. Malleo-incudal Joint.-Helmholtz has graphically de- scribed this joint as follows : "It is, in fact, like the joint used in certain watch-keys, in which the handle cannot be turned in one direction without carrying the steel shell with it, while in the opposite direction it meets with only slight resistance. As in the watch-key, so here, this joint, between the hammer and anvil, admits of a slight rotation about an axis drawn transversely through the head of the hammer toward the end of the short pro- cess of the anvil ; a pair of cogs oppose the rotation of the manubrium inward, but it can be driven outward Fig, 4151.-Ligamentous Support of Ossicles seen from above. (Helm- holz.) e, g, Attachment of the ligamentum mallei externum; m, head of malleus ; i, body of incus ; hl, posterior attachment of incus; Tu. entrance to Eustachian tube from the tympanum; St. stapes; M.st. stapedius muscle; T.t. tendon of stapedius muscle leaving the cochlear process; Ch. T, Ch. T, chorda,tympani, marking the free edge of the fold of mucous membrane, bounding the pouches ; f, the upper tendinous fibres of the ligamentum mallei anterius, originating above the spina tympanica major ; Sp.t., malleo-incudal joint. from the sigmoid crest on the front of the neck of the ham- mer, and are inserted into the sharp edge of the segment of Rivinus on the temporal bone. It prevents the hammer from being forced inward, and, being inserted above the axis of rotation of the hammer, it prevents the manu- brium, which is below the axis of rotation, from moving too far outward toward the auditory canal. The ligamentum mallei posticum is really the poste- rior edge of the ligament just described as the external ligament of the malleus. As the line followed by this bundle of fibres passes through the spina tympanica major, and since it represents very closely the axis of rotation of the hammer, Helmholtz has suggested that it should be considered a separate ligament, and he has given to it the name it bears. As this ligament and the ligamentum anterius are, in a mechanical sense, one liga- ment, although the hammer comes between them, the two sets of fibres have been named the axis-ligament of the hammer (Helmholtz). The plane of the axis-liga- ment is not quite horizontal, being a little higher in front than behind. In all its motions as a lever (pendulum- like) the malleus swings about this axis as the fixed point. All portions of the bonelet above its short pro- 339 Tympanic Mem- brane. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. without carrying the anvil with it." It is of that kind of joint known as ginglymus. The mechanism of this joint is best understood when it is known that the malleus is a lever, the fulcrum of which passes just below the short process. This, of course, leaves the head and neck, i.e., the articulating surfaces, for the malleo-incudal joint, and all the free tympanic parts of the malleus above the line of support of the lever, the handle or manubrium being below. The latter is the long arm of the lever, and conse- quently all its movements are repeated in an opposite direction on the head of the malleus. Each inward movement of the handle, therefore, causes a slight out- ward motion of the head of the hammer, and a firm locking of the malleo-incudal joint, by which the incus is carried about an axis drawn transversely through the head of the hammer toward the end of the horizontal or short process of the anvil. The incus, or anvil, being also suspended as a lever, about the line just named, when all above that line moves outward, all below the line moves inward, i.e., as the upper part of the incus is moved outward the long process swings inward and carries the stapes ahead of it, thus forcing the foot-plate of the latter into the oval window. The Stapes, or Stirrup. -The smallest bone in the body, and the innermost one of the three auditory ossicles, is the stapes, or stirrup. Its name is derived from the strik- ing resemblance it bears to a stirrup. (Fig. 4153.) It is foot-plate, which fits into the oval window, is not at- tached to the latter, which leaves the stapes free to move slightly in and out of this fenestra. The mucous mem- brane of the tympanic cavity extends over the outer or tympanic surface of the base of the stapes. Regarding the fixation of the base of the stirrup in the oval window, the conclusions of A. H. Buck (1869) are as follows : 1. The base of the stapes is fastened to the edge of the oval window by means of a ligament of elastic fibres. 2. These fibres gradually converge toward the edge of the foot-plate of the stapes. 3. The ligament arises from the periosteum in the neighborhood of the oval window and passes over to the base of the stirrup, when it again as- sumes the function of periosteum. 4. The breadth of the ligament is the same all around the periphery of the base of the stapes. The Malleo-incudal and Incudo-stapedial Joints.-The malleo-incudal and incudo-stapedial joints may be re- garded as a variety of symphysis or synchondrosis.10 These connections, furthermore, are not to be regarded as true or ordinary joints. They are all of peculiar structure, since between the cartilaginous surfaces of the bones there is a fibrous, or a fibro-cartilaginous, inter- mediate substance. Riidinger reasserts the true joint- like structure of the articulations of the ossicula.11 He also maintains that in both the malleo-incudal and incudo- stapedial joint there is a fibro-cartilaginous disk con- nected with the capsular ligament, but not with the hyaline covering of the articular surfaces of the bones. If the tegmen tympani be removed, let us say, from the right tympanic cavity, the malleo-incudal joint and the incudo-tym- panic joint will beexposed to view (see Fig. 4154), and just in front of the head of the malleus, but below it, will be keen the tendon of the tensor tym- pani muscle coming up- ward and inward from the left, to be inserted into the tubercle on the neck of the hammer. Above this tendon, winding from within outward, and to the right (in the figure) around the neck of the malleus, is seen the chorda tympani on its way to the Glaserian fissure. The suspensory ligament of the mal- leus is attached to the under surface of the roof of the tympanic cavity, but is not shown in the figure, as it has been removed with the tegmen. Dimensions of the Ossicula.-Urbantschitsch, by com- paring the ossicula auditus of fifty different tympana, found that the malleus varied in length from 7 mm. to 9.2 mm., the average length being 8.5 mm. The short process varies from 1.2 mm. to 2.6 mm., with an average length of 1.6 mm. The long process (the Folian) was found in one case, an individual thirty years of age, to be 2.5 mm. long, and in another, a man twenty years of age, 5.8 mm. long. The manubrium has an average length of 5 mm. from the short process above to the point below. In the incus the distance of the upper end of the articular surface from the free end of the horizontal ramus is, on the average, 5.3 mm. The under end of the surface of the joint is 4.6 mm. distant from the incudo-stapedial joint. The incus is the most porous of the ossicles. The average length of the stapes is 3.7 mm. ; its average breadth between the rami, 2.3 mm. Its head is either entirely straight (twenty-nine times) or inclined toward the anterior (eighteen times) or posterior limb (three times); in one case the head pointed upward, i.e., toward the upper edge of the foot- plate of the stapes.™ The Weight of the Ossicula Auditus.-The weight of Fig. 4153.-Right Stapes. (Magnified four diameters: Henle.) A, From within ; B, from in front; C, from beneath ; b, foot-plate or base ; <1, capitulum ; c, anterior ; a, posterior shaft or crus of stapes. divided into a head, a neck, and two branches or legs (crura), and a foot-plate or basis. The head, which is like a cup-shaped button, is placed at the junction of the two crura. It is designed for the reception of the lenticular process of the incus, with which it forms a ball-and- socket joint. There is a meniscus in this joint, accord- ing to Riidinger. On the posterior surface of the head of the stapes the stapedius muscle is inserted. The two legs, or crura, are furrowed on their inner surface, which makes them stronger than if they were flat. The legs of the stapes arise from the base or foot-plate, forming a graceful arch, and unite above in the head as stated above. The foot-plate, or basis of the stapes, is nearly oval (slightly kidney-shaped), thicker at the periphery than in the centre, is slightly convex toward the vestibule, and concave on its tympanic surface ; it fits into the oval window, where it is held by a fibrous packing. This per- mits a slight inward and outward motion on the part of the stapes. When this ossicle is in position, the long axis of its base is horizontal and coincides with that of the oval window. In this position the convex edge of the base looks upward, and its concave edge, which gives it its slight kidney-shape, looks downward. The liga- mentum obturatorium stapedis is a thin membrane stretch- ing across the space between the base and the legs ; it is attached to the crista of the former and the furrow on the inner edges of the latter. The stapes (stirrup) meas- ures nearly 4 mm. from its head to the under surface of its base. The latter is 2.5 mm. long in its horizontal diameter, 1 mm. in its vertical diameter (the bone, of course, must be imagined in normal position), and about a | mm. thick at its edges. It is slightly concave toward its centre. , The Joint between the Base of the Stirrup and the Oval Window.-According to Helmholtz (" Mechanik der Ge- horknochelchen ") the base of the stapes is surrounded at its edge by a band of fibro-elastic cartilage 0.7 mm. thick. Over the inner surface of the base of the stapes, which presents toward the cavity of the vestibule, in the plane of its outer wall, extends the periosteum of the wall of the vestibule, but the fibrous band on the edge of the Fig. 4154.-Right Tympanic Cavity viewed from above; Malleo-incudal and Incudo-stapedial Joints. (Mag- nified 2 diameters: Henle.) c, Head of malleus ; e, short process of incus; /, tendon of tensor tympani muscle ; d, capsule of incudo-tympanic joint; a, ligamentum mallei anterius; b, chorda tympani nerve. 340 Tympanic Hem- brane. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the auditory ossicles varies greatly with the age of the individual. It is also a fact that the proportionate weight in the parts of the malleus and incus above the axis-line tends to act as a mechanical counter balance, and renders the two bones better able to swing upon the axis-line. It also serves to increase the delicacy of a mechanism which responds to sound-waves in excursions so infinitesimal that the highest powers of the microscope cannot detect them (Helmholtz). The three ossicles which have been described, when joined together, form the so-called chain of auditory bonelets. They then act as sound conductors between the membrana tympani, in the external ear, and the ves- tibule, in the internal ear (see Fig. 4155). Every inward movement of the tympanic membrane is followed by a similar i n - ward motion of the stapes, and the foot- plate of the latter im- presses the lymph in the labyrinth, and mediate- ly, the termi- nal filaments of the audi- tory nerve in the cochlea and other parts of the internal ear. The compres- sion of the lymph in the labyrinth finds a compensatory yielding at the membrane of the round window. Were this not so, the nerve-fila- ment would be in danger of too much compression with each sound wave which carries the chain of ossicles inward. The membrana tympani forms most of the outer wall of the tympanic cavity. The limit of this outer wall is made by the annulus tympanicus. Upon the inner surface of this outer wall of the tympanic cavity lie the manubrium of the malleus, the chorda tympani, and the dupli- cature of mucous membrane about the latter, which forms also the so-called pockets of the tym- panic membrane. These pockets or pouches of the membrana tympani are the spaces lying between the upper edge of the membrana tympani and the aforesaid duplicature of mucous membrane around the chorda tympani nerve, in the so- called horizontal portion of its passage through the tympanic cavity. There are two, the ante- rior or smaller one, and the pos- terior or larger pocket, formed in the following manner. (See Fig. 4156, 1, 2, and 3.) After the mucous membrane of the tegmen tympani has been reflected over the chorda tympani, it ascends again to reach the upper edge of the drum-membrane, in order to form the inner or mucous layer of the tympanic mem- brane ; therefore the chorda tympani nerve is found at the free edge of a fold of mucous membrane which, with the membrana tympani, forms a groove opening downward. (Fig. 4156, 3.) Since the chorda tympani clings to the inner surface of the neck of the malleus, this groove or pocket is divided into two compartments, named as already mentioned. They were first described by Von Troeltsch, in 1856. He claimed that the poster- Fig. 4155. -Diagrammatic Representation of the Relation of the Ossicles to one another and to the Membrana Tympani, and to the Internal Ear. (Buck.) T, Cavity of tympanum ; L, labyrinth ; M, A, E, meatus auditorius externus; hammer; A, anvil; 8, stirrup; M, T, mem- brana tympani; F, R, fenestra rotunda. weight of the ossicula, one to another, is not constant. In the new-born child the proportionate weight of the malleus to the incus is generally as 20 to 17, and in a malleus weighing 20 milligrammes, the weight would be distributed as follows : The head of the malleus, including that portion of the neck just above the short process, sixteen milligrammes ; the long pro- cess, including the short process, four milligrammes. In an incus weighing seventeen milligrammes the body of the incus, including the short process and the base of the processus longus as far downward as the lower lip of the inferior articulating surfaces, fourteen milligrammes ; and the long process with the os lenticulare attached, three milligrammes, the corresponding stapes weighing very nearly four milli- grammes. In the adult the weights of the malleus and the incus are, as a rule, more nearly equal; in some cases, however, the proportionate weight of the malleus to the incus is as seven to eight.13 According to the same ob- server, the distribution of the weight of the ossicula, above and below the axis-line (see p. 339), is as follows : In a malleus which weighed twenty-one milligrammes, and an incus twenty- five milligrammes, the combined weight of the portions of these two bones, above the axis-line, was thirty milligrammes ; that below the line, sixteen milligrammes, or in the proportion of 15 to 8. This preponderance of Fig. 4157.-Section through the Long Axis of the Mal- leus nt Right Angles to the Membrana Tympani. From an adult. (Brunner.) Bony edge of the so-called scute or inner edge of upper wall of auditory canal, in the segment of Rivinus; y, head of the malleus; p, neck of the malleus; o, handle of the malleus; I, short process of same; j, membrana flaccida; A, liga- mentum mallei externum ; m, chorda tympani; n. ten- don of tensor tympani; /, a cavity according to Prus- sak and others; a, carti- lage ; b, b, fibres of the membrana tympani ; c, dermoid layer of the mem- brana tympani; e, Haver- sian canals ; f, medullary space. Fig. 4156.-Diagram- matic Representa- tion of the Forma- tion of the so-called Pouches of the Mem- brana Tympani. (C. H. Burnett.) 1, Mu- cous membrane of the tegmen tym- pani ; 2, reflection of same over the chorda tympani; 3, pouch of the mem- brana tympani; 4. 4, inner surface of the membrana tym- pani; 5, section through osseous floor of the tympanic cavity ; 6, umbo of the membrana tym- pani ; 7, short pro- cess of malleus. 341 Tympanic Mem- brane. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ior one contained in its structure traces of the fibrous layer of the tympanic membrane, but this is denied by Gruber and Bochdaleck. The posterior pouch is about 3 mm. high and 4 mm. broad. This pouch is best seen when the tympanic membrane is viewed from within, but it can also be seen from without when the tympanic membrane is thin and well illuminated. The anterior pouch lies in front of the malleus, and is much smaller than the posterior pouch. Its inner wall is composed of raucous membrane only. It contains "all the elements which proceed from or enter the Glaserian fissure." There is a third or middle pouch of the tympanic mem- brane described by Prussak and Gustav Brunner (Fig. 4157, i). This cavity is bounded behind by the neck of the hammer, below by the upper surface of the short process of the malleus, in front by the membrana flac- cida, and above by a ligamentous band, the ligamentum mallei externum, which is inserted between the margo tympanica and the spina mallei. This cavity is separa- ted from the anterior tympanic pouch by the upper blind end of the latter abutting on the neck of the ham- mer ; posteriorly, it communicates with the tympanic cavity by a good-sized opening, above the position of the posterior tympanic pouch. This pouch, being thus placed in communication with the tympanum, may be- come filled with mucus or pus, and consequently rup- tured. Charles H. Burnett. 1 Archiv f. Ohrenheilkunde, Bd. xi., pp. 99-113. 3 Trautmann: Archiv f. Ohrenheilkunde, Bd. viii., 1673. 3 Trautmann : Loc. cit., p. 28. 4 Kessel: Archiv. f. Ohrenh., Bd. viii., 1874. 5 Gruber : Studien iiber das Trommelfell. Wien, 1867. 8 Gewebelehre, p. 707. 7 Helmholtz: Mechanism of Ossicles of the Ear and the Membrana Tympani. 8 Gruber: Op. cit.,p. 35. • Archives of Otology, 1885, p. 46. 18 Gustav Brunner : Monatsschr, fiir Ohrenheilk., No. 1, 1872. n M. f. O., No. 3. 1872. 12 Archiv fiir Ohrenheilkunde, Bd. xi., 1876. 13 Dr. C. J. Blake: Transactions American Otological Society, vol. i., p. 543. TYMPANIC MEMBRANE, ALTERATIONS OF THE. The tympanic membrane being a complex structure, stretched as a partition between the external auditory meatus and the tympanum, and consisting of a membrana propria of radiate and circular fibres in intimate relation with the handle of the malleus, and sheathed by exten- sions upon it of the coverings of the spaces which it separates-cutaneous externally and mucous within-its lesions are not only numerous, but complex. It may share in affections of the external canal or in those of the tympanum, and it has its own primary localized altera- tions ; yet in practice we generally find its lesions made up of two or more of these elements. Its disorders may be viewed most systematically from an anatomical stand- point, with reference to the tissues involved and the pathological lesion presented ; yet there are practical advantages in modifying this view so as to bring it into better accord with clinical methods, or even, at the risk of some repetition, in looking at both aspects of the matter. The major portion of the study of the pathology of the drum-membrane has been clinical, especially in America, where autopsies are comparatively difficult to obtain, particularly when involving, as these generally do, some mutilation of the head in the removal of the temporal bones. It seems in place therefore to review briefly the clinical methods of investigation. Upon illuminating the drum-membrane in a normal case, the points which especially attract notice are the lustre of the surface, the color and transparency of the membrane, its relation to the handle and short process of the malleus, the position and curvature of its surface with reference to the plane of the annulus, and its in- clination to the axis of the canal through which it is seen. Each of these points affords room for considerable physiological variation, and perfection of function is entirely compatible with wide deviations from an ideal appearance; yet it may be accepted as true that such variations are anomalous and noteworthy in every in- stance ; and their groupings into certain typical combi- nations are full of meaning. Inspection of the tympanic membrane is not at all an infallible means of diagnosis of ear disease-the appear- ances are only at times pathognomonic, often negative ; yet it can be of the greatest aid in a difficult study, and will often give indications for treatment of vital impor- tance, as well as furnish data for diagnosis and progno- sis. Facility in the inspection is, therefore, of impor- tance not only to the specialist, but to the general practitioner ; since it is into the latter's hands that the case generally falls at the critical early stage, when it is most readily controlled. Some experience is requisite to enable one to rightly comprehend the picture presented, and it often happens that the cases where prompt diag- nosis is most important are the most difficult to see and the most perplexing. Even to judge of the distance from the eye of this or that point is almost impossible at first, and the relation to each other of the parts seen sometimes demands most careful study by the expert for its comprehension. Sight must often be aided by touch, and the delicate probe be carried under full illumination to the point to be investigated. Crusts of cerumen or inspissated discharge, and flakes of epidermis, must be displaced in order to be sure that they hide nothing of importance. As a probe, the cotton carrier, especially the delicate, tapering form with a wooden handle, can- not be surpassed, its tip being guarded with cotton when tender tissues are to be touched. Delicate manipulation is requisite, for all of these parts are little tolerant of handling, even when uninflamed ; and mere awkward- ness or carelessness in the management of a speculum can not only cause pain, but may give rise to a quick flushing up of the drum-head and bottom of the meatus, which may materially change the picture and lead to misunderstanding of the condition. Indeed, it is a good rule to begin the inspection without any speculum, as there are many cases that may be well seen without it, and it is not well to be needlessly dependent upon artifi- cial aids. Yet the fact that its use alarms or pains the patient, while demanding extreme care and gentleness in its employment, should not be a bar to its insertion in every case where the view without it has not been wholly satisfactory. Specula of various patterns, as well as sizes, are of great convenience, since cases are met withat times where it is of great importance to examine the drum-membrane, but such an inspection is possible with only one of the specula at our command. As Dr. Buck has well pointed out, the conical instruments of Wilde, serving as dilators in case of swelling of the meatus walls, will not infrequently give us a view' of the bottom of the canal which cannot otherwise be obtained. Yet the surgeon should habituate himself to working without a speculum in all cases where it is not actually required as an aid to the full illumination which we need, since he may thus have the whole track under his eye and have more room for any operative manipulation. Ample illumination is essential, and artificial light should be employed whenever daylight is not sufficient. The color of the light must, of course, always be taken into consideration in our estimates, and it must be borne in mind that the artificial light generally seems to have a greater power of penetration, and brings to view details behind the membrane more perfectly than does diffused daylight. Direct sunlight is only rarely available, and should be reflected into the ear by a plane mirror only, since its concentration by a concave mirror may burn. Ordinarily it will dazzle the observer as much as help him, unless Lauder Brunton's speculum is used. This in- strument, with its magnifying lens, is sometimes of great use in studying doubtful cases ; and with the ordinary speculum and mirror a magnifying lens of three or four inches focus is sometimes very useful. The pneumatic speculum of Siegle, already described (Fig. 955), is of great value in diagnosis and often in treatment, and should be constantly employed. The forehead-mirror, if of convenient form, is much to be preferred to the hand-mirror, as it gives the observer at all times the use 342 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tympanic Mem-* brane. of both hands, and with it the surgeon will be much less often in need of specula to succeed in illuminating and studying the ear. The various methods and means of in- flating the tympanum through the Eustachian tube, come into constant requisition in the study of the conditions of the drum-membrane ; but having been already fully treated, need no further notice here. Congenital.-In considering the anomalies of the drum-membrane, we need not delay long over its con- genital variations. Not that there is any doubt as to their occurrence, but because they generally consist in so slight a degree of variation in size, form, thickness, or color as to be within merely physiological lim- its, or else are but parts of grave defects of structure, which over- shadow them in importance and are almost incompatible with the posses- sion of hearing. There is room to doubt whether genuine cases of defect, total or partial, of the tympanic membrane, which were to be ascribed to lack of development, have been met in individuals possessed of anything like normal hearing ; and it will probably be wiser to consider as pathological lesions (sometimes prenatal) the instances of such anomalies that have been recorded. Such is the attitude to-day of most authorities as to the foramen of Rivinus-an open- ing which has been described as constantly occurring in the membrana flaccida above the short process of the malleus. It is often not to be found by careful search ; while, on the other hand, its presence is quite certainly pathological in some cases-a point that will be referred to later. This is well stated by Riidinger recently : " I can in conclusion make the statement that my unbroken series of heads of many reptiles, birds, mammals, and of the human foetus, have shown that no open epithe- lial hiatus, no foramen, and no epithelial-lined canal ex- ists in the drum-membrane." "A normal foramen of Rivinus does not exist " (Schwartze).1 Abnormalities of the ossicles have been occa- sionally met, as in the case of the hook-shaped malleus- handle observed by Buck2 (Fig. 4158); and Hinton3 has figured a case where a process, apparently of solid bone,extended horizontally backward from the neck of the malleus. Other less conspicuous irregularities of the malleus are not very infrequent; but in some at least of these there is room for the belief that we have instances of united fract- ure. A matter of consid- erable clinical importance deserves notice in this con- nection-the inclination of the plane of the drum- membrane, or better of the annulus, to the axis of the external auditory meatus. This is unquestionably sub- ject to very considerable variations as an individual peculiarity; but the view which ascribed the differences to a variable relation of the planes of the two drum-membranes to each other and to the plane of the base of the skull, is probably errone- ous. Pollak and Politzer4 have shown that the inclina- tion of the plane of the annulus is fairly constant-being no greater in the infant than in the adult; while daily clinical experience shows marked variations in the rela- tion of the axis of the external meatus to the planes of the skull. Further discussion of the point is not here in place; but this much is of importance as bearing upon the apparent obliquity of the drum-membrane as seen in life; and should be borne in mind in forming our judg- ments as to the shape and posi- tion of the structure in our clinical studies. Pathological.-The first point which claims attention in the examination of the tympanic membrane is the lustre of its surface, or its lack of lustre. The latter can hardly ever be regarded as normal, the dulness indicating that the epithelial covering is either rough or sod- den with fluid. The size, form, and brilliancy of the reflection, when present, is always note- worthy ; and a light spot else- where than on the lower ante- rior quadrant may be set down as anomalous. All gradations of opacity of the epidermis may be met, from the merest dull- ing of the "cone of light " to conditions where the structure is hidden by chalk-white scales. These scales are generally merely epithelial, but may contain chalky particles (Lu- cae) or cholesterine (Politzer). Although generally consecutive upon more marked involvement of the drum-membrane, this desqua- mation may be an independent affection, constituting an otitis desquamativa (Buck). False mem- branes are met in rare instances, generally of mycotic nature, but occasionally diphtheritic, " otitis crouposa." The thin dermis of the membrane may also be involved and show thickening and opacity, either coincidently with superficial disturbance, or as a residuum of past inflammation. It is quite often involved in otitis externa, especial- ly the parasitic form, where in rare instances the fungus-growth is con- fined to the drum-head, at least at first, and the mycelial threads pene- trate its tissue. Localized hyper- trophies are occasionally seen in the form of horny or warty out- growths, generally of elongated form, but sometimes flat and sessile (Buck). An instance of the former is shown in Fig. 4159. Other localized outgrowths occur as pearly nodules upon the surface of the membrane, often multiple, and generally consecutive to a long-standing tym- panic inflammation (Ur- bantschitsch).6 They pre- sent a pearly lustre, are firmly seated, and on rupt- ure of the thin sac are found to contain epitheli- um, fatty detritus, choles- terine. A notable instance is figured by Politzer, Fig. 4160. The only similar growth which I have seen occupied the site of a pouting per- foration which had healed several months before. They may disappear spon- taneously, and do not re- cur upon removal. More typical cholesteatomata of larger size are occasionally met, having the concentric epithelial structure inter- Fig. 4160.-In a young man whose ear-affection had lasted a year, there was a tiny per- foration in the lower anterior quadrant of the left mem- brana tympani, and upon the upper part of the drum-head were eight glistening globular bodies of pin's-head size ar- ranged in a semicircle. These were found with the probe to be hard and firmly seated upon the membrane. (Polit- zer.) Fig. 4158. Fig. 4161.-Extensive de- struction of membrana tympani, partially re- placed by a retracted and plicated cicatrix. The malleus-handle greatly thickened and apparent- ly truncated, with its short process covered with granulations. The incus seems lost and the stapes isexposedto view, covered by an almost invisible membrane through which its dim- pled head shows perfect- ly. The promontory is rough, and there is a red streak posteriorly of un- certain nature. Fig. 4159.-James D., aged seventy. A blackish conical mass, looking like cerumen, lay in front of the right drum membrane, with its outer part touching the anterior wall of the meatus. When seized with the forceps it was found to be attached to the short process, but was removed by slight torsion and traction. It proved to be a cuticu- lar horn, 6 mm. long by 2 mm. in diameter, composed of cap-like layers arising from the short pro- cess. No reaction nor recurrence followed its removal. Fig. 4162.-The left membrana tym- pani of a man thirty-six years of age, in great measure destroyed by scarlatinal otitis in childhood, only a triangular portion remaining an- teriorly. Its place is supplied by a thin cicatrix irregularly depressed, leaving the malleus apparently prominent, although really retract- ed and fast to the promontory. From the short process a blackish string, slightly bifurcated at its tip, projects forward and downward and moves but slightly under press- ure. 343 Tympanic mem- brane. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. spersed with crystals. One, superficially placed at the umbo, has been reported by Kiipper; others upon the substantia propria by Wendt; and Hinton has noted as a "sebaceous tumor" a similar growth upon the internal surface of the drum-membrane. (Vide Fig. 19, Pl. xxxi.) Granulations and polypi are occasionally seen upon the surface of the intact tympanic membrane, and are more frequent in cases of perforation. In chronic my- ringitis they are sometimes very marked, as shown in Politzer's case illustrated in Fig. 4184, where the whole surface is covered with them. The region of the short process may be- come a mulberry mass of minute granulations as in Fig. 4161, per- sisting long after all intra-tympanic inflammation is past ; and Fig. 4162 shows a case where a peculiar blackish string, projecting stiffly from the short process, seemed to be the remains of a shrivelled poly- pus which had its origin upon that structure. Tn a few instances they have been observed as marked villous outgrowths. Blisters at times result from the rapid out-pouring of fluid upon the drum-membrane, especially in acute my- ringitis ; and the epidermis may be raised into a promi- nent, tense, and transparent bleb, or the sac may hang down in front of the membrane. The contained fluid is often straw-yellow serum, but may be reddish or opaque. Abscesses occasionally form between the lamellaj of the tympanic membrane, giving rise to circumscribed yellowish, opaque areas, at times multiple ; and they may open upon the surface of the membrane, forming open ulcers or leading to perforation. Such conditions are rare, but since first noted by Wilde,6 they have occasion- ally been reported. The pain and interference with the hearing are apt to be considerable, and the differential diagnosis from commencing perforation by pus from the tympanic cavity is difficult. Pressure with a blunt probe will generally indent such an abscess, and the de- pression so caused will persist for a time ; whereas it would promptly disappear if the tympanum were the source of the fluid (Bock). Such a case is shown in Fig. 4183. Politzer figures a case where a superficial sac-like blister and an abscess were present side by side. Resorption may take place without rupture, and Urbantschitsch is of opinion that many chalky de- posits are at the site of such ab- scesses ; but evacuation is probably more common, and may take place in either direction. Opening out- ward they may form ulcers ; but these rather rare lesions are more often the result of injury to the sur- face of the drum-membrane, as by the contact of a foreign body or a ceruminous mass. Fig. 4165 shows an ulcer due to the last-named cause. As the tympanic membrane is very vascular and its two sets of capillary loops are prolongations of the external and in- ternal blood-channels, respectively, and are in communi- cation with each other, it quite readily becomes flushed by the injection of these vessels and thus loses its trans- parency. The vessels of the cutaneous surface are often of sufficient size to be readily discerned with the naked eye, not only in the band just behind the malleus-handle, but as radiating and branching lines of crimson color over the whole surface. Roughness in the use of the speculum, as well as more direct irritations of the mem- brane by instruments or otherwise, will cause sufficient congestion to bring into view many vessels even upon the normal drum-head ; and pressure upon the veins of the neck in the Valsalva inflation or other straining effort will produce a like result. As the outflow of blood from the tympanum is largely along the anterior wall of the meatus, pressure with a speculum may congest the mem- brane by interfering with its venous channels (Ur- bantschitsch). The congestion may attain any grade, the membrane in case of severe inflammation being sometimes of an almost uniform crimson ; and the cedema and infiltration which accompanies it may not only veil the individual vessels, but even hide the manubrium so completely as to obliterate all the normal appearances. The short process is gen- erally discernible, appear- ing like the " point " of an acne pustule in the red surface (Politzer). New- formation of vessels doubt- less also occurs in the infil- trated cutis, which may be thickened to many times its normal proportions, as show'n in the section of Politzer's, Fig. 4166. Blood may escape from the dis- tended vessels, or in case of violence even from nor- mal ones, and form ecchy- moses of varying size, or even prominent " blood- blisters." Absorption will usually take place in a short time and the stained area grow rusty and fade away ; but such spots at times persist long enough to migrate quite a distance across the membrane, gen- erally moving toward the upper posterior margin, and sometimes passing out upon the meatus wall. This is probably an evidence that the growth of the epithelial surface is centrifugal (Politzer) ; but the similar behav- ior of perforations of all the layers, which has been re- ported, seems harder of explanation. The substantia propria of the membrane may be thick- ened or thinned pathologically ; both alterations being more often irregular and localized. In the former case the opaque areas which result may be due to the deposit of fatty or granular matter, or to fibrous organization of exudates ; and either the radiate or the circular layer of Fig. 4163. Fig. 4165.-The right membrana tym- pani of a man sixty years of age after the removal of a hard and very adherent ping of cerumen. A dark red, rough and moist surface was seen in front of the malleus- handle, bounded by a raised edge of cuticle. The remainder of the membrane was nearly normal ex- cept for injection, and the light spot was merely lacking in brill- iancy. Examination of the ceru- minous plug showed that it had been in contact with the ulcerated surface. Healing was prompt un- der boric-acid powder. Fig. 4164.-Politzer illus- trates a large tense sac hiding the upper poste- rior portion of the right membrane and tilled with clear yellowish fluid. It disappeared in two days. Fig. 4160.-Transverse Section of Inflamed and Thickened Membrana Tympani, showing distention of the vascular channels and small- cell infiltration of the cutis, with little or no change in the mucous surface and the substantia propria. From a woman dying of puerperal fever in the course of which otitis media, without perforation, de- veloped. e, Epidermis ; c, thickened cutis with its vessels ; pr, fibrous membrana propria ; s, moderately infiltrated mucosa. (Politzer.) fibres may be the seat of the change, giving a correspond- ing form to the thickened area. As in the arcus senilis of the cornea, such a change is apt to take place in the periphery of the drum-membrane in advanced life, some- times blending with the normal peripheral opacity, or again lying wholly within it. Exudation products are prone to undergo calcification, and even true ossification 344 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tympanic Mem- brane. has been demonstrated, as shown in Fig. 4167, from Politzer. Calcification is a frequent result of chronic suppurative inflammation, but may also occur in the non- suppurating form, as first noted by Moos. The deposit is usually of amorphous chalky grains in the corpuscles and around the fibres of the substantia propria; but the deposit often ex- ceeds the thickness of the normal membrane and involves or sup- plants all the layers. Cases are not infrequent where chalk deposits seem to stand out above both the inner and the outer surface of the membrane, and give a gritting sensation and sound when touched with the probe. So, too, in clinical cases ; but careful study will usually show that the mass is sheathed with delicate membrane, w hich flushes on irritation. At times this cannot be demon- strated, and the entire structure seems to have been re- placed by the chalky deposit. The area involved varies greatly, as does the location ; the deposit occurring as a minute speck, as a small disk, a considerable crescent, as in Fig. 4168, or as an entire substitute for the drum-head. The area adjacent to the malleus-handle and the pe- riphery of the membrane are rarely involved, the intervening area be- ing the favorite seat; but in excep- tional cases the manubrium is en- sheathed in the calcification, and it seems to extend to the extreme mar- gin of the membrane. The edges of perforations are favorite sites for the change, as shown in Fig. 4169 ; and while the membrane is involved more often than cicatricial tissues, yet these may also calcify, as illus- trated in Fig. 4170. Such deposits are occasionally the seat of pigmen- tation. The deposit of chalky matter is usually a slow process, occupying months ; but considerable areas have been ob- served to form within a few weeks. The apparent growth is at times extremely rapid ; but wre have probably here only the uncovering of a pre-exist- ing' deposit by the clearing up of the epidermal layer which had hidden it from view. The mucous layer of the tym- panic membrane is usually involved in the very numerous cases of tym- panic inflammation, as well as in those of the drum-head itself. Its lesions are not often clearly rec- ognizable, however, as there is apt to be some opacity in the external layers modifying or hiding its ap- parent condition. It is generally markedly thickened in the secretive forms of otitis media, sometimes with villous or cystic outgrowths ; and rare instances are on record of patches of false membrane upon it in diphtheritic (Moos) and syphilitic cases, which could be recognized in the clinical study. Tubercles have been observed in it (Schwartze), generally soon breaking down ; and many of the cases of "sieve-like" multiple perfora- tion are probably to be thus explained {tide Figs. 4204 and 4179). They appear as circumscribed yellowish nodules of pin's-head size; and the drum- membrane is more often pallid than injected-an appearance increased by the presence of exuda- tion in the tympanum. Extravasations, infiltra- tions, and chalk deposits in it are rarely recog- nizable with certainty through the membrane in life ; but are not in- frequently found post mortem. Changes in the form of the tympanic mem- brane are numerous and important. Its curvat- ure as a whole depends largely, in the normal state, upon the tension of the tensor tympani; and, in all conditions, the action of this muscle is doubt- less considerable; while it is claimed that its retractive effect is increased after death by the rigor mortis. Weber-Liel and others have pointed out that the muscle often undergoes atrophic and sclerotic changes in diseased conditions of the Eustachian tube, in common with the tensor veli palati; and in such cases there is very apt to be retraction of its ten- don, sometimes to an extreme de- gree. Unequal pneumatic pressure upon the two surfaces is also an important cause of an unduly de- pressed condition of the drum- head, and is quite constantly seen in cases where tubal obstruction interferes with the ventilation of the middle ear. Partial retractions are also common ; generally of thin atrophic areas or of the thin dis- tensible cicatrices which close former perforations ; but quite of- ten of the central portion of the membrane alone - the peripheral part of the structure proving more resisting than the rest by reason of the greater develop- ment of the circular fibres. There is often a distinct angle formed between the part maintaining its position in the plane of the annulus and the indrawn area, con- stituting the "break" which the Germans call "knickung." " Kneeing" might be offered as an English term in lack of a better. This is usually visible at the lower anterior portion of the disk, near its margin, and will give rise to a bright curvilinear reflection, parallel to the margin and generally close to the annulus tendinosus, in distinct con- trast to the darker aspect of the adjacent depressed sur- face. A representation of such a condition is given in Fig. 4171, after Politzer. More than one such reflection may be visible, indicating that several such abrupt " terrace-like " sinkings are pres- ent in the membrane, as illustrated in Fig. 4172. Fig. 4167.-Section of a Partially Calcified Membrana Tympani from a Young Man, who died of Tuberculosis after Suffering with a Purulent Otitis. The layers of the membrane are altered beyond clear recognition, and a small area in the midst of the calcification shows bone corpuscles. (Politzer.) Fig. '4170.-E xtensive Horse-shoe of Calcifica- tion in the Right Mem- brana Tympani of a Girl of Nine Years, in whom Suppurative Otitis fol- lowing Scarlatina had existed for years. The discharge ceased under treatment and the per- foration at the umbo be- gan to close by cicatriza- tion. Six months later the closure was far ad- vanced and the cicatrix was the seat of a chalk deposit, thinner than, and separate from, tho older calcification. Fig. 4168.-Right Mem- brana Tympani, show- ing an Oval Cicatrix closing a Perforation in Front of the Manubri- um. Posteriorly a large crescentic mass of chalk occupies theentire thick- ness of the membrane and stands out above it on both surfaces. From a preparation of Polit- zer's in the College of Physicians, Philadel- phia. (Randall and Morse.) Fig. 4169.-Retracted Left Memhrana Tympani. showing a Depressed and Adherent Cicatrix below the Umbo, with Calcifi- cation of the Margin of the Perforation. Below the short process, a round disk of chalk ap- parently standing above the general surface. Fig. 4171.-A Schematic Section of an Indrawn Membrana Tym- pani, showing Abrupt Change of Plane near the Lower Margin. The edge of the depression being at right angles to the illuminat- ing rays, reflects them back and forms a narrow glistening line ; while the adjacent surface is de- pressed so as to give back little of the incident light. (Politzer.) 345 Tympanic Hem- brane. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. When the membrane, as a whole, is retracted, there is usually a marked change in the size and form of the light spot. It often loses the triangular form which has secured it the name of "pyramid" or "cone of light," and may be shortened, narrowed, reduced to a mere point, and perhaps even lost, though the latter condition is prob- ably due to concomitant dulness of the surface. The handle of the malleus is changed in direction, being drawn inward, and this may manifest itself either in foreshorten- ing or in apparent deviation, gen- erally backward, from its normal position, rarely forward. The ex- planation of this appearance is readily seen from Figs. 4173 and 4174, where the former shows the normal inclination of the drum- membrane and the manubrium, and the dotted lines indicate how far the tip of the handle really lies behind the short process, and how much shorter it appears than it really is. In the latter figure, a retracted drum-head is shown, in which the manubrium is in the usual line of sight, and its short process would seem almost directly in front of its tip. The umbo would hence appear raised, and the up- per portion of the membrane appear in profile, since its plane would be in the line of sight. The retraction of the membrane may be extreme, constituting the condi- tion of "collapse" (Wilde), illustrated in Fig. 4175, where the manubrium is so drawn up and back that its tip is higher than the short process. The membrane, atrophied by stretching to a scarcely visible film, is closely ap- plied to the inner wall of the tympanum, except down and anteriorly over the mouth of the Eusta- chian tube. The localized depres- sions of atrophied areas or of cicatricial membranes form dark spots which can at times hardly be dis- tinguished from open perforations. They may be in contact with the inner wall, and reveal its convexity and color as clearly as though it were covered merely with a film of moisture. The thin membrane is usually glisten- ing and gives back a reflection that aids in its recognition, but at times only the disten- tion of the lax tissue, by in- flating the tympanum or rare- fying the air in the outer canal, will reveal its presence. Such a case is shown in Figs. 4176 and 4177, where a large depressed cicatrix, which is almost invisible, becomes a marked bubble-like protrusion upon using the air douche. The tympanic membrane may also be displaced out- ward, rarely as a whole, al- though such cases have been described, where the reddened convex surface seemed like a polypus filling the bottom of the meatus. Partial bulg- ing is not uncommon, being most usually seen in the upper posterior quadrant of the drum-head, where the plane of the membrane is most nearly in the line of light, and any increase in convexity being seen in profile is most noticeable. But this region is most often distended in fact as well as in appearance, probably for the same reason that it is more mobile, viz., that it is less tightly stretched by the action of the tensor tympani. Its nearly horizontal position makes it more easy for exudation to re- main in contact with it, and fluid coming from the closely adjacent antrum may readily be collected here. Inflation of the drum cavity will generally affect this area most markedly, and the distention of the cavity by secretion at times causes a bagging forward of this quadrant which may conceal the malleus-handle, or even hang down like a purse in front of the lower portions of the membrane, as in Fig. 4178. The partial bulging formed by the inflation of disten- sible cicatrices has been already noted, as also the fact that a col- lapsed membrane becomes at times convex by reason of its being pressed upon the convexity of the promontory ; both are conditions ordinarily recognized with ease, but may at times present puzzling appear- ances. A clinical point may be noted here-that it is important to examine both drum-membranes in every case before inflating in any way, even al- though attention is asked to only one ear;so that any such change in the posi- tion of the drum- head may aid and not embarrass the diagnosis. Such lim- ited protrusions of the membrane are rarely possiblewhcre the fibres of the mem- brana propria are intact, and are evi- dences that these fibres have been either destroyed or pressed aside. Ac- cordingly, we find that these thin cic- atrices or distentions contain little or no strong fibrous tissue, but consist almost solely of the cutaneous and mucous layers. Where the whole membrane is "collapsed" its peculiar fibres are atrophied almost beyond recognition. Perforations of the tympanic membrane are frequently met, almost always caused by the bursting through of fluid secretion from the drum cavity, though oc- casionally as the results of trauma- tism, and rarely from external ul- cers or interlamellar abscesses. The form, size, and character of such openings are of infinite variety, but they generally begin as small round- ed openings, most frequently situ- ated in the thinner intermediary zone midway between the manu- brium and the periphery, and have edges slightly thickened and round- ed. From such beginnings they may enlarge rapidly, especially in scarlatinal and diphtheritic cases, and lead to total de- struction of the membrane. The thickened margin is rarely destroyed, however, and the portion adjacent to Fig. 4172.-Retracted Membrane, showing Foreshortening of Mal- leus handle, Prominence of the Posterior Fold, and Visibility of the Margin of the Pocket of v. Troelsch as it passes forward to the Manu- brium. The light spot is shortened, and beyond it anteriorly are two parallel curvilinear bright lines, marking the edges of abruptly depressed areas of the drum-head, one within the other. From a girl of ten years, with long- standing nasal and tuba! obstruction. Fig. 4175.-Left Membrana Tympani of a Boy of Six Years with Nasal and Tu- bal Obstruction. Manu- brium drawn up almost out of sight, the tip be- ing higher than the short process ; behind it the incudo-stapedial joint is visible, and below and posteriorly the dark niche of the round window is discernible. There is a faint reflection of light near the normal position and a stronger one on the promontory near the stapes. Fig. 4176.-A large rounded loss of sub- stance of the mem- brana tympani be- low reaches up to the tip of the manu- brium, which pro- jects slightly into the upper margin. It is closed by a deli- cate cicatrix applied to the promontory and moulded upon its inequalities. The edges of the depres- sion are sharp-cut and overhang, so that the area seems an unclosed perfora- tion. Fig. 4177.-Inflation of the middle ear forces the delicate cicatrix out like a bubble into the meatus, where it seems larger than the opening and hides its edges and the handle of the malleus. In a few minutes the dis- tended sac loses its tension, and be- comes plicated as it collapses, soon to resume its old posi- tion in contact with the inner tympanic wall. Fig. 4173.-Diagram of Normal Posi- tion of Membrana Tympani, show- ing the Inclination of the Manubri- um and Upper Segment to the Axis of the Auditory Canal. Fig. 4174.-Diagram of a Retract- ed Membrana Tympani, show- ing the Manubrium drawn al- most directly inward. Fig 4178.-Purse-like Dis- tention of the Upper Pos- terior Quadrant of the Left Membrana Tym- pani. (Schwartze.) 346 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tympanic Mem- brane. the manubrium is also so nourished that, unless the mal- leus-handle undergoes caries, a rim of membrane will re- main along it. Its tip, however, often seems to protrude into the opening, especially when the perforation is dry. A single perforation is the rule, but two or more are oc- casionally met, and sometimes, generally in tubercular cases, they are so numerous that the condition merits the name of "sieve-like perforation " (Schwartze). Such a case is well illus- trated in Fig. 4179, from a drawing kindly furnished by Dr. Spear, in whose practice it occurred. The pallor of the lower part of the membrane was in marked contrast to the purplish infiltration of the part about the manubrium, where all details were lost, and suggests an extreme malnutrition, which prob- ably led to a rapid and ex- tensive destruction, though the case was lost sight of before this occurred. From a clinical point of view the perforations in the membrana flaccida are of peculiar importance, es- pecially those above the short process, since they are not only badly located for good drainage, as are all perforations high up, but are apt to be associated with rather inaccessible areas of suppuration in the pouches of Prussak and v. Troelsch, which frequently lead to caries of the ossicles and of the margo tympanicus. Von Troelsch suggests that the thinness of the membrane closing the "foramen of Rivinus" predisposes to perforations in Shrapnell's membrane-a needless utilization of an ex- ploded idea. Fig. 4180 shows such a perforation, and Fig. 4202 in a later section, illustrates the destruction of the bone in such cases. Also clinically noteworthy are the perforations which form at the summit of a protruding portion of the drum- head, since they mark an insidious and dangerous form of suppuration ; and as they afford but imper- fect and easily obstructed exit to the discharge, reten- tion is very apt to occur. Perforations usually remain open as long as any dis- charge continues; and then, except in unfavorable cases, tend to cicatrize. In frank acute cases, where the open- ing has been small, it may close with astonishing ra- pidity and leave no trace behind, the fibres of the substantia propria having been merely pressed aside. Where there has been loss of these fibres the healing is never so complete, and a weak cicatrix is left, which is apt to be depressed. In unfavorable cases closure does not take place, but discus- sion of this may be deferred to the account of suppura- tive conditions of the tympanum. Myringitis.-Turning now to the clinical side of the subject, we have first to consider the inflammations lim- ited to the drum-membrane itself, myringitis, acute and chronic. Acute myringitis may arise from any of the causes ordinarily producing coryza, such as exposure to cold and dampness, and also from localized violence. The direct action of cold wind upon the drum-mem- brane may be a localized cause when the auditory meatus is unduly open ; and physicians using any form of aus- cultation apparatus which dis- tends the orifice, should bear this in mind and protect the ear by a flake of cotton when the air is felt to enter too freely. The inflammation is generally characterized by severe pain and some dulness of hearing, with a sense of fulness and tinnitus ; but these latter symp- toms depend largely upon in- volvement of the remainder of the tympanum, and are, there- fore, variable in degree and inconstant. Movement of the auricle, pressure upon the tra- gus, or movements of the jaw, may all increase the pain, which ordinarily has rather a shooting than throbbing character. Inspection shows in the earlier stages congestion of the drum-membrane, with marked vessels passing down behind the hammer-handle to send out radiating branches to inosculate with those coming in from the periphery. The lustre and color of the membrane rarely remain long unaltered; the surface soon becomes dull through the loos- ening of its epidermis, while serous infiltration gives a yel- lowish , or increased congestion, a suffused red tint to the whole structure. The vessels of the mucous surface can rarely be distinguished through the membrane ; but they brighten the redness of its tint, as may also the congestion of the pro- montory beyond. The opacity caused by infiltration is apt to mask or wholly obliterate both of these elements, however. Comparison of the degree of redness with the visibility of the malleus-handle will usually indicate which of the layers is involved. Serum is generally poured out sufficiently to dull the lustre of the epidermis, and may raise it in blisters from the dermis ; and extravasa- tions may occur either as mere blood-stained blotches or as blood-blisters standing out prominently above the sur- face. Blisters lifting the cutis as well as the epidermis will usually be more opaque and redder than those of the superficial layer only. The bursting of blisters may leave ex- coriated surfaces, which become open ulcers ; but more usually they collapse without manifest rupture, and the epidermis returns to its place, to be thrown off only in the later stages of the affection. Ab- scesses may form between the la- mellae (Wilde), and show themselves as yellowish points much resem- bling the localized pointing of pus perforating from the tympanum. They may follow superficial cau- terization of the membrane (Schwartze), or occur independent- ly, but coincident with intra-tym- panic suppuration. The diagnostic point has been made that pressure with a blunt probe will usually indent the prominent and inelastic abscess, and this dimple will remain visible for some time, as shown in Fig. 4183, from Schwartze. The contents of an abscess are also unaffected by inflation of the tympanic Fig. 4181.-Injected Membrana Tympani, showing Radiating Network of Vessels with Hid- ing of the Manubrium, only the Short Process showing as usual. (Politzer.) Fig. 4179.-Fivefold Perforation of the Left Membrana Tympani. The openings are round and of small size, two of them tiny, and are all in the intermediary zone. Above the membrane is so infiltrated and swollen that no trace of malleus is visible; the rest of the surface is yellowish-white and sodden, with- out visible vascularization except for the three conspicuous vessels which run up to the umbo. The tympanum is full of fluid, which ap- pears at each opening and gives a brilliant little reflex, pulsating with the heart-beat. (Spear.) Fig. 4182.-Shows "a Blister of the size of a Hempseed in Front of the Umbo. From a man twenty-four years of age, who for two days had had an inflammation of the membra- na tympani. Ou the third day of the disease the blister had disappeared, the dim membrana tympani was cov- ered here and there with black ecchymotic spots; on the fourth day the power of hear- ing, which was only slightly lessened during the existence of the blister, was again en- tirely normal." (Politzer.) Fig. 4180.-Right Membrana Tym- pani of a Boy of Five Years, with Constant Discharge for Three Years. A perforation about 1.5 mm. in diameter is with difficulty seen above the short process, and intra -tympanic injections bring away epithelial flakes and masses of fetid secretion. The rest of the membrane is slightly opaque, thick- ened, and injected. Fig. 4183.-Inter!iniellar Abscesses of Hight Mem- brana Tympani, one at Umbo showing the Pit- ting caused by Pressure of a Probe. Three others are seen down and for- ward. (Schwartze.) 347 Tympanic mem- brane. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. cavity ; and, on evacuation, no complete perforation will be found. They may burst inward instead of outward (Politzer), a result recognizable by the sudden disappear- ance of the pus and the distensibility of the empty sac on using the air douche. Opening outward, they may form open ulcers or lead to perforation. Toynbee is authority for numerous instances of ulceration, sometimes exten- sive, found post mortem, which was limited to the mucous or to the cutaneous surface; but it is questionable if either of these conditions has been often recognized in the living subject. Abscesses and ulcers must be set down as rare conditions, and such appearances may almost always be ascribed to otitis media, and perforation may nearly al- ways be accepted as conclusive evidence that the pus has been poured out in the tympanum, and has thence forced its way through all the layers of the drum-membrane. The whole membrane is usually involved in the inflam- mation, but cases are met where the affection is only partial. The upper portion is usually earliest and most markedly involved, and the malleus-handle may be wholly concealed by the congestion, infiltration, and epi- dermal thickening, even its short process ceasing to stand out distinctly as a white point. Resolution usually takes place promptly under favor- able conditions, without treatment ; and the membrane loses its infiltration, its congestion, its opacity, and its dulness in the order named, a scaly desquamation and a liability to congestion on slight occasion remaining for some time. Good hygiene only is called for. The ra- pidity of the resolution marks the difference between my- ringitis and otitis media ; the latter will be also likely to show considerable interference with the hearing; and the occurrence of this symptom would give indication for gen- tle inflation, otherwise un- called for. Severe pain should be met by leeching and ano- dynes. With less favoring condi- tions, or after undue interfer- ence, the affection may pass over into the chronic form, or may constitute but a part of an inflammation of the tym- panum. Chronic myringitis occasionally arises indepen- dently-its causes being often obscure, or such as become efficient only by many repetitions-but more often it occurs as a relapse after an acute attack, or is left after an otitis externa or media. Progressing dulness of hearing may be its only symptom ; but there is generally enough of pain and discomfort to call the attention to the ears, and lead to the employment of various household reme- dies of very questionable benefit. Inspection will gener- ally show quite marked opacity, general or local, the epidermis rough or scaly, the vessels visible or perhaps so engorged as to blend into a general tone of red. Ul- cerated and granular surfaces are generally to be found, and the secretion may be profuse and very fetid. Papil- lary or polypoid granulations may occur (Fig. 4184), as also abscesses and perforations. Politzer notes cases where the tympanum was simultaneously involved and filled with secretion, and the discharge was free into the meatus ; yet no perforation could be discovered through- out the history of the case. This absence of perforation and of the muco-purulent character of the discharge, which would point to an intra-tympanic origin, may be the only differential points to distinguish it from an ordi- nary purulent otitis media. The deafness, which might be extreme, would be largely referable to the deeper trouble. Resolution is probably the natural tendency of the disease ; but interference, accidental or injudicious, is so usual that such a result is very rare. Recovery may take place with little thickening of the membrane and still less functional imperfection ; but there will be usually remains of the tympanic accompaniments. The treatment differs in no marked manner from that of otitis media. Cleansing, drying, and the boracic-acid powder will usually meet prompt success. Crusts may form upon the membrane and suppuration recommence beneath them, so it is well to use the boric powder but lightly as the discharge lessens, so that inspection and cleansing shall be easier. For the granulation Polit- zer wrarmly commends the tr. ferri chlorid. or the gal- vano-cautery. Wilde used topical applications of silver nitrate, even when no granulations were present, and I have seen cases where such treatment seems to have been successfully employed. Incisions, either as superficial scarifications or penetrating all the layers, have been commended, especially for the acute and subacute cases ; but may often be advantageously substituted by leech- ing. Injuries of the drum-membrane are comparatively rare accidents, thanks to its well-protected location at the bottom of a narrow and tortuous passage; yet it may be penetrated by foreign bodies, accidentally or inten- tionally introduced, or may be ruptured, either by vio- lence involving the whole head, or by pneumatic press- ure. The last injury is occasionally seen as the result of explosions or the discharge of fire-arms, especially heavy ordnance, or from a box or other blow upon the ear. Toynbee,7 lays stress upon the importance of unexpect- edness in producing the result, and believes that, if given from behind, a very moderate blow may do more than a severe one that is seen coming. The further point which he makes, that there has been in almost all of these cases pre-existent disease, is probably well-founded ; and the condition of the uninjured ear, and of the pharnyx and nares, will generally afford evidence in favor of such a view-a point of some importance in medico-legal cases. The right hand being generally used in strik- ing, and the blow given from the front, the left drum-membrane is more often the seat of injury. Most writers have seen a few cases, but rarely any large number. One which I have observed is shown in Fig. 4185, and was seen on the third day after the young man had received a severe blow with the closed hand upon the left ear. An explosive noise with pain, tinnitus, and lessened hearing im- mediately resulted ; and a serous discharge soon began, which was quite purulent when he presented himself for treatment. The ragged tear extended vertically almost across the pos- terior half of the membrane-otherwise the case was an ordinary acute purulent otitis media. The other ear had long been subject to a purulent discharge, and the pha- rnyx was granular and in bad condition. Improvement was rapid under cleansing, inflation, and boric insuffla- tion ; but he passed out of sight before the rupture had cicatrized. Politzer cites the ten years' experience of Staff-surgeon Chimani, who had seen 54 cases among 5,041 soldier-patients, of which 38 were due to blow's upon the ear (all but tw7o on the left side), 6 to falls upon the head, 3 to the kick of a horse, 2 to the blast of a trum- pet, 1 to a fall into w7ater, and only 2 to the discharge of heavily loaded fire-arms close to the ear. The introduc- tion of breech-loading guns has removed what was for- merly a frequent source of such accidents, since now artillery-men stand more out of the influence of the con- cussion. A very interesting observation has been made by Sexton of a group of cases injured by the premature explosion of a shell. Wilde ascribes a rupture to the " kick" of an overloaded fow'ling-piece. Sexton notes rupture due to pulling the ear, the lesion generally occurring in the membrana flaccida. Air-pressure in diving-bells and caissons has been known to cause rupture, and diving to a considerable depth was followed by rupture in two cases reported by Wilde. I have keen recollection, from personal experi- ence, of the painful pressure upon the drum-membrane felt at twelve or fifteen feet below7 the surface. Violent coughing, sneezing, or blow ing of the nose, has been Fid . 4185.-Rupture of the Left Membrana Tym- pani. A vertical gap ex- tends almost across the posterior half of the membrane, and the ves- sels are full, especially behind the manubrium. Fig. 4184.-Chronic Myringitis with Marked Polypoid Out- growths Covering the Mem- brane. (Politzer.) 348 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tympanic Mem- brane. known to cause rupture, as in the case figured by Toynbee (Fig. 4186), and the bleeding from the ears occasionally seen in whooping-cough may be due to this cause. Yet air-pressure from within has prob- ably never burst a membrane ap- proximately healthy, unless in the cases where rupture with out- turned edges has been found in the ears of criminals executed by hanging (Ogston, Schwartze). The opposite condition, of rare- faction of the air in the meatus, has been known to produce rupt- ure. Biirkner figures such a tear caused by a kiss; and aeronauts have not infrequently suffered from bleeding from the ears, prob- ably due to a like lesion. Such ruptures of the membrane are generally described as straight or angled linear tears, gaping so little that the blood-stained margins alone mark the site until, on inflation, the lips of the opening are separated by the escaping air. Sometimes, however, they are round, oval, or polygonal; and Politzer seems to have most frequently met them in this form. They occur most often in the lower posterior quadrant, are rarely multiple, and their form doubtless depends upon the re- lation of their direction to the fibres of the membrana propria. According to Helmholtz, rupture of the circu- lar fibres should precede that of the radial, and thus give rise to the radiate openings which Politzer depicts (Fig. 4186); but the cases reported by others do not well agree with this. Rupture of the membrane by penetrating bodies is most often due to the introduction of hairpins, ear-picks, and similar objects into the meatus, either to remove ceru- men or because of irritative condi tions such as eczema ; a slight jar or other interference may then force the body through the drum- head. Instrumental interference for the removal of foreign bodies or impacted masses of cerumen, carried out with more energy than discretion, is also responsible for far too many injuries of this sort; and teachers are forced to preach the syringe as the only proper in- strument for such a purpose, even when, personally, they rarely employ it. Yet even the syringe is not harmless; and Urbantschitsch and others report cases of rupture from its use. Such an accident may be due either to close adhesion of the ceruminous mass to the membrane, or to the yielding of the unduly weak tissues before the stream of fluid, as would prob- ably have occurred in the case reported by Wilde, where the patient got water into the meatus in his bath, and pressing the finger in to dislodge it, forced the fluid through the membrane into the pharynx. Politzer notes penetration of the drum-head by flying splinters of wood ; and Lautenbach has reported a case where a beard of wheat, whirled into the air by a passing train, pierced the membrane and set up a severe inflam- mation. The penetration of the membrane by a twig has been frequently noted, generally brought about by a sudden turn of the head ; although Wilde tells of a man who fell upon his head, the twig thus entering his meatus. The only case which I have seen was in a gen- tleman, who met with the accident as he mounted his horse beneath a tree to which he had tied him. The meatus was here short, broad, and straight; and doubt- less it is so in the majority of such cases. In ruptures caused by efforts to extract foreign bodies or ceruminous masses, the body may be driven through into the tym- panum (Moos); and I recently extracted from the drum cavity, in an acute purulent otitis, a firmly impacted bead, such as is sometimes used on the tip of a penholder, which had probably been thrust through the membrane and left behind as the handle was withdrawn. Such a history was denied ; but the explanation was suggested by the recollection of a similar misuse of a penholder in childhood, which probably accounts for a cicatrix in my own right membrana. Furthermore, the drum-mem- brane has been pierced from within by a Eustachian bougie incautiously used ; and dislocation of the ossicles has probably been thus brought about, since a bougie thus passed will most often strike the malleus, some- times the other ossicles (Eitelberg). The character of the lesion in these cases will, of course, vary widely, the wound corresponding more or less with the size and shape of the vulnerating body. A rounded opening is doubtless most frequent. Injuries of the head by blows or falls are also not very infrequently accompanied by rupture of the drum-mem- brane ; and this forms one of the most important phases of this subject. Bleeding from the ears, and the escape of yellowish or blood-stained watery fluid, has often been pointed to as diagnostic of fracture of the base of the skull in such cases. It is quite likely that, in many, a fracture has taken place ; but careful investigation of the ear is called for before it is at all safe to assume that the cranial cavity has been opened by a fissure, and that the fluid which is escaping is cerebro-spinal fluid. The rupture occurs most often in the upper anterior portion of the membrane-Shrapnell's membrane-and is often accompanied by fracture of the thin Rivinian segment of the temporal bone ; but it is quite possible that the membrane may be torn without lesion of the adjacent bone, and that the bleeding, or the serous discharge, should come merely from it or from the tym- panum. An interesting case comes to mind, where a man fell in walking with a heavy beam on the left shoulder. He was more or less stunned, and shortly after, found that the left side of his face was paralyzed, and that he was deaf, with blood and serous fluid run- ning from both ears. When he visited my clinic two days later, there was sero-purulent discharge from each ear ; inflation forced air through each drum-membrane, but the swelling of each meatus made accurate diagnosis of the lesions impossible. The contusions of the stylo- mastoid region seemed to account fully for the damage to the facial nerve ; and the absence of marked re- action or of any other paralysis spoke against serious lesion of the cranial base, such as would involve both temporal bones. Speedy recovery under treatment made it very probable that the injuries were localized in the tympana and membranae, and that the injury to the facial was at its exit. Visible or otherwise indubitable fracture of the walls of the meatus may be met without recogniz- able implication of the cranial cavity or its contents, and may heal promptly and satisfactorily. To the aurist, it is important to know that, in all these cases, concussion of the labyrinth or other lesions may accompany the rupture of the membrane, and most seriously modify the prog- nosis as to the hearing. Fracture of the malleus-handle has been rarely seen- sometimes occurring without visible rupture of the mem- Fig. 4186.-Irregular Linear Rupture of Posterior Por- tion of Right Membrane Tympani, with its Edges in Apposition. (Toynbee.) Fig. 4187.-Double Rupt- ure of Right Membrana Tympani in a Woman of Thirty, produced by a fall upon the ear-seen on the third day. The two tears have radiating directions, and show marked gaping. (Polit- zer.) Fig. 4188.-Ununited Fracture of the Manubrium, the handle being broken at about its middle, and the lower fragment displaced backward. Valsalval inflation corrected the displacement, but it soon recurred. brane. Movements of the drum-head may cause wide displacement of the fragments, but inflation will usually bring them into good apposition, as in the case of un- united fracture observed by Weir (Fig. 4188), where 349 Tympanic mem- brane. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the separated fragments came into line upon the use of self-inflation. Union will usually take place, but mal- position is probable, as in the cases reported by Turn- bull 14 and Biirkner 15 (Fig. 9, Pl. xxxi.). Hyperostotic enlargements have been noted upon the manubrium, with resulting distortion (Politzer), and the history of traumatism made it probable that they were remains of callus after union of a fracture ; and a similar condition in a preparation of Politzer's, in the museum of the College of Physicians of Philadelphia, has been figured in Illustration 53. Randall and Morse. Hinton records a case where the manubrium seemed present in the drum-membrane, wholly detached and separated from the short process, and 1 have seen a case of a similar appearance. It is probable that such a frag- ment is more often lost, as in the case seen by Burnett,16 where the lower two-thirds of the malleus-handle had disappeared after fracture caused by violent attempts to remove a foreign body, and only the truncated upper third remained. An interesting case of displaced frag- ment is figured by Schwartze, which has been confused with Weir's case, and is cited as his, though having no similarity to it. Dislocation of the ossicles may also occur from such traumatism, and is, of course, very serious when the stapes is the structure involved. An extraordinary case was seen by Frankel, where efforts to remove a foreign body caused a fissure of the head of the malleus, and the girl, aged three years, died of meningitis. The exact causation of rupture of the drum-membrane, except when directly wounded by penetrating bodies, is not clear. Baumgarten thinks that ecchymosis precedes and conduces to the tear, and it is certainly almost in- variably present in the lips of the opening. Congestion of the vessels of the head doubtless has some influence ; and there is room to believe that in the diver, as also in the person executed by hanging, asphyxia is more im- portant than the pressure of air or water. The relation, in whooping-cough, of extravasations in the conjunctiva and elsewhere to similar lesions of the drum-membrane and to rupture, is worthy of study. In many cases, however, pneumatic pressure may quite surely be as- signed as the cause-the membrane yielding at its thin- nest and weakest part, mid-way between the umbo and the periphery. Like the surgical openings of the tympanic membrane, almost all ruptures tend to heal spontaneously, even al- though intercurrent accidents shall have set up suppura- tion in the drum-cavity. This purulent inflammation is more common after puncture, probably because of injury to the inner wall of the tympanum ; and will often be avoided if there is no improper interference. Protec- tion alone is required and inflation is uncalled for, un- less the manubrium has been fractured and displaced. The minimum of cleansing should be attempted, and leeching, in case of pain, is almost the sole measure ad- visable. A few cases have been published-notably polygonal lesions caused by a snowball striking the eai' -where at least for months no closure took place. Wilde states that they rarely close, although he reports numerous cicatrized cases. The healing is from within outward in the gaping cases (Politzer), and may leave no scar behind ; but generally a marked whitish linear cica- trix will remain, or the gap may be closed by a delicate distensible membrane as after perforation by purulent inflammation. The blood effused in the wound-margins will be absorbed, or will migrate across the membrane ; the injection, which may have been extreme, will disap- pear, and any defect of hearing, due to the lesion itself and not to labyrinth trouble, will pass away. Where suppuration has taken place, the case simply passes into a condition of purulent otitis media, and is to be treated as such. In catarrhal otitis media the membrane can long retain much of its normal lustre, and its curvature may remain unaltered ; but the various layers will usually be gradu- ally implicated, its opacity will increase through injec- tion, infiltration, and maceration of the epidermis ; and interference with the normal ventilation and drainage of the tympanum will retain the secretion and cause undue pressure upon the inner surface of the drum-head. The consequent pressing outward of the membrane may be general, and cause a flattening of its normal funnel shape ; but usually the relative weakness of one part causes it to yield, and a limited protrusion results. This is most frequently seen in the upper posterior quadrant, both for reasons already given, and because the libres are here longer and less well supported. It may be not unimportant, also, that this portion of the membrane is most nearly horizontal, so that gravitation may exercise some influence upon it. Behind it lies the opening into the mastoid antrum and cells, and the secretion escaping from them may easily be held in contact with the mem- brane here by swelling of the mucous membrane of the promontory. A bleb-like protrusion will thus form, tilled wholly or in part (Fig. 4189) by the exudate ; and its distention may cause it to overlap the malleus-handle, or even to hang down as a sac in front of the posterior half of the membrane. Rupture may occur spontaneously, or upon such slight violence as sneez- ing or blowing the nose, with evacuation of the fluid and per- haps rapid closure of the open- ing ; but such a result is rare, unless the exudate has taken on a purulent character. Ser- ous or mucous collections are rather slow of formation-the mucous membrane of the tym- panum and Eustachian tube is not so swollen as to offer insu- perable obstacles to the natural drainage, and the drum-bead, unless weakened by ulceration, will not prove the point of least resistance, but will with- stand the pressure upon it. The subjective symptoms of fulness, pain, tinnitus, and hardness of hearing belong to the tympanum in general rather than to the drum-mem- brane alone, and have been already treated of in a preced- ing volume. The acute catarrh is apt to be coincident with evident myringitis-the distinction between them being rather a matter of degree-and the diagnosis will depend upon which seems the primary or the preponde- rating condition. The chronic catarrh may be wholly "dry" or "sclerotic," either through the passing away of the acute stage, or since the causes have been such from the start as to reduce rather than to increase secre- tion. Infiltration of the membrane is very usual, how- ever, and degenerative changes of these areas lead to thickening, opacity, and perhaps calcification ; or, on the other hand, to atrophy and thinning. The exudation in the subacute cases being generally viscid and slow of re- moval and absorption, evacuation by paracentesis is called for as soon as a few days' treatment of the naso pharynx and attempts to inflate the tympanum have failed to secure its disappearance. Catarrhal otitis media is very prone to manifest itself in inflammation of the tympanic membrane of greater or less severity ; and in its chronic form is a frequent cause of persistent alteration of the structure. In the early stages the external vessels of the drum-head may show little congestion, although those along the malleus-handle are generally full; and the membrane may have merely a pinker hue by reason of the injection of its mucous lining. The congested condition of the covering of the internal tympanic wall also appears to some extent, and its swelling may bring it almost or quite into contact. The collection of fluid within the tympanum is often clearly visible through the drum-head, as Politzer first pointed out; and the diagnosis may be made not only as to its presence and quantity, but also as to its character. It is more usually a thin straw-yellow serum which ob- scures the redness of the promontory, and if it but partly fills the cavity, shows the level of its upper surface by a line across the membrane. (Fig. 4190.) Fi». 4189.-Globular Protrusion in the Upper Posterior Quad rant of the Right Membrana Tympani, through the bottom of which a yellowish-green exudate shows defined above by a curved line. In a woman thirty years of age, on the second day of the affection. Thinning of the distended area remained after recovery. 350 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tympanic Mem- brane. This line, like that of fluid within a more or less trans- parent vessel, is usually dark, but with a faint light line of reflection running parallel above or below it. Some- times it is wholly light, as in Fig. 4191 ; and in all cases its appearance can be varied by change of the direction and char- acter of the illumination. Occa- sionally a hair in the external meatus may closely simulate the appearance, and require careful study to avoid an error. The line is rarely straight, for the narrow- ness of the tympanic cavity causes it to be curved through capillary attraction ; and this curve, which is usually concave upward, may be double or wave-like. The sur- face of the fluid has the natural tendency to assume a horizontal position, and change of the posi- tion of the head may cause corre- sponding change in its direction; but this cannot be certainly counted upon, as the surface line is at times oblique and remains unaltered with the movements of the head, owing to capillarity, to the viscidity of the exu- date, or to limiting surfaces. Sometimes the tympanic cavity is tilled almost completely, and Ihe air above the fluid is a mere bubble in front of or behind the malleus-handle, as in Fig. 4192, from Politzer. At times the tympanum is com- pletely filled, so that no surface line is visible, and only the color of the membrane or other indica- tions testify as to the presence of the fluid. Inflation of the middle ear by any method will usually es- tablish or confirm the diagnosis- the entrance of air partially or wholly expelling the fluid, or so changing its level as to leave no doubt in the mind. Bubbles of air may be forced into the exudate and be visible as dark rings within the drum, where their appearance and at times their movements are most characteristic and striking, as shown in Fig. 4193, from Polit- zer. The formation of small bubbles has a diagnostic value in indicating extreme narrowing of the isthmus of the Eustachian tube. Bubbles may in like manner be present at a first exam- ination as the result of a recent auto-inflation in blowing the nose. The outward movement of the drum-membrane on inflation usually broadens the cavity, and the level of the fluid sinks even if none has been ex- pelled ; while the corresponding increase in the thickness of the stratum of fluid modifies its tint as seen through the drum-head. Sie- gle's pneumatic speculum may also give aid in a diagnosis that is not always easy even with a transpa- rent membrane, and is especially useful in case of impermeability of the Eustachian tube. Opacities or other abnormalities of the drum- head may conceal an exudation be- hind it, and may at times simulate its presence, as iq the case illus- trated in Fig. 4194, which was seen in Dr. Spear's clinic. The effect of disturbance of the ventilation of the tympanum and lack of equalization of the pneumatic pressure upon the two sides of the drum-head, is apt to be markedly manifest in the chronic dry catarrh. The air within the tympanic cavity is absorbed through osmosis, and the rarefaction resulting, if it be not renewed, causes a pressing inward of the membrane. The pneumatic de- pression is maintained or increased by involvement of the tensor tympani in some cases, and the malleus-han- dle is drawn strongly in by its action under irritation, or by its pathological implication in the degenerative changes of the tubal muscles leading to its sclerosis and shorten- ing. Its tendon may also be affected with its sheath of mu- cous membrane. The fibres of the drum-membrane are tightly stretched, and those of the lower anterior quadrant especi- ally may be much elongated by the tension, the tip of the manubrium being drawn far above and behind its normal position. The inclination of these fibres to the axis of the external meatus may be little changed, and the reflection of light may remain as large and brilliant as ever ; but much more generally the " cone of light" becomes narrower, shorter, and less triangular, while inequalities of the curvature cause it to break into several portions. Differences in the relative rigidity of the membrane, original or acquired, are generally the causes of this unequal yielding; and the marked thick- ening of the circular fibres of the membrana propria, usual near the periphery of the drum-head, is apt to lead to a sharp change in the plane of the membrane at the inner margin of this thickerring. This "kneeing" is very marked in some cases, and gives rise to a more or less brilliant linear reflex at the angle thus formed, which is usually near and parallel to the annulus tendinosus. It may be visible in other locations, however, as in the case represented in Fig. 4194, where it runs horizontally across the lower half of the vibrating membrane, giving much the appearance caused by fluid within the tym- panum. In some instances the membrane shows several succes- sive "terrace-like" changes of level, as illustrated in Fig. 4172. The obliquity and the natural in- drawn form of the drum-head are always more noticeable in an opaque membrane ; so that some care and a due consideration of this circumstance are requisite in judging from the appearance of this alone, as to the extent of the retraction. Most characteristic in many of these cases is the appear- ance of the malleus-handle. In its natural position this is seen consid- erably foreshortened, its tip being several millimetres further from the eye than the short process. Retraction exaggerates this per- spective shortening and may bring the tip so directly into line with the short process, that a careful study is needed to be sure that the manubrium has not been lost. Generally it is drawn visibly back- ward as well as inward, and seems therefore to run more horizontally across the upper part of the mem- brane, its tip being in extreme cases, as in Fig. 4175, higher up than the short process. In most of these cases the mal- leus-handle stands out above the surface of the mem- brane in a marked degree, not only with the short pro- cess protruding "like a thorn," but with almost its entire length prominent, due in part to depression of the membrane along it. Its anterior margin shows this most noticeably, because it naturally presents an edge almost comparable to the spine of the tibia, and has a shaded Fig. 4190. - Serous Exu- date in Left Tympanum, with nearly horizontal surface line shining through the drum-mem- brane. (Schwartze.) Fig. 4193.-Foamy Secretion in the Tympanum after Infla- tion, in a case of serous accu- mulation. From a patient with acute naso-pharyngeal catarrh. Fig. 4191.-Collection of Fluid Exudate in the Lower Part of the Tym- panum. marked by a glistening line across the membrane. From the right ear of a young man in the middle of an acute coryza. Cure by Polit- zerization. Fig. 4194.-Marked Par- tial Retraction of the Middle of the Right Membrana Tympani, in a case of chronic catar- rhal otitis. The lower portion is in about nor- mal position, and the manubrium and upper part are not greatly in- drawn ; while the middle portion is so abruptly retracted as to form a sharp "knee" overhang- ing the dark depressed area above it, and giv- ing rise to a glistening line running across the membrane near its mid- dle and closely simulat- ing the surface line of an exudate in the cav- ity. In front of the manubrium is visible a whitish undefined thick- ening. Fig. 4192.-Large Collec- tion of Fluid in the Left Tympanum. The sur- face is visible only in front of the manubri- um. From a man with chronic naso - pharyn- geal catarrh. Exudate removed by paracentesis of the drum. 351 Tympanic Mem- brane. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. depressed portion of the membrane beyond it to empha- size its prominence, and also because there is a rotation of the whole manubrium around its long axis which, though slight, is sometimes the most striking element of the altered relation. This rotation finds its explanation in the fact that the tendon of the tensor tympani is at- tached to the anterior surface of the malleus-handle, and may be of diagnostic value in pointing to the tensor as largely responsible in certain cases for the retraction. Coincident with these varia- tions of the manubrium is the increased prominence of the anterior and posterior folds which form the upper boun- dary of the vibrating mem- brane. The posterior fold es- pecially is generally strongly marked and may stand out like white tendon, with quite a shadow beneath it, where the membrane is much depressed. (Fig. 4195.) The sinking in of the membrane at this point may bring it into contact with the lower edge of the posterior pouch (v. Troelsch) (Fig. 4172) and the chorda tympani nerve which traverses it ; and these structures, usually but dimly seen even through a very trans- parent normal membrane, are strikingly visible through a thickened drum-head. The long descending process of the incus is in contact and connection with the chorda, and will come into view even in cases in which it is not thus incontact; and the depressed membrane may not only touch, but even envelop, the incudo-stapedial articulation and the tendon of the stapedius, and even the posterior crus of the stapes, as shown in Fig. 4197. The last-named structure is probably not seen as often as is supposed, the stapedius tendon being at times mis- taken for it. Lower down, the promontory is approached or touched by the retracted membrane, and its rounded surface may be very evident with the dark niche of the round window behind it. Inflation of the tympanum may wholly change this picture, as is shown in Figs. 4195 and 4196, where a drum-head greatly retracted, with marked folds standing out prominently as they stretch to the short process, and a manubrium drawn far up and back, becomes in a moment almost normal in position, except for the bulging outward of its stretched fibres. So, too, in Figs. 4197 and 4198 the large, thin area which is at one moment depressed into close contact with the underlying structure, is blown out at another into a thin bel- lying sac protruding into the meatus. The malleus - handle being forced inward with the depres- sion of the membrane or by the tensor tympani, or both, the pressure will be conveyed through the malleo - incudal joint and the incus to the stapes, and the foot-plate of this ossicle being pressed unduly in upon the labyrinth, tinnitus and im- paired hearing usually result. The interference with the stapes may also be caused directly, as we have seen, by contact of the membrane, which may envelop it so as greatly to impede its proper movements. Relief of this pressure may be accomplished promptly and satisfactorily by in- flation in many cases ; but in some the retraction of the tendon of the tensor cannot be thus combated, or the Eustachian tube is not permeable. Tenotomy of the ten- sor tympani has been done at times with marked benefit, and in other cases the still simpler operation of dividing the prominent posterior fold close behind the short pro- cess, has greatly improved the hearing and lessened or removed the tinnitus. When other efficient means of re- lief fail, these means are worthy of consideration. Even more common and important is the interference with the tympanic apparatus by the results of adhesive in- flammations of the cavity forming cords, bands, or mem- branous adhesions of the ossicles and other structures, producing undue fixation of the stapes, rigidity and thickening of the membrane of the round window or even occlusion of its niche, and other interferences with the sound - conducting apparatus. Such bands and adhesions are occasionally visible through the drum-membrane, and their ef- fect in fastening that structure to those within is seen in its altered position or form ; but more often such lesions can only be inferred from the func- tional disturbance, and their nature judged from a careful study of the alterations of the tympanic membrane, and the indications which it affords of the character of the pathologi- cal process which has been go- ing on. The suppurative form of acute otitis media is distin- guishable from the catarrhal in the earlier stages by no clear-cut symptom; more acute pain, quicker and more marked loss of hearing-a greater intensity in all respects-is generally to be noted, and the involvement of the drum-membrane is often more marked and intense. Localized distention or abscess-formation will generally mark the point threatened with perforation, and marked pulsation of the yielding area before its rupture is occa- sionally observed ; but, arising at night, as the acute symptoms so often do, it will not infrequently be found that rupture has already taken place when the case is first seen. The location of the perforation, and its size and shape, present the widest variations. Most authori- ties agree that the lower anterior portion is most often affected-so, as the upper posterior portion is most often bulging, this does not always indicate the " pointing" of the discharge ; yet it very often does-the other cases, where the anterior quadrant is pressed forward, being much more difficult to recognize. The opening is gen- erally of small size at first, and its enlargement depends upon the gravity of the involvement of the drum-mem- brane. In scarlatina and diphtheria and other specific fevers, the breaking down of the membrane is most rapid and extensive, and total destruction, with detachment and loss of the ossicles, may speedily take place. Ordina- rily, the deafness and pain will grow steadily worse for a period less than twenty-four hours, and will be relieved by the per- foration of the membrane and the commencement of the dis- charge. Perforation is gener- ally sudden enough to cause an explosivesensation, that assures the patient that " the gathering has burst," and the relief, though perhaps only tempo- rary, is most marked and grateful. Children who cannot otherwise indicate their sensations, .will usually cease their wailing or moaning, and perhaps sink into a long, heavy, and undisturbed sleep. The febrile movement, which may have been high, will rapidly decline, the skin will become moist, and twitchings or other symptoms of cerebral irritation will vanish. These latter points will be most striking in the case of children in whom the de- lirious and convulsive symptoms have marked the aural disease, and a condition of apparently unmistakable men- Fig. 4195.-Left Membrana Tympani of a Man Thirty Years of Age, in whom, as a Consequence of Coryza, a Marked Swelling of the Mu- cosa of the Tube has occurred. The indrawn membrane is of violet-gray color. Relief of the extreme dulness of hear- ing after three weeks' treat- ment by inflation. (Politzer.) Fig. 4197.-Right Meinbrana Tympani in a Boy Seventeen Years of Age, who has Suf- fered with Chronic Middle- Ear Catarrh for Eight Years. Naso pharyngeal catarrh with great swelling of the mucous membrane of the tube. The depressed area rests upon the inner wall and shows the incu- do stapedial joint. (Politzer.) Fig. 4196.-The Same Mem- brana Tympani immediately after the Inflation. (Polit- zer.) Fig. 4198.-The Same Drum- membrane immediately after the Air Douche, which Raises his Hearing nearly to the Nor- mal. (Politzer.) 352 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tympanic Uem« brane. ingitis will disappear as if by magic. The discharge is generally copious-at first thin, serous, perhaps blood- stained, but soon showing a more creamy, purulent char- acter. Mucus is generally present at the first, and appears again during the decline of the discharge in slow cases. Its presence may be of aid in rendering certain the nature of the case when inspection and inflation alike fail to prove the presence of a perfora- tion, and it has prognostic value in a chronic case, as marking a condition which may be called " sub-involu- tion," which is likely to prove very obstinate and unmanageable. The per- foration differs greatly in appearance, largely in ac- cordance with its size. When small and clear, it will present a blackish point, but before the dis- charge has wholly ceased it will rarely remain clear for more than a moment after cleansing, but will be filled by a drop of fluid which reflects the light brilliantly and shows most unmistakably the movements caused by pul- sation in the inflamed tissues. The close proximity and direct connection with the internal carotid artery need hardly be adduced to account for this. Larger perforations will show more of the inner wall of the tym- panum and its color, and when ex- tensive, may uncover any of the structures within. The beginning of the Eustachian tube, with its narrow isthmus, may be seen ante- riorly, the rounded eminence of the promontory in the middle, and the niche of the round window posteriorly. The roughnesses of the floor of the cavity, and the bony trabeculae, which often stand out about the fenestra, show plainly in some cases, as illustrated in Fig. 4199, while the tip of the descend- ing process of the incus, and per- haps the stapes, are visible above. As to this latter point, one will often be struck by the apparent great variation in the height of the incudo-stapedial joint - at times barely visible below the posterior fold, while again it may seem well down in a perforation which does not reach to the fold (Fig. 4200). This is due, not to any real variation in the oval window and the ossicles, but to the variability of the axis of the ex- ternal auditory meatus. Just as in any case we may vary materially the picture which is presented to us by looking through the upper or the lower portion of the canal, so in different cases the appearance will vary according as the meatus has an upward, a horizontal, or a down- ward direction relatively to the hori- zontal plane of the head. The perforation may occur high up in the vibrating membrane, as in Fig. 4201, or in the membrana flaccida, as explained in a preceding section. In these latter cases, involvement of the bone is frequent, and caries may destroy the margo tympanicus, uncovering the head of the malleus and the body of the incus, as shown in Fig. 4202, or may attack the neck of the malleus, destroy its articular surface, and lead to exfoliation of the incus or of all the ossicles. At times the head of the malleus is de- stroyed, but its manubrium re- mains in its normal position. The stapes is fortunately the least likely to be damaged in these processes, and remaining in normal position, it, or even its mere foot-plate, serves to conduct the sound-vibrations to a surprising degree. Multiple perforations are found in some instances, though they are doubtless rare, as Politzer, when publishing his Beleuchtungsbilder, had never seen a case. Not a few have since been recorded, sometimes of multiple open- ings, as shown in Fig. 4203, which I saw in his clinic, in 1883. Another notable instance is shown in Fig. 4204, seen in Dr. Spear's clinic in Boston, and published by his kind per- mission ; while Fig. 4179, al- ready given, shows another five-fold perforation, of which Dr. Spear has most kindly furnished the drawing. A perforation above the short process or above the posterior fold coexists, in rare cases, with one or more perforations in the vi- brating membrane, as may be beau- tifully seen in some of Politzer's preparations belonging to the Phila- delphia College of Physicians, one of which has been published by Morse and myself. A similar case, in which the chorda tympani nerve is laid bare, is shown in Fig. 4205, and I have seen a similar case. One other form of perforation deserves especial notice - the "pouting" perforation, where the opening is at the apex of a nipple- like protrusion. Such a perfora- tion is usually very small, often not actually visible as an opening at all, but recognizable only as the point through which the discharge is welling. It is seen more often in sub- acute, muco - purulent in- flammations, and should always be regarded as hav- ing peculiar elements of danger. It is generally in the upper part of the mem- brane, where it is not well located for drainage, while its form disposes it to be easily clogged. Premature closure is not infrequent, leading at times to serious trouble from retention of secretion, and its narrow- ness almost absolutely pre- cludes any medication of the tympanum from the meatus. It frequently calls, therefore, for enlargement by incision, in order both to secure freer discharge and to permit of more thor- ough treatment. The dan- ger which has been ascribed to insufflations of boric-acid powder in such cases be- longs to the case, not to the treatment. Such a case, Fig. 4202.-Large Loss of Bone at the Inner End of the Upper Wall of the Meatus, in a Wom- an Twenty-six Years of Age, in whom the tympanic sup- puration began in childhood, and ceased only a few years since. Membrana Tympani dry, gray, and opaque, retract- ed down and forward from the umbo, atrophic behind the manubrium. Through the opening are seen the malleus head, the anterior ligament and the body of the incus with its long process. A very deli- cate membrane which closes the opening and applies itself closely to the ossicles, bellies out on inflation. Hearing, 0.5 metre for acoumeter, 5 m. for loud whisper. (Politzer.) Fig. 4199.-Right Ear of a Boy, Eight Years of Age, with long- standing suppurative Otitis after Scarlatina. The membrane is ex- tensively destroyed, leaving but a narrow margin all around, except where a triangular portion remains along the retracted manubrium. The tip of the incus process is just visible posteriorly, the niche of the round window appears behind, and the irregular depressions of the floor of the tympanum below. Anteriorly, we look into the Eus- tachian tube to the isthmus. Fig. 4203. - Right Mem- brana tympani of a Man, about Fifty Years of Age, showing Four Per- forations in the Lower Portion. The narrow, most posterior, opening closed under observa- tion. Fig. 4200.-A Large Reni- form Perforation of the Right Membrana Tym- pani in a Man Twenty- one Years of Age, is closed by a delicate, al- most invisible cicatrix closely applied to the un- derlying structures. The niche of ttie round win- dow posteriorly, and the incudo - stapedial joint alone are seen as clearly as though not covered. The tube was but slight- ly permeable, and little functional improvement or change of the picture was afforded by inflation. Fig. 4204.-Right Membrana Tym- pani of a Man, Forty Years of Age, who died about a year later of Tu- berculosis. An oval perforation occupies the anterior portion of the membrane, a more pear-shaped one is down and back from the umbo, and a third of kidney-shape is up and back. Two small and elon- gated openings are close to the first and the third. The membrane shows plications below the umbo. Fig. 4201. 353 Tympanic Mem- brane. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. where the perforation is in the lower posterior quadrant, is shown in Fig. 4206. Polypoid growths are very frequently met in chronic suppuration of the tympanum, but they rather rarely arise from the drum-membrane itself, although at times emerging through a small perforation so as to seem to arise upon the membrane. They may be found at times, however, taking their origin from the margin of a perforation, or from the outer sur- face of the drum-head, as in Fig. 4207 ; and in rare instances they may arise from the mucous layer of the membrane. They are im- portant as forming at times valve- like obstruction to free drainage, and their prompt removal is called for whenever at all practicable, as they are much in the way of thor- ough treatment. The forceps care- fully used will often surpass the snare for this purpose. The course, dangers, and treatment of purulent otitis media have already been considered in a preceding ar- ticle ; what concerns us here is the involvement of the drum-membrane. The perforation will often be, or at least appear, larger after the cessation of the discharge, and this being most usually promptly at- tained after the use of boric-acid powder, it has been urged that this method exerts an unfavor- able influence upon the subsequent healing. Cer- tainly the perforation-mar- gins after its use are apt to be thin and dry, and offer little promise of cic- atrization. Yet it may be accepted as a fact that the great majority of per- forations do cicatrize ; and the burden of proof lies upon those who urge that the dry treatment retards healing - a treatment which so often cuts short the suppurative process and thus limits the destruction and consequent need of repair. Little aid is furnished in forming a prognosis as to certain and prompt closure, by the size, form, or location of the opening. Pin-hole perforations are sometimes slower to close than extensive losses of substance, and the prognosis as to function is still more vague. The thin cicatrices formed consist, as a rule, of delicate connective- tissue sheathed with epithelium, and, lacking the elasticity and strength of the membrane itself, are more mobile and distensible. Their function is. therefore, rather to protect the interior of the tym- panum from the unnatural expos- ure to the atmosphere than to serve as portions of the membranavibrans. The peculiar fibres of the membrana propria are rarely, if ever, regener- ated, and there is reason to believe that in cases where perfect healing has been found, the fibres had been merely separated, not destroyed, and have resumed in the cicatrix their normal position. Traumatic ruptures, which have caused extensive laceration of these fibres, generally leave marked and permanent cicatrices, even when healing has been immediate and no gaping has occurred-the linear scar may be con- spicuous where the rupt- ure itself was hardly visi- ble. On the other hand, small perforations may close with great prompt- ness, and the most careful scrutiny fail to discover any scar. The time oc- cupied in the cicatrizing process is very variable, generally months or years, when the loss of substance has been large. It may be encouraged by freshening the margins of the opening or by stimulating with nitrate of silver ; but better still, by covering the opening by Blake's tiny disk of paper or the delicate membrane lining the egg- shell of the chicken. The use of the artificial drum- membrane, elsewhere treated of, may lead to a like result. In some cases closure of the perforation does not take place. The margins seem to "skin over," and remain round- ed and thickened. How far such an opening, un- less extensive, interferes with the function of the membrane, it is probably beyond the tests now at our command to deter- mine. Coincident inter- ference with the more important structures-the stapes and membrane of the round window-will often compli- cate or prevent this determination. Politzer has, on the other hand, reported a case where in both ears perfora- tion persisted, and the re- maining membrane showed total calcification ; but the stapes had been set free by erosion of the descending process of the incus, and the two fenestra? remaining normal, a loud whisper could be heard eighteen metres. In such a case the perforation serves a good purpose by allowing the waves of sound free access to the oval window, when transmission through the chain of ossicles would be imperfect or impossible ; and instances are met where marked improve- ment of hearing is secured by an artificial perforation. Unfortunately such open- ings can rarely be main- tained, in spite of many in- genious methods designed to secure such a result; un- less the recently-suggested turning down of a triangu- lar flap (McKeown) proves less disappointing than its predecessors. An important point as to the cicatrix closing a perfora- tion is, whether it remains free or becomes attached to adjacent structures. The latter condition is often met in Fig. 4205. - Uncovered Chorda Tympani in a Boy, Nine Years of Age, whose otorrhoea, begin- ning before the fourth year, had ceased about six months. On touch- ing the cord he has prick- ling and a sour taste at the tip of the tongue. (Politzer.) Fig. 4208.-Diagrammatic Section of a Small Depressed Cicatrix attached to the Promontory. Fig. 4209.-Diagrammatic Section ot a Large Free Cicatrix depressed into contact with the inner tympanic wall and stretched in all directions, so that the margins of the perforation overhang it. Fig. 4206.-Right Membrana Tym- pani of a Man, Thirty-two Years of Age, recently recovered from Ty- phoid Fever. Muco-purulent catarrh of the middle-ear of two weeks' dura- tion. Below the umbo is a reddish- yellow protrusion, yielding but little on pressure, from the point of which the discharge flows, and on being cleansed, a minute opening is visi- ble. General injection of membrane, especially behind the manubrium. Treatment failed until a good-sized opening was made with needle, then prompt recovery ensued. Fig. 4210.-Right Membrana Tym- pani of a Woman, aged Forty-five, with Long-standing Intermittent Suppuration of the Tympanum re- cently recurring. Small central perforation in a free cicatrix stretched across in front of the lower half of the manubrium. Periphery of membrane thickened and opaque, calcified anteriorly: the central portion depressed and presenting a sharp "kneeing" be- low. Closure of the perforation by drying of the scanty discharge leads to further depression of the cica- trix, and brings it into contact with the lower portion of the manubri- um, which is then seen to be entire and perhaps bound down to the promontory. Fig. 4207. - Left Mem- brana Tympani of a Woman, Thirty Years of Age, with long-standing purulent Otitis media. A reniform perforation involves much of the lower half of the drum- head, and a polypus arises by a narrow pe- duncle in front of the short process. Upon its removal, no perforation was found at its point of origin. 354 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tympanic Mem- brane. cases where the loss of substance has been large ; and it may perhaps occur secondarily when a free cicatrix be- comes depressed into contact with the inner tympanic wall and forms adhesions to it. It is more often primary, however ; in such cases the malleus-handle and the re- mains of the drum-mem- brane have been drawn in and become attached to the promontory, or the mucous membrane of the latter is so swollen as to meet the others. Such a cicatrix will generally show marked de- pression and remain im- movable in spite of inflation or the use of the pneumatic speculum. It may be of small size, and is then of narrow oval form, its long axis corresponding to the direction of the radial fibres, as in a specimen of Politzer's nowT in the museum of the College of Physicians of Philadelphia (Ill. 59, Randall and Morse), and its sides drawn steeply in to their point of attachment to the promontory, as shown in the diagram (Fig. 4208). When more extensive it will often be difficult to say, at first glance, whether we have be- fore us an open perforation, a depressed but free cicatrix, or a closely attached scar. The inner wall of the tympanum will be distinctly seen, generally yellowish-white, dry and glazed, and only upon inflation will the distinction be possible. With a permeable Eustachian tube the air will pass out through an open perforation with a pe- culiar recognizable sound, the exact character of which varies with the position, size, and con- dition of the opening. When a free indrawn cicatrix exists, or when an atrophic area of the membrane gives an almost iden- tical condition (Figs. 4175 and 4197), the inflation will cause a bulging forward of the thin tis- sue so that it stands out like a bubble into the meatus. Some care is advisable in the use of the air douche, for the bel- lying out of the lax scar takes place with a flap that is most disagreeable, if not painful, and its rupture is quite possible. It is also noteworthy that extra- vasations will, not infrequently, be seen as a result, probably pointing to the tearing of delicate attach- ments. The appearance of the dis- tended cicatrix varies greatly-at times it looks dull and opaque, and shows folds and pouchings which protrude in front of the rest of the structure and hide it from view, while again its tension may be such that it is as transparent as ever, and only by the altered form of the light-reflection, or in some cases by the indenting with a probe, can we recognize that it has changed its position. Its protru- sion will generally" be but short- lived, and it will sink back into the former position after the lapse of a few moments. When its depressed position brings it into contact with the stapes, or in some other way causes it to interfere with the due transmission of vibrations, marked improvement of hearing may result from its distention by the in- flation-often, however, to be as quickly lost as it settles back into contact again. Various endeavors have been made, more particularly in the cases in which the condition is the "collapse" of the atrophic drum-membrane, to prevent its return after inflation. Re- peated incisions have been practised in order to thicken and contract it; and painting with collodion has been re- commended (McKeown) to ac- complish the same result. A rare but interesting condition is that termed "dislo- cation of the manubrium," in which the malleus-handle or a part of it becomes loosened from its attachment to the mem- brane and stands out in front of it, or is drawn in behind it. Urbantschitsch makes a distinc- tion between true cases of the sort, and the apparently similar cases where the detached mem- brane is a cicatrix and not the drum-head itself. Having seen only the latter form, I am some- what sceptical as to the loosen- ing of the manubrium from the drum-membrane itself. A case of the sort is shown in Fig. 4210, and a diagramatic section of the condition in Fig. 4211. Where the new tissue forms attachments binding the manubrium and the margins of the perforation to the deeper structures instead of closing the opening, and the promon- tory remains uncovered, its mu- cous membrane, if not already altered by the inflammation, usually undergoes an epidermal change and becomes dry and glazed. The attachments may stretch as swelling subsides and permit the membrane, so far as it remains, to occupy its normal position, and they will then appear as cicatricial bands or membranes stretching across the intervals. Such bands are also sometimes seen after adhe- sive inflammations through the intact drum-head, or, as in Fig. 4212, through one which has cicatrized after ex- tensive destruction. Inflation and the pneumatic speculum may do much in some of these cases to relieve harmful tension upon the chain of ossicles, even when a complete septum does not exist ; and their use has sometimes been pushed to the extreme, and suction by a sy- ringe or other " rareficateur " has been used with the hope of tearing loose these adhesions. Extravasations and ruptures may easily be produced in this way, and such procedures need caution and judgment in their employment. In extreme cases, cutting operations for the loos- ening of cicatricial bands (Prout), especially to release the stapes, have been done with success (Figs. 4213, 4214, and 4215); and in case of anchylosis, the ossicular chain has Fig. 4215.-Adhesions between Stapes and Adjacent Laby- rinth-wall, Severed by a Hor- izontal Section below the Stapes. (Politzer.) Fig. 4211.-Diagrammatic Section of the same Case, showing the knee below and the manubrium drawn in behind the middle of the membrane. Fig. 4216. - Fixation of the Chain of Ossicles, with Adhe- sion of Tip of Manubrium to Promontory. Long process of incus divided by fine cutting- forceps, and shank of incus thrust up and back to avoid reattachuient. (Politzer.) Fig. 4212.-(From Politzer.) Fig. 4213. - Malleus-handle Bound to the Stapes by close Adhesions, in a Man of Forty- eight Years of Age, cut loose with Marked Improvement of Hearing. (Politzer.) Fig. 4217. - Malleus-handle Fast to Promontory, De- tached by Circumcision of Cicatrix. (Politzer.) Fig. 4218.-Large Loss of Sub- stance of Right Membrana Tympani, with Formation of an Adherent Cicatrix, v, Thickened anterior remains of membrane fast to promon- tory : «, stapes-head with an opening above it leading into the attic of the tympanum. The Eustachian tube is wholly shut off from commu- nication with the major part of the tympanic cavity. From a preparation in Politzer's collection. Fig. 4214.-Fibrous New Formation Insheathing the Stapes, freed by Ob- lique Incisions in Front and Behind, Uniting Be- low. Hearing improved for conversational voice from 1 m. to 7 m. (Pol- itzer.) 355 Tymp. Membrane, Tympanum. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. been broken by cutting through the descending process of the incus or disarticulating it from the head of the stapes (Fig. 4216). The adhesions are apt to reform and the result may be thus quickly lost, and in many cases unseen and deeper lesions may render the operation useless ; but hearing often remains improved in spite of renewed attachments, and the relief to the annoying tinnitus may be well worth the operation. In case of adhesion of the tip of the malleus-handle to the inner wall of the tympanum, as in Fig. 4218, of which Fig. 4219 is a diagrammatic section, Politzer employs a rounded knife shaped like a gum-lancet, while for section of the incus shank or calcareous thickenings of perforation margins, such as in Fig. 4220, he uses a delicate pair of cutting- forceps, figured in the last edition of his text-book. Of three cases of the latter operation, one gave a brilliant re- sult, one only temporary im- provement, and the third none -the stapes being doubtless anchylosed into the oval win- dow. The probe should be used to study the mobility of the various structures, and to ascertain how far alteration of the pressure affects the hearing, and Politzer accepts notable improvement obtained in this way as an indication for opera- tion. As our methods of diag- nosis improve, and the differ- entiation of the cases where it is possible to localize the lesion in the sound-conducting appa- ratus grows more exact, it is very probable that these cases will be oftener recognizable, and the justifiability of op- erative interference will be increased. B. Alexander Randall. 1 Schwartze: Handbuch der Pathologischen Anatomie (Klebs) Gehor- Organ. Berlin, 1878. 3 Buck : Diagnosis and Treatment of Ear Disease. New York, 1880. 3 Hinton : Atlas of the Membrana Tympani. London, 1874. 4 Politzer : Lehrbuch der Ohrenheilkunde, II. Auflage. Stuttgart, 1887. 5 Urbantschitsch : Lehrbuch der Ohrenheilkunde. Vienna and Leipzic, 1880. 8 Wilde: Diseases of the Ear. American edition. Philadelphia, 1853. 7 Politzer: Die Beleuchtungsbildern der Trommelfells. Vienna, 1865. 8 Randall and Morse : Photographic Illustrations of the Anatomy of the Human Ear. Philadelphia. 1887. 9 Toynbee : Diseases of the Ear. London, 1860. 10 Sexton. 11 Ibid. 13 Lautenbach: A Peculiar Case of Injury of the Ear. Polyclinic, November, 1886. 13 Weir : Ununited Fracture of Manubrium of Malleus. Transactions of the American Otological Society, 1870. 14 Trumbull, C. S. : Perforating Wounds and Injuries of the Mem- brana Tympani. Medical and Surgical Reporter, February 22, 1879. 15Biirkner: Atlas von Beleuchtungsbildern des Trommelfells. Jena, 1886. 16 Burnett: A Treatise on the Ear. Second edition. Philadelphia, 1884. Explanation of Plate XXXI.-Through the extreme kindness of Professor Kurd Biirkner, of Gottingen, and the courtesy of his publisher, Gustav Fischer, of Jena, a number of the illustrations of Professor Bflrk- ner's " Atlas von Beleuchtungsbildern des Trommelfells," Jena, 1886, have been reproduced and form Plate XXXI. They are from original colored drawings by Professor Biirkner himself, and are selected as the most interesting of his large collection. Detailed descriptions of them follow : Fig. 1.-Normal left drum-membrane as seen by diffused daylight. Fig. 2.-Normal right menbrane by lamp-light. Fig. 3.-Rupture of a partially thinned left membrana tympani by a kiss. Slight ecchymosis of the lower flap-like margin of the tear, with in- jection of the vessels of the manubrium. Fig. 4.-Rupture of the left drum-membrane by a box on the ear. Ragged rent with extravasation in the wound-margins and injection of the vessels along the malleus-handle. The rent extends nearly vertically behind the umbo and gapes slightly. Fig. 5.-Rupture of the left membrane by puncture with a knitting- needle. Ecchymosis at the lower periphery of the rounded opening and injection of the manubrium vessels. Fig. 6.-Double rupture of the right membrana tympani caused by a fall into the water. Slight injection. A semi-lunar rent in upper poste- nor quadrant and a longer, more crescentic tear below. Both are rather parallel to the circular fibres. Fig. 7.-Ecchymosis on the right membrana tympani back of the tip of the malleus-handle. Fig. 8.-Pigmentation of the region of the umbo in the right mem- brana tympani-the remains of an extravasation. Fig. 9.-Fracture of the malleus-handle on the left, with malposition of the anteriorly displaced lower fragment. Retraction of the cicatrized neighborhood of the umbo, with distorted reflection of light and cres- centic opacity of the lower anterior quadrant. Fig. 10.-Injection of the cutis of the upper half of the right drum- membrane. Little dulling of the lustre or obscuring of details. Fig. 11.-Radiate injection of the right membrana tympani. The malleus-handle hidden by vascularization, and only the short process visible. Fig. 12.-Acute myringitis of the left membrana tympani. Inflamma- tion limited to upper half, where a hemispherical swelling hides all de- tails except a faint indication of the short process. Fig. 13.-Acute myringitis of the left membrane, with intense radiate dark injection. Exfoliated epithelium upon the posterior portion and a line of purulent fluid below. Fig. 14.-Acute myringitis of the right membrana tympani, with two abscesses in the posterior half. Fig. 15.-Granulations upon the left membrane in chronic myringitis. Fig. 16.-Chronic myringitis, with hiding of all details by epidermal exfoliation. Fig. 17.-Chronic myringitis of the left membrana tympani, with radiating injection, swelling of the entire membrane, and a sac-like bag- ging posteriorly filled with pus. Fig. 18.-Ulceration of the right membrana tympani in chronic my- ringitis. Line of pus collection below. Fig. 19.-Cholesteatomata on the left membrana tympani, after the removal of an impacted mass of cerumen. Injection of the vessels of the manubrium and dulling of the light triangle. Fig. 20.-Exostoses upon the left drum-membrane, before and behind the manubrium. Fig. 21.-Sunken left drum-head in simple acute otitis media, with prominence of the posterior fold, dark coloration of the membrane, and bright point in front of the short process. Fig. 22.-Strongly indrawn right drum-head in a case of acute simple otitis media. Marked prominence of the posterior fold ; broken triangle of light and anomalous light spot in front of the short process. Fig. 23.-Marked retraction of the left membrana tympani in acute catarrhal otitis. Both anterior and posterior folds prominent; incus- shank discernible ; " kneeing" of the intermediary zone, and dark colora- tion of the membrane. Fig. 24.-Injection and swelling of the left membrana tympani in acute simple otitis media. Fig. 25.-Exudation in the right drum cavity, with curved surface- line visible through the membrane. Fid. 26.-Exudation with angular surface-line in the left tympanum ; marked prominence of the posterior fold; punctate light spot in front of the short process. Fig. 27.-Distention of the upper posterior quadrant of the left mem- brana tympani by serous exudation. Fig. 28.-Sac-like distention of the posterior half of the right mem- brana tympani. Acute otitis media simplex, with diffuse injection of the membrane. Fig. 29.-Bubbles formed by the air douche in the exudate within the left tympanum. Fig. 30.-Distention of the left membrana tympani by exudate 'n sim- ple acute otitis media. Bulging hypenemia and swelling of th- entire membrane. Fig. 31.-Crescentic opacity of the posterior portion of tt t mem- brana tympani in chronic otitis media simplex. Fig. 32.-Peripheral opacity of the right membrane inchrmuc jatarrh. Fig. 33.-Flaky opacity of the left membrana tympani in chronic otitis media. Fig. 34.-Sunken, clouded membrane, with prominent posterior fold and quadrate reflex. Fig. 35.-Radiate atrophic areas in the opaque right membrana tym- pani. Fig. 36.-Atrophic left membrana tympani, showing the incudo-stape- dial joint. Fig. 37.-Atrophic and relaxed left membrane in chronic catarrhal otitis. Fig. 38.-Distention of the posterior half of the right membrana tym- pani by yellowish exudate. Fig. 39.- Hyperaemia of the promontory in sclerotic catarrh of the tympanum, showing through the retracted membrane. Fig. 40.-Right membrana tympani, showing hyperaemia and swelling of its mucosa, and opacity in the membrana propria. Fig. 41.-Milky opacity of right membrana tympani, with marked peripheral thickening and broken light spot. Fig. 42.-Thickened and sunken left membrana tympani, with shining through of promontory; sclerosis. Fig. 43.-Broadened and distorted manubrium; promontory discerni- ble; sclerotic catarrh. Fig. 44.-Attachment of the umbo to the promontory in case of marked retraction of right membrana tympani. Fig. 45.-Adhesion of the upper posterior quadrant of the sunken drum-membrane to the chorda tympani and the incudo-stapedial joint. Umbo in contact with promontory. Fig. 46.-Adherent bands in lower posterior part of tympanum tying down the membrane. Fig. 47.-Injection, swelling, and discoloration of the right membrana tympani with congestion of the manubrium ; crescentic light reflex, and exudation in tympanum visible in lower portion. Acute suppurative otitis media. Fig. 48.-Small perforation in lower anterior quadrant of the injected left membrana tympani. Exfoliation of epidermis hiding manubrium and leaving but faint indication of the short process. Small (pulsating) point of light from the fluid in the perforation. Acute otitis media suppurativa. Fig. 4219.-Sche- matic Section of a Case of At- tachment of the Manubrium t o the Promontory. (Politzer.) Fig. 4220.-Movable Cicatrix in Front of Manubrium, but a Rigid Perforation-margin Causes Fixation of the Mal- leus. Before its division, ac- oumeter 10 ctm.; speech, 1 m.; afterward, acoumeter, 55 ctm.; speech, 4 m. (Pol- itzer). 356 Reference Handbook of THE Medical Sciences Plate XXXI The Human Tympanic Membrane, in Health and in Disease. Copied by permission from Prof. Kurd Biirkner's Atlas von Beleuchtungsbildern des Trommelfels; Jena, 1886: Fischer. Linowkh, Eddy a Ghuh, Litm. N. Y REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tymp. Membrane. Tympanum. Fig. 49.-Purulent collection in front of lower portion of right mem- brana tympani hiding details. Fig. 50.-The same membrana tympani after cleansing. Perforation back of umbo; gray-red membrane with irregular and dim light spot. Acute suppurative otitis media. Fig. 51.-Pouting perforation of the posterior portion of the right membrana tympani. Membrane red, especially the very prominent poste- rior half. At the nipple-like apex of its lower part, a small perforation. Light reflex broad and faint, and short process barely discernible. Fig. 52.-Small perforation in Shrapnell's membrane above the short process, from which a drop of exudation is hanging. Membrana flaccida red and swollen, and manubrium strongly injected. Broken light spot. Fig. 53.-Freshly formed perforation in the swollen and livid right drum-membrane, showing a (pulsating) point of light from the fluid within it. Membrane bluish red, with sodden flakes of exfoliated epi- dermis giving here and there tiny glistening reflections. Vessels along malleus handle visible. Fluid in the bottom of the meatus gives a faint crescentic reflex. Fig. 54.-Small perforation in centre of anterior half of membrane in chronic suppurative otitis. Membrane dull, with apparently thickened manubrium, and the mucosa of the inner tympanic wall dark red. Fig. 55.-Perforation in the upper posterior quadrant of the right membrana tympani in chronic suppuration with caries. The dislocated incus is seen in the opening. Fig. 56.-The same membrane several months later, showing thicken- ing along the manubrium, the incus gone, and the stapes visible. Granu- lation masses hang out over the lower margin of the opening. Fig. 57.-Reniform perforation in lower half of membrana tympani, with thickening of the membrane, especially along the malleus handie, and dulness of the surface. Glistening layer of fluid near anterior mar- gin. Fig. 58.-Heart-shaped perforation involving the major part of the left drum-head, leaving but a narrow remnant along the manubrium and at the periphery. Discharge has ceased and the tympanic mucosa appears yellowish red, with a glistening streak posteriorly and branching vessels upon the promontory. Fig. 59. -Central perforation of the middle of membrana tympani, with the tip of the manubrium projecting into the opening which shows the congested inner wall. Fig. 60.-Partially adherent central perforation, with marked retrac- tion of the membrane. Manubrium drawn in and up, and posterior fold prominent. A cicatricial band fastens the upper margin of the opening to the congested promontory. Comma-shaped reflection of light. Fig. 61.-Double perforation in lorver part of the left membrana tym- pani in chronic suppurative otitis media. Manubrium indrawn ; light spot broken and tympanic mucosa injected. Fig. 62.-Two large oval perforations of the right drum-membrane, leaving but a narrow band of normal membrane extending up to the mal- leus handle. Anteriorly a whitish crescent of chalk deposit. Discharge has ceased and the promontory is reddish yellow. Fig. 63.-Large, round perforation, with marked retraction of the right membrana tympani, through the upper part of which the incus is dis- cernible. Promontory red and hyperplastic. Fig. 64.-Extensive destruction of the right drum-membrane, leaving but a narrow periphery, with such retraction of the manubrium that it is almost lost to view. Thickening around the short process, and granular condition of tympanic mucosa. Fig. 65.-Large perforation in lower anterior quadrant, filled by poly- poid granulations of the mucosa of the tympanum, standing out as a raspberry mass in the plane of the membrane. Fig. 66.-Perforation in lower quadrant, through which projects a knob of polypoid granulations hiding the margins of the opening. Manu- brium markedly retracted with prominence of the posterior fold. Cres- centic opacity of posterior part of membrane. Fig. 67.-Commencing cicatrization of a perforation below the umbo of a much-retracted left membrana tympani, with "cone of light" extend- ing in upon the bluish-gray scar tissue. Fig. 68.-Scar in anterior portion of opaque and retracted left mem- brana tympani. Broadening of the tip of manubrium and area of thick- ening of membrane posteriorly. Fig. 69.-Central heart-shaped perforation closed by a thin cicatrix. Light spot upon the depressed scar, and thickening of the perforation margins. Fig. 70.-Central depressed cicatrix of left membrane, with the tip of malleus handle projecting into the opening. Chalk deposit near anterior margin. Fig. 71.-Almost complete replacement of the left membrana tympani by scar tissue. Marked retraction of manubrium, behind which the incus is visible. Broken reflex upon the indrawn cicatrix. Fig. 72.-Two rounded cicatrices in left membrana tympani, with re- tracted malleus handle. The membrane is thin and dark above, showing the descending process of the incus, but gives a marked cone of light be- low. Fig. 73.-Cicatrized double perforation, with irregular chalk deposit below in the right drum-membrane. Fig. 74.-Sunken left membrana tympani, with thin cicatrix which closes a rounded perforation below, bellying out after the inflation. Fig. 75.-Irregular crescent of calcification in posterior portion of the dull left drum-head. Fig. <6.-Two oval deposits of chalk in the left membrana tympani, occupying the greater part of each half of the membrane, and extending close on either side of the manubrium. Fig. 77.-Right membrana tympani, showing a large calcified area anteriorly, a small one up and back, and a perforation below with chalk deposit in its thickened lower margin. Fig. 78.-Left membrana tympani, with irregular chalky deposits on either side of a depressed cicatrix closing an oval opening, the lower mar- gin of which is calcified. Fig. 79.-Dark-red retracted left membrana tympani, with large per- foration, out of the anterior portion of which a dark crimson polypus pro- trudes. Promontory yellowish red. Fig. 80.-Cholesteatomatous mass protruding from a perforation in the red and swollen right membrane. TYMPANUM, FOREIGN BODIES IN THE. Attention will be called, in the following article, solely to the con- sideration of such foreign bodies as lie wholly or in part within the limits of the tympanum, or drum-cavity ; the subject of foreign bodies lying within the external audi- tory canal having been already considered in an article, by Dr. Samuel Theobald, which the reader will find published in the first volume of this Handbook. An exhaustive treatise upon the subject of foreign bodies in the tympanum will not be attempted, a Ref- erence Handbook, intended primarily for the use of general practitioners not being the proper place for a presentation of such an article, and in its stead the writer will merely endeavor to set forth such general and practical considerations as may be of use and of in- terest to the majority of those likely to consult the pages of this work, and will point out some of the sources from which a more detailed knowledge of the subject can be obtained by those among his readers who may re- quire or desire it. At the very threshold of our subject it may be well to pause and give a precise definition of the term " foreign bodies " as used in this article ; and, at the risk of being thought to have overstepped the narrow limits of his nec- essarily brief contribution, the writer gladly avails him- self of this opportunity to remind all his readers-whether specialists or general practitioners-that any substance, whether solid, fluid, or gaseous, not naturally existing in the healthy tympanum, is, strictly speaking, and from a surgical point of view, to be regarded as a foreign body. Bearing in mind this fact, we should consider all instru- ments, appliances, and medicaments introduced within the drum-cavity as foreign bodies, and, unfortunately, experience has shown that too often they fulfil the sad function surgically assigned such foreign bodies, in that they prove themselves to be exciters of, or maintainers of, a condition of inflammation. In judicious and expe- rienced hands, and in obedience to the maxim that " Be- tween two evils the less is always to be chosen," such " corpora extranea " may nevertheless be looked upon as what, for the nonce, we may term justifiable foreign bodies. Or, again, we may properly class as bodies foreign to the tympanum all polyps or other pathological growths, or even the remains of parts of the natural structure of the tympanum when altered by or separated from their surroundings by a process of inflammation. Such foreign bodies as these can hardly be termed jus- tifiable, although it may be, under certain circumstances, quite unjustifiable in the physician to attempt their re- moval. Finally, we come to the consideration of such unnatural or out-of-place substances as through accident, carelessness, or intentional violence find their way within the limits of the tympanic cavity-that is, to the consid- eration of foreign bodies in the commonly accepted sense of that term ; and these alone are the foreign bodies whose presence in the drum-cavity we are about to dis- cuss in the present article. Concerning these bodies we shall attempt to answer briefly the following eight questions : a. What bodies of this class have been found either wholly or in part within the drum-cavity ? b. How do they effect an entrance within the tympa- num ? c. How frequently are such bodies therein found ? d. What symptoms indicate their presence ? e. To what pathological conditions do they give rise ? f. How' may their presence within the tympanum be ascertained ? g. When should their removal be attempted ? h. How should such removal be effected ? a. The foreign bodies of whose entry, either wholly or in part, within the tympanum I have been able to find a record, although limited in number, are very vari- ous, and some of them very curious in kind ; a list of such bodies is herewith appended, the name of the ob- server in the case of many of them being added in paren- theses : A brass ball 34 mm. in diameter (Troeltsch) ; a corset ring (Bartscher); an " artificial drum" (A. H. Buck); a 357 Tympan u ni. Tympanu m. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. shaving from a hard-rubber nasal syringe (Schalle) ; a portion of the slender panicle stem of the oat-plant (Urban tschitsch); pencil-heads (Israel and Gorham Ba- con) ; Politzer's eyelats (Voltolini and II. D. Noyes) ; an ascaris (Itard, Andry, Dagand, Bremeau, and Winslow); a bent pin, 1|inch long(J. R. Kealy); locust-beans (Wein- lechner) ; a pebble; a stone-splinter (Moos); a paper- ball ; a cherry-pit; a coffee-bean; bits of a wooden match (R. O. Du Bois); and larvae of muscida lucidia, and muscida sarcophaga.* b. As might be expected the direction from which nearly all observed foreign bodies in the tympanum have entered that cavity is from the side of the external audi- tory canal. Among those just specified, only a very few effected their entry by way of the Eustachian tube, viz., the oat-stalk, the splinter from a nasal syringe, and probably the ascarides. It is further to be remarked that a large percentage of foreign bodies in the tym- panum have owed their presence therein to carelessness and unwarrantable or clumsy interference with the same bodies previously lying in the auditory canal, and that abundant records show such interference to be quite as frequently chargeable to a physician as it is to a frightened nurse or mother. The hard-rubber shaving, mentioned above, was syringed into the tympanum through the nostrils and Eustachian tube ; the " artificial drum " had, to all appearance, been crammed through a perforation in the drum-membrane, and this, too, by a physician, instead of being laid against the surface of the membrane. c. In reply to the inquiry concerning the frequency of occurrence of foreign bodies in the tympanum, it may be said that rare as is the occurrence of a foreign body in the auditory canal, in the tympanum proper such a body is still more rarely discovered. Thus, for example, out of a total number of 77 intelligibly described cases of foreign bodies in the ear, collected by Dr. Ludwig Mayer, in 1870, no less than 66 were in the auditory canal, 3 were in the Eustachian tube, and 8, or but a trifle over ten per cent., were in the tympanum. d. Turning to a consideration of the symptoms pro- duced by the presence of a foreign body in the tym- panum, an examination of well-recorded cases shows that even within the drum-cavity such a body may give rise to no symptoms at all (although it is far more apt to cause trouble than it would were its position wholly within the auditory canal) ; that the symptoms may be, and often are, of the gravest sort, and that these graver symptoms are largely due to impaction and to the vio- lence with which the body has been forced from the au- ditory canal (or through the Eustachian tube) into the tympanum ; and finally, that no positively diagnostic symptom pointing to the drum-cavity as the location of the body exists, the same inflammatory symptoms, both primary and secondary, and the same reflex symptoms which result from the presence of a foreign body in the auditory canal being observed in the case of a foreign body in the tympanum. The nature of the symptoms and their degree of severity in both cases depend chiefly upon the violence with which the body has entered, the violence with which efforts have been made to extract it, the degree of impaction existing, and the nature of the body itself, whether living or dead, whether rough or smooth, chemically irritating or the reverse, large in proportion to the containing cavity, or small in propor- tion to the same. e. These symptoms depend upon the pathological conditions characteristic of a more or less severe otitis media, and in the case of the purely reflex symptoms upon the disturbance induced in the cerebral and sym- pathetic nerve-centres, receiving branches from the ex- ternal and middle ear, by the purely mechanical or in- flammatory irritation of these aural branches. For an ac- count of the pathological conditions, and the symptoms attributable to, and diagnostic of, the induced otitis me- dia, the reader is referred to Dr. J. Orne Green's article describing Purulent Inflammation of the Tympanum, in Vol. II. of this Handbook, pp. 591-622. The various " reflexes," such as ear cough, ptyalism, facial paralysis, paroxysmal sneezing, vertigo, epileptiform convulsions, hyperaesthesia, hemiplegia, etc., are in part alluded to in Dr. Theobald's article already cited ; but their discussion belongs rather in the pages of systematic works upon diseases of the ear, than it does within the narrow limits of the present article, and they are best considered in the detailed accounts of special cases which are to be found in such treatises, and in the periodicals devoted spe- cially to otology. f. Concerning the diagnosis of a foreign body within the tympanic cavity, all that need be said in this place is that it must be made partly from the symptoms, but chiefly, in every case, and exclusively in many cases, from a carefully and skilfully conducted examination of the ear itself. A careless examination will often prove misleading to the physician ; an examination unskilfully conducted will be little less damaging to the patient than will an unskilful attempt at extraction. fl. Most assuredly no attempt at extraction should be so much as thought of until the existence of the body and its position in the ear has been unmistakably deter- mined, and in the case of a small, smooth, and chemically unirritating body lying beyond a membrane presenting but a very small perforation, or, it may be, no perfora- tion whatever, the noli me tangere rule may be followed with an entirely clear conscience even by the specialist, and should be implicitly obeyed by every physician who is not experienced in operations upon the drum-mem- brane ; for in the case of all such it is a rule to whose infringement a heavy penalty is attached by nature, and this penalty is commonly paid by the patient. h. As to the method employed to extract a foreign body from the tympanum, it is as impossible to lay down a rule which shall be of universal application as it is in the case of a foreign body lying wholly in the auditory canal. All methods properly adaptable to the latter case are equally adaptable to the former, and of all methods which may be employed, that of syringing is by far the safest. The temptation to resort to the use of forceps, hooks, curettes, probes, etc., is stronger than in the case of a foreign body less deeply situated ; while the risks to be apprehended from their use, especially in unprac- tised hands, is even greater. The rules, suggestions, and warnings set forth in Dr. Theobald's article treating of the extraction of a foreign body from the auditory canal may profitably be studied by the physician who desires to arm himself and his patient against the risks justly to be apprehended from undue or unskilled interference with a foreign body lying in the tympanum, and both physician and patient will do well to remember that it is often by far the safest course to let the foreign body lie undisturbed, and to devote their energies rather to the combating of such inflammatory symptoms as may have been caused by its presence, until the advice of an ex- perienced specialist can be obtained. As illustrative of the degree of impaction which might be induced by an unskilled and forcible attempt at removal, it may be well to cite, in this place, an instance recorded by many writers on otology, where, even after death, it was found difficult to remove a bit of stone which had become im- pacted in the mastoid cells, and whose impaction, rather * Roosa, in his full and interesting account of foreign bodies in the ear (Treatise on Diseases of the Ear, sixth edition, 1885), says of these maggots that, with the single exception of a case reported by Dr. Gruen- ing, they have invariably been found in connection with a perforation of the membrana tympani and suppurative disease of the tympanum. Some three or four years ago the writer saw, at Dr. G. B. Hickok's clinic, at the New York Eye and Ear Infirmary, a case in which the auditory canal was filled with living maggots, the drum-membrane being intact, and no history of pre-existing otorrhoea being ascertainable. The eggs had apparently been conveyed to the auditory canal on the patient's finger-nail a few days before his visit to the infirmary. While positively denying the possibility of any pre-existing aural dis- charge (a denial as to the trustworthiness of which the patient's intel- ligence, the appearances found by careful examination of both the af- fected and the unaffected ear, and a critical cross-questioning of the man himself, all seemed to bear ample testimony), the patient nevertheless admitted that, while standing at a saloon bar, some four or five days be- fore, he had scratched his ear with a finger of the same hand with which he had just helped himself to a fragment of cheese. Dr. Hickok and I coincided in the opinion that the man could have had at the most only a slight degree of dry eczema of the canal, and that he had, in all probabil- ity, infected his ear with the flies' eggs on the occasion just described. 358 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tympanum. Tympanum. than its mere presence in the ear, had caused the patient's death from suppurative meningitis. The narrow limits of this article preclude the possibil- ity of laying before its readers a detailed clinical history of many cases ; but their attention is particularly called to the following, among those already cited, as being cases whose histories will be found especially instruc- tive. As illustrative of the slight degree of disturb- ance which may be set up by the presence of a foreign body in the drum-cavity, reference may be made to cer- tain cases related by Voltolini {Monatsschrift fur Ohren- heilkunde, 1876, No. 5), where a Politzer's eyelet, a small smooth body made from hard rubber, lay within the drum-cavity without exciting inflammation, and to a case reported by Bartscher and quoted by Gruber, where for nine months a corset ring lay impacted in the tym- panum of a child previously affected with chronic otitis media purulenta, without giving rise to serious trouble. (" Noch nach neun Monaten war das Kind frei von alien moglichen Folgen.") On the other hand, among the cases wherein unsuccessful attempts at extraction were followed more or less rapidly by a fatal result, reference may profitably be made to two instances reported by Weinlechner {Weiner Spitalszeitung, 1862), the one of an impacted pebble, the other of an impacted coffee-bean, and to a case described by Mayer {Monatsschrift fur Ohren- heilkunde, 1870) where, several weeks after the abandon- ment of unsuccessful attempts to extract a paper ball from the tympanum, the patient died from abscess of the brain and the offending body was discovered and ex- tracted post mortem* As regards the method of exit of the body, viz., by way of the Eustachian tube, the bent-pin case of Dr. Kealy is, perhaps, the most curious of all. A full account of this case will be found in the Medical Times and Gazette for December 17, 1859. Urbantschitsch's case of a fine oat-stem (Haferrispenast), which worked its way from the pharynx along the Eustachian tube into the tym- panum, and was thence extruded by the suppurative in- flammation and consequent perforation of the drum- membrane which its presence occasioned, is curious as concerns both entrance and exit of the body. In the case where two bits of wood were extracted from the tym- panum by Dr. R. O. Du Bois, these foreign bodies, the larger of them about half an inch long, had apparently lain in the tympanum for several years, having been broken off from a piece or pieces with which the patient had been scratching his ear. The patient was an intelligent man, and his report of his case bore out this supposition. The case was one of chronic external and middle otitis of the desquamative variety, and these pieces of wood were only discovered after the passage had by repeated attempts (extending over several weeks) been cleared to a point below the level of the tympanic ring of the dense mass of laminated epithelium with which it was oc- cluded. f Dr. Buck's interesting and instructive case of "artificial drum" in the tympanum will be found more fully described in his work entitled "Diagnosis and Treatment of Ear Diseases." The subject of foreign bodies in the drum-cavity is discussed more or less at length in nearly all the special works on otology, but par- ticularly in those of Dr. D. B. St. John Roosa, " Trea- tise on Diseases of the Ear," and of Dr. Josef Gruber, "Lehrbuch der Ohrenheilkunde," both of which works, and the former especially, the writer would recommend to those of his readers who may wisely decide to study the subject in greater detail than it has been possible to present it in this article. Huntington Richards. TYMPANUM: INTIMATE PATHOLOGICAL RELA- TIONS BETWEEN THE POSTERIOR NARES AND THE MIDDLE EAR. Preliminary Remarks.-A very large percentage of the diseases which affect the middle ear attack first the posterior nares, and advance through the Eustachian tubes to the middle ear. This is explained by the fact that the mucous membrane lining the nostrils, pharynx, posterior nares, Eustachian tubes, and tympanic cavity, is continuous. Many of the acute inflammations of the middle ear originate in the anterior nares, as colds in the head ; " thence the inflammation spreads to the posterior nares, involves the mouths of the Eustachian tubes, and creeps through these tubes to the tympanic cavity. The pathological changes occurring in the mucous membrane are identical throughout. When in the course of scarlet fever, measles, diphtheria, or small-pox, the ears become affected, the eruption or efflorescence charac- teristic of the disease attacks first the mucous membrane of the pharynx or nares, spreads to the naso pharynx, and thence through the Eustachian tubes to the middle ear; the pathological changes are the same. In what are usually called the chronic catarrhal diseases of the middle ear, if we examine the nares, posterior nares, and pharynx, we almost always find there conclusive evi- dence of chronic catarrhal changes in the mucous mem- brane, and when w'e inquire into the history of the case, we usually find that the catarrh of the nose and throat preceded by months, or even years, the first manifesta- tion of disease in the ears. Adenoid vegetations in the naso-pharyngeal region, and swelling of the mouths of the Eustachian tubes, may themselves cause symptoms of disease in the ear before the mucous membrane of the tympanic cavity has become involved ; but if not re- moved or suitably treated, before long we shall find the drum-membrane opaque, gray, and cloudy, a sure sign that the mucous membrane of the middle ear is also at- tacked by chronic inflammation. The starting-point for the inflammation in the diseases I have mentioned, is either the anterior nares or the pharynx, but the posterior nares occupy a sort of mid- dle ground over which the disease passes on its way to the middle ear, and if the process can be checked before the Eustachian tubes are involved it does comparatively little harm. The naso pharynx can be treated with com- parative ease, and has outlets sufficiently large to allow the escape of secretions, however profuse they may be ; while, on the other hand, it is difficult to medicate the middle ear, and as this is a closed cavity (with the excep- tion of the Eustachian tubes, which latter, when inflamed, open but seldom and imperfectly), it becomes quickly filled with secretion, causing often serious symptoms and complications. These facts have led the modern aurist to consider it a part of his duty to see that the naso-pharyngeal region, as well as the middle ear, is properly treated ; and the anterior nares and pharynx must, to a certain extent, be included also. Every aurist knows that each spring brings numbers of patients seeking relief for trouble in the ears. This means simply that, as colds and sore throats are more prevalent in the spring than at other times of the year, and also usually more severe, a larger proportion of people are likely to have diseases of the ears. He knows also that if the colds and sore throats had been carefully treated while the inflammation was con- fined to the nares or pharynx, as the case may be, or even after it had spread to the posterior nares, there would have been, in most cases at least, no extension to the middle ear. The importance of remembering this can- not be overestimated. The general practitioner should remember it, and not consider a simple cold in the head or sore throat as of too little importance to require treat- ment ; the public should be instructed, so far as it is pos- sible, that it is worth while to take care of a cold in the head ; the aurist should never forget it, and should warn his patients that it is especially important for them, having already disease in the ears, that they should not * Dr. George Pilcher, in his Treatise on the Ear, reports a very in- structive case, wherein several London hospital surgeons caused the death of a little child by violent attempts to extract a foreign body which was found neither ante nor poet mortem. + The occlusion of the canal by this mass, rather than the mere pres- ence of the fragments of wood below it, appeared to be the cause of the exacerbation in his symptoms, for the relief of which the patient first ap- plied at the New York Eye and Ear Infirmary. I saw the patient on the occasion of his first and second visits, but it was several weeks later, and when the acute symptoms had considerably abated in violence, and the gradual process of softening and excavation of the extremely hard mass had progressed to a deeper level, that Dr. Du Bois, during my absence on vacation, discovered and removed the underlying foreign bodies. 359 Tympanum. Tympanum. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. take cold ; and further, he should instruct them how, in case they have taken cold, they can best check the in- flammatory process before it has spread to the Eustachian tubes and middle ear. There is a considerable class of ear patients whose deafness is apparently caused entirely by repeated attacks of " head colds," and each cold, if severe, leaves them a little deafer than they were before. During the greater part of the year they do not lose ground, but usually the spring, with its crop of colds and sore throats, takes away a little of their hearing. I need hardly point out how important it is for these patients to cut short a cold, to treat it while it is confined to the nares and naso-pharynx. There is another class of patients, who at some pre- vious time have had a discharge from the ears which has ceased ; they either have a scar closing the perforation in the drum-membrane, or they have a dry perforation. In some of these cases, particularly in children, every severe cold in the head is followed by a repetition of the discharge from the ears. In still other cases, in which there is already a purulent discharge from the middle ear, all efforts to cause this discharge to cease are un- availing until treatment is directed to the naso-pharynx, as well as to the middle ear, and the improvement in the condition of the former of these cavities is followed by diminution in the discharge from the latter. It seems as if the mucous membrane of the posterior nares, when chronically thickened and inflamed, and es- pecially if adenoid vegetations be present, were a smould- ering fire ready to break out into a flame which would spread to the middle ear whenever a cold in the head gave it the needed stimulus. Pathology of Acute Inflammation of the Posterior Nares and Middle Ear.-If we examine into the pathology of an acute inflammation of the posterior nares, as seen in an ordinary cold in the head, we find the mucous mem- brane swollen, red, tender, and secreting a profuse, thin, serous discharge; as the cold progresses, mucus begins to be mixed with the serum, the discharge is less in quan- tity, is white and thick, next it becomes entirely mucous, and is transparent like the white of egg ; the congestion and swelling of the mucous membrane go down, the mucous glands return to a healthy condition, and at last only secrete sufficient mucus to keep the parts moist; and then the cold is well. If the inflammation has spread to the middle ear, we shall find the same state of things in the tympanic cavity. At first a red, swollen, and tender mucous membrane, secreting great quantities of serum ; but as the middle ear has no means of getting rid of this serum (except through the Eustachian tube, which shares in the swelling and is consequently wholly or partially closed), the tympanic cavity rapidly fills up, causing throbbing, deafness, and tinnitus ; pressure of the fluid upon its walls causes pain, which, if the inflam- mation continue unabated, increases in severity ; the drum-membrane is bulged outward, and finally gives way, and we have a thin serous discharge in the external auditory canal exactly similar to that which came from the nares in the early stages of the cold. If the disease in the ear run a favorable course, the serous discharge changes to a mixture of serum and mucus, diminishes in quantity, becomes thick and white, then colorless, and finally ceases, and the perforation in the drum-mem- brane closes. This is the history of a simple acute in- flammation of the middle ear which runs a favorable course. The changes in the mucous membrane are the same as those seen in the nose and naso pharynx, and the character of the discharge at each stage of the inflam- mation is the same. Pathology of Chronic Inflammation of the Posterior Nares and Middle Ear.-In chronic inflammation of the posterior nares, commonly known as "chronic catarrh," there are three stages: First, a general swelling of the mucous membrane and hypersecretion of mucus. Next, the glands become distended with their contents, and press upon the muscular fibres which pass between them, whose duty it is, by contracting, to squeeze the contents out of the glands ; the muscular fibres are para- lyzed by the pressure brought to bear upon them, and are even less able than before to assist in emptying the distended glands. Many of the latter become small abscesses, their lining membrane is destroyed, and they are useless ; those that remain are swollen and their ducts are obstructed. In the third stage there is atrophy, or granular or fatty degeneration of most of the mucous glands, an increase of connective tissue, and diminution in the number and size of the blood-vessels ; the nose and throat become dry and parched, the morbid secre- tion of the diseased glands dries on as a crust or scab ; the nostrils and vault of the posterior nares, which in the earlier stages were smaller than normal from swell- ing of the mucous membrane, now become more patu- lous than they should be, and the mucous membrane is shrunken instead of being swollen. Many aurists be- lieve that the changes in the mucous membrane of the Eustachian tubes and tympanic cavity are similar to those just described-at first thickening of the mucous membrane and hypersecretion of mucus, which close the Eustachian tubes and clog the movements of the chain of ossicles ; the articulations of the malleus, incus, and stapes share in the chronic thickening and become less movable than normal ; then, as the process goes on toward the third stage, the Eustachian tubes become ab- normally patulous, the middle ear, from the destruction of its mucous lining, becomes abnormally dry, the artic- ulations of the ossicles, from the deposits of connective tissue, become less and less movable, like a chronically inflamed joint in any other part of the body-as, for ex- ample, a stiff knee or elbow-joint-and we have what is known as sclerosis of the middle ear, one of the most un- satisfactory forms of disease of the ear to treat which can possibly be met with. The importance of treating the posterior nares, and, if possible, not allowing these changes to spread to the middle ear, can be seen when we consider that those forms of treatment which are most effectual in combating the disease in the naso- pharynx, are inapplicable to the tympanic cavity, which is both difficult to get at, and too prone to inflammation to permit of the use of remedies which are perfectly safe when applied to the posterior nares. Treatment of Acute Inflammation of the Posterior Nares.-Admitting, then, that for many persons a cold in the head is a serious matter, what is the best method of curing it ? It is of the utmost importance to take it in hand as soon as the burning and tickling sensations in the nos- trils manifest themselves. Just before going to bed, let the patient take a hot foot-bath, and snuff the nostrils full of the following.powder, which is a modification of Ferrier's snuff : IJ. Biborate of sodium 3 iij. Subnitrate of bismuth 3 ii. Sulphate of morphine gr.v. M. Sig.-To be used like snuff at bed-time for cold in the head. Do not blow the nose after using it. This powder often causes a sharp, burning sensation for several minutes, and causes the nose and eyes to dis- charge profusely, but this soon ceases. The patient may wipe the nose if necessary, but is cautioned not to blow it, as he would blow all the powder out, and would thus receive little or no benefit from it. The powder is moist- ened by the discharge and forms a coating to the inflamed mucous membrane of the nares ; while the patient is asleep it runs backward to the posterior nares and bathes the mucous surface there also. The patient should sleep warmly covered up, in order to promote perspiration as much as possible. In the morning, as soon as he gets up, he should take a saline cathartic, Epsom or Rochelle salts, to clear the bowels thoroughly. If these direc- tions are carried out on the evening of the first day of the cold, they are usually sufficient to cure it. Some- times it is necessary to repeat the use of the snuff the next night, using, however, a smaller quantity. The only objection to the snuff is that there is a small quantity of morphine in each pinch, and persons who are very susceptible to it will have a headache the next day ; bufunless this be severe, having checked the cold 360 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tympanum. Tympanum. is more than compensation for the discomfort of a head- ache. For patients who have any tendency to the opium habit this remedy is of course contra-indicated. Quinine in doses of three to five grains, and repeated as often as is necessary until the symptoms of a cold in the head have disappeared, is another good remedy, as is also five grains of quinine and five grains of Dover's powder, taken upon going to bed the first evening that the cold makes its appearance, followed the next morning by a saline cathartic. There are, however, two objections to quinine taken in such doses as are usually required to check a cold ; first, it certainly does have a direct ten- dency to cause congestion in the ears, and secondly, pa- tients who have been accustomed to check all colds by its use, ofteu find that they have become intolerant of the drug, and that a comparatively small dose, which they used to take with perfect impunity, causes nausea, faintness, and headache. For children, promoting free perspiration while they are asleep is usually all that is necessary if the cold be treated early enough. A drink of hot lemonade with a teaspoonful of sweet spirits of nitre in it, or, for older children, half a tumbler of lemonade with two teaspoon- fuls of either of the two following mixtures in it will be found useful; the child should sip the lemonade just before going to sleep. 5. Nitrate of potassium 5.0 (75 grains.) Spirit of nitrous ether 10.0 ( 3 ijss.) Solution of the acetate of ammonium, Camphor water aS 45.0 (about 3 xj). Sig.-Fever mixture. Dose, teaspoonful, and repeat as often as necessary to bring on free perspiration. 5. Citrate of potassium 3 ij. Spirit of nitrous ether 3 ij. Tincture of aconite gtt. vj. Syrup of lemon | ss. Pure water ad ? iv. M. Sig.-Fever mixture. Dose, teaspoonful, and re- peat as often as necessary to bring on free perspiration. Another prescription, useful for adults or older chil- dren, is Beard's cold powder. B. Pow'dered opium gr. iv. Powdered camphor gr. viij. Carbonate of ammonium gr. xij. M. Divide into four powders, with a tinfoil wrapper for each powder. Sig.-One powder at bed-time, and repeat if necessary the next day. In giving this to children, the quantity of opium may be diminished and that of carbonate of ammonium in- creased. There are, of course, numberless other reme- dies for cold in the head which are useful, but those given above are as efficient as any. Treatment of Chronic Inflammation of the Posterior Nares.-The treatment in chronic inflammation of the naso pharyngeal space is first directed to cleansing that cavity of the discharge which has collected there. A few years ago it was the custom for anyone who thought he had chronic catarrh to purchase a fountain syringe, and set to work douching his nose and naso-pharynx. This practice, although it usually cleaned the nose satis- factorily, was followed in such a large number of cases by acute inflammation of the middle ear, owing to the fluid being forced through the Eustachian tubes, that it soon fell into disfavor; it should never be done, except after giving the patient the following rules, which he must faithfully observe. The fluid must be warm and the vessel containing it must not be raised higher than the patient's forehead, so that the stream shall pass into the nostrils very gently ; the fluid must be introduced only into the narrower of the two nostrils ; the head must not be inclined backward ; the mouth must be kept open, and the patient instructed not to swallow ; if he feels that he must swallow, he is to compress the tube which con- ducts the fluid to his nose and so temporarily stop the flow. At best the method is dangerous for the ears, and should not be employed if it be possible to cleanse the nose and naso- pharynx in any other way. The same objection applies also, to a certain extent, to snuffing fluids from the palm of the hand, or syringing them through the nostrils. By any of these methods, in a certain number of cases, the fluid is forced into the Eustachian tubes and mid- dle ear, but the two latter are infinitely less dangerous than the nasal douche of Weber. A safer, and I think equally efficient, method is to pour the cleansing fluid into the nostrils from a glass or tin vessel shaped like a sauce-boat. The patient is told to fill the vessel with hot milk, put into this one saW-spoonful of a mixture of table salt and bicarbonate of soda, one-half each ; stir it for a moment until it dissolves ; put a towel over the chest and shoul- ders ; place a basin on the knees ; tip the head wrell back and pour a little of the solution into one of the nostrils ; when the fluid runs through into the pharynx, it and any mucus that comes with it should be spit out into the ba- sin on the knees ; then pour a little into the other nostril, and dispose of it as before ; repeat this several times in each nostril, until the milk comes through clear and the nostrils feel unobstructed. The patient must be cautioned not to blow the nose after he has finished, as he might force some of the milk into the Eustachian tubes ; he may wipe the nose, but not blow it. It is best to use this method only at bed-time, and care must be taken to prevent soil- ing the clothes. After using it, the patient must go at once to bed, leaving the mucous membrane of the nose and naso-pharynx bathed with the milk solution. The instrument here figured cannot be purchased ready-made in this country, but a tinman can make it from a rough drawing sufficiently well to answer all practical purposes. If the vessel cannot readily be pro- cured, the solution may be transferred from a tumbler to the nares by means of a teaspoon. The strength of the solution should be a saltspoonful to one-third of a tumbler of hot milk. Sprays, applied both through the nostrils and behind the soft palate, are safe and efficient remedies for cleansing the naso-pharyngeal tract. The solution given above, substituting water for the milk as less likely to clog the spray, is good ; or one-third lister- ine and two-thirds warm water may be used. The following is the formula for Dobell's solution, which is often of great service. B- Carbolic acid xxx. Biborate of sodium, Bicarbonate of sodium aa 3 j. Glycerine 3 iijss. Water enough to make fiv. M. Sig.-Dobell's solution ; to be used as a spray for the nose and naso pharynx. Should this solution be employed for a long time, it will be necessary to decrease the amount of carbolic acid one- half. There are also many other useful sprays, the for- mulae for which can be found in any treatise on diseases of the nose. Besides cleansing the parts, it is often neces- sary to make applications, in the form either of powders, or of liquids painted on to the mucous membrane with a brush or cotton-tipped probe. The bismuth, morphine, and biborate of sodium snuff, described above, is often useful in the earlier stages, when there is hypersecretion of mucus. The following may also be used : B. Powdered catechu 3 ss. Powdered acacia 1 ss. M. Sig.-Snuff. Fig. 4221.-Glass Vessel for Pouring Fluid into the Nostrils, '/e actual size. (From Politzer.) 361 Tympanum. Tympanum. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cauterization by the electro-cautery, nitrate of silver, glacial acetic acid, etc., is also often necessary, espe- cially about the mouths of the Eustachian tubes ; for the reduction of the swelling in the neighborhood of these orifices in many cases aids materially the treatment directed to the middle ear. In the later stages, when the posterior nares are abnormally dry, after thoroughly cleansing the parts, swabbing them over with the follow- ing solution keeps them moist, and stimulates the mu- cous glands to increased secretion : 3. Potassium iodide 0.2 (gr. iij.) Iodine (pure) 0.02 (gr. J.) Glycerine 20.0 (Jv.) M. Sig.-To be applied to the nostrils and posterior nares on a brush or cotton-tipped probe. For a more extended account of the methods of treat- ing dry catarrh of the naso-pharynx, medicated cottons, etc., the reader is referred to the articles on the Nose and Pharynx. It is unfortunately difficult to cure chronic catarrh of the posterior nares, in the sense of causing the symptoms to disappear never to return, for the next severe cold often brings a recurrence of the symptoms ; but it is usu- ally possible to greatly improve the diseased condition of the mucous membrane-which is a point of the greatest importance, since, as we have seen, middle-ear disease is so often consequent upon inflammation of the naso- pharynx. Adenoid Vegetations may be considered to result from chronic inflammation in the naso-pharynx. In the Bos- ton Medical and Surgical Journal of March 15, 1888, is an article by Dr. C. J. Blake, on the "Relation of Ade- noid Growths in the Naso-pharynx to the Production of Middle-ear Disease in Children." I cannot do better than to quote his concluding sentences, which set forth this relation most forcibly. In the same number of this jour- nal is an article by Dr. Franklin H. Hooper, entitled " Adenoid Vegetations in Children ; their Diagnosis and Treatment," and from this I quote the author's excellent description of the best method of removing these growths. He has also been kind , enough to allow me to make use of the woodcuts representing the instruments which he employs. Dr. Blake says : " In reference to the aural symptoms, the cases under consideration may be divided into three classes. The first includes those in the earlier stages of the adenoid growths, which have had occasional earache and the occasional impairment of hearing, apparently readily referable only to what is called a head-cold. These children have very variable hearing, are frequently accused of inattention and disobedience, and are either too young to know, or have too slightly noticeable an impairment of hearing to appreciate, that their derelic- tions are sins of the flesh and not of the spirit. The effects to the ear of the removal of the growth in the naso-pharynx are often appreciable only to the trained observer ; the child is freed from a catarrhal affection and the improvement in hearing, if any is noticed, is taken for what it is, a matter of course. An objective examination of the ears, however, shows that there is no longer a slightly congested condition of the tympanic mucous membrane, and in the course of time the thick- ening of the mucous coat of the membrana tympani is seen to be decreasing. In the second class are the more advanced cases, in which the preliminary stages being passed, the impairment of hearing and the structural changes have become recognized as fixed facts ; the im- pairment of hearing in some of these cases being so great and so persistent that the child is regarded either as a deaf-mute, or even as idiotic, the well-known effects of obstruction of the hearing upon the mental development favoring the latter supposition. In many of these cases it has been found that catheterization of the Eustachian tubes-the air douche proving ineffectual on account of the blocking of the Eustachian orifices and interference with the movement of the palate by the growth-has de- cidedly and immediately improved the hearing, and en- tirely changed the objective symptoms in the ear; the membrana tympani, previously dull both in color and in lustre, returning to the normal appearance in a greater or less degree in both respects. The improvement in both appearance of the ear and in hearing power in these cases, consequent upon the use of the Eustachian catheter, is, however, but temporary, the true cause of the abnormal condition remaining. "In by far the largest majority of such cases the re- moval of the adenoid growths is followed by an imme- diate and gratifying improvement in hearing, which in some of them remains unabated. In others, however, the impairment is again noticeable at the end of a few days. In all these latter cases there is accompanying, and as a result of the adenoid, a considerable swelling and congestion of the naso-pharyngeal and tubal mucous membrane, enough in itself to interfere materially with the physiological action of the Eustachian tubes. The free bleeding following the operation upon the adenoids sufficiently depletes the swollen mucous membrane to bring about a condition of freedom for the middle ear temporarily, which is permanently attained, subsequent- ly, only by patiently continued treatment. "To the third class belong those cases, already alluded to, in which suppurative otitis media is a result of the disease in the naso-pharynx* plus some local exciting cause, or is merely a coincident of a suppurative disease of the middle ear of other origin. That the maintenance of patency of the Eustachian tube is an important factor in the successful treatment of these cases, is well recog- nized, and in at least two of the cases which are the subject of this joint memoir, the effect of the removal of the adenoids upon the response of the ear to the same treatment which had been previously pursued, was most gratifying. " A classification of the cases mutually observed, and operated on under ether, by Dr. Hooper, which are the only ones here included, shows that out of the whole number, thirty-nine, or nearly eighty-three per cent., had evidence of more or less implication of the ear, and that of that number in thirty-five, or nearly ninety per cent., the result, as evidenced by the improvement in hearing, was eminently satisfactory. "Comment upon the importance of a recognition of these cases, and the application of an early remedy, is, in view of these and similar results of other observers, and of the known consequences to the hearing in later life of the persistence of these abnormal conditions, quite unnecessary. It is well to bear in mind, however, that with the removal of the adenoid growths, the work-as regards the ear-is not entirely done, and that the rhinologist and otologist must act as friends in council ; the removal of the cause is the first step, it is true, but though, as Dr. Holmes says-and this seems especially true of children-' Nature is kinder than the doctors think,' some assistance is needed in many of these cases to help on the removal of the consequence of the cause." In describing the operation which he considers most effectual in removing these growths, Dr. Hooper says : "The method I consider the best for a child when there is a large mass to be removed, and which I have carried out with great satisfaction in one hundred and four children of ages ranging from twenty months to fourteen years, is as follows : The child is thoroughly etherized. It is then placed in a good light, and seated upright in the lap of an assistant, the operator being seated opposite to it. The child's mouth is held open by a small-sized mouth-gag inserted between the teeth on the right side. Any accumulation of mucus in the pharynx is to be wiped out. The operator should now pass his index-finger up behind the soft palate and assure himself of the quantity and situation of the growths. Then gently pulling the soft palate forward and upward by means of a palate-hook held in the left hand, a pair of post-nasal forceps, held in the right hand, is intro- duced, closed, into the naso-pharyngeal cavity. One soon learns to feel the growths with the closed end of the forceps. The blades are then opened, the mass grasped and pulled off, either by direct traction or by a 362 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tympanum. Tympanum. slight twisting movement of the forceps, but under no circumstances is force to be exerted. If the grow'th comes away with difficulty, release the blades of the forceps and begin over again, taking hold of a smaller portion of the growth. Force as well as hurry is to be avoided. The rapidity with which the operation is com- pleted depends upon the amount of the haemorrhage. If there is much bleeding after a portion of the mass has been removed, wait until it has ceased, and then proceed with the operation. This it is usually necessary to do from three to six times or more before the cavity is cleansed out. The finger is to be inserted in the cavity from time to time, until it is found that it is practically free. When it is considered that enough has been ac- complished with the forceps, I hold the child's head well forward, so that the blood may flow out of the nose, and with the ball of the index-finger of the left hand, and the finger-nail, attempt to smooth down the remaining ragged edges by passing the finger first into one choana, then into the other, and then backward and downward along the posterior wall of the naso-pharynx ; also, when nec- essary, along the lateral wall of the cavity, the Eustach- ian prominence, and in the fossa of Rosenmuller. This manipulation with the finger causes the blood to flow more freely than the previous evulsions with the forceps. Occasionally, also, after the larger portion of the growths has been plucked off with the forceps, a post-nasal cu- rette may be introduced behind the soft palate and the remaining ragged masses scraped away. The steel finger-nail fixed to the finger and used as recommended by Sir William Dalby, is also serviceable for this pur- pose. In certain cases Meyer's ring-knife, introduced through the nostril, is of use to scrape around the Eusta- chian orifices, the end of the instrument being guided by the forefinger behind the soft palate, as practised by Mr. Butlin,1 of London, whose method, in fact, of deal- ing with these growths, with the exception of the posi- tion of the patient and the management of the soft palate, does not differ very materially from the one described. But, as a rule, the happiest results may be accomplished with the forceps and the forefinger alone. With proper care and assistance there is no danger for the child, and in one sitting, occupying from ten to twenty minutes, it is practically cured of a complaint which may have existed for years. " The removal of the growths, however, is not accom- plished in all cases with equal satisfaction. The con- ditions which make the operation difficult are an exces- sive amount of mucus in the throat, a large, thick tongue, enlarged faucial tonsils, a long distance from the lips to the posterior pharyngeal wall, a small space between the free border of the palatal curtain and the pharynx, and a deep naso-pharyngeal cavity. In no case has it been necessary to repeat the operation, though in two children, where the operation was prolonged owing to some com- plication, it was thought at the time that a second sitting would be needed. Yet these children did perfectly well, which leads me to think that we need not be too ener- getic, or imagine that every particle of the growths must necessarily be brought away. The principal object of the operation is to establish free nasal respiration. If this be effected, a small amount of adenoid growth left behind may not do harm. The vitality of the remaining tissue is probably destroyed, and it will atrophy. " The growths do not recur after removal. In operat- ing, as I invariably do, with the child in the upright po- sition, it will be urged that there is danger of blood be- ing sucked into the larynx. In speaking with practical surgeons concerning the operation, this criticism has al- most always been advanced. But the objection is theo- retical, and with care and prudence no accident of this nature need be feared. There are no large blood-vessels in the naso-pharyngeal cavity to be wounded, and it is characteristic of the bleeding from the growths that it ceases completely in a few moments. The blood does not come with a gush, but will be seen to be trickling slowly down the posterior wall of the pharynx. That which is not sponged out Hows into the stomach, and will be vomited later. Liquids naturally flow down the oesophagus, and not down the windpipe. The danger in operations about the mouth is from a clot of blood becoming wedged in the glottis, and it is easy to guard against its formation in this operation. The bleeding varies greatly in different cases, and as far as I am aware, there is no way of foretelling in any given case how pro- fuse the haemorrhage may be. The vascularity of the growths does not seem to be proportionate to their size, for some of th(* largest masses have bled insignificantly. In beginning the op- eration go slowly and watch. When a portion of the growth has been re- moved, wait until the bleed- ing has ceased, and then proceed with the operation. These children with ob- structed noses, especially if they happen to have en- larged faucial tonsils, are usually bad etherizers, and in many the accumulation of mucus in the lower pharynx is excessive, all of which is calculated to make the operator feel anxious ; but no annoyance in any case has been caused by blood in the wundpipe, and no surgeon who has been present at the operations, either at the Massachusetts General or the Boston City Hospital, or in my private practice, has seen cause for alarm on this score. There is more to be feared from vomited food lodging in the larynx than from a clot of blood. The ether, there- fore, should be adminis- tered on an empty stomach. The degree of etherization must be sufficiently pro- found to abolish reflex ac- tion of the soft palate, so that it will yield to being held forward by the palate-hook without re- sistance. It is impor- tant to keep the palate out of the way of the forceps, and no effort should be made to grasp the growths when it is contracted. For, should its posterior sur- face or other healthy wall of the cavity be nipped, an obsti- nate and annoy- ing haemorrhage may take place. It will be an ad- vantage for the operator to have a small index-fin- ger; also a light , hand and a deli- cate touch. It need hardly be said that he should pos- sess a perfect familiarity with the situation of the differ- ent anatomical structures in the naso-pharyngeal cavity, and know the difference, when feeling with the finger or with the forceps, between the parts in a normal state and when covered by adenoid growths. In selecting a pair of post-nasal forceps for the operation, it will not do to Fig. 4222. Fig. 4223. 363 Tympanum. Tympanum. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. take the first pair that comes to hand. The average in- strument in the shops is unnecessarily cumbersome, and unnecessarily long. For children, the curve of the cut- ting end of the forceps should be small, and the length of the handles as short as possible and perfectly firm, so that when the cutting ends are in contact there will be no "give" at the handles. The ease and success with which these growths are removed under ether, when the sense of touch plays such an important part, depends very much upon thp proper selection of instruments. The drawing on preceding page shows the exact size of forceps* (Fig. 4222) which have been found to be the most serviceable for the average child up to the age of fourteen. The conventional hard-rubber palate-hook is also shown, Fig. 4223, as well as the mouth-gag pre- fine it to the pharynx. It is not necessary here to give a long list of gargles. I must however add, that the frequent use of gargles is beneficial to the ears, not only by bathing the diseased mucous membrane with a sooth- ing, stimulating, or astringent solution, according as the one or the other may be required, but also because, by the muscular effort exerted in the act of gargling, the contents of the distended glands are squeezed out, thus reducing the swelling of the mucous membrane, and by the contraction of the levator and tensor palati muscles, the Eustachian tube is opened, allowing air to pass to the tympanic cavity. When the mouths of the tubes are swollen, or blocked up with mucus, this is a very important aid to the aurist in his treatment of the ear ; so important is it, that the patient is often told to gargle frequently with plain water, the mere act of gargling being helpful, even when the patient is not conscious of having a sore throat. Acute Infectious Diseases.-In the acute infectious dis- eases, such as scarlet fever, measles, diphtheria, small- pox, and whooping-cough, the effort of the attending physician should be directed to confining the inflamma- tion to the throat or nose, as the case may be, by the use of suitable gargles, sprays, or washes. Unfortunately we have nothing which can be regarded as a specific against the spread of these inflammations, but much may be done by removing the secretions as fast as they form, and by the use of soothing and antiseptic applications. The spread of the inflammation to the ears should also be carefully watched for, and at the first symptom of trouble in the ears they should be examined by an aurist. This ought to be as much a part of the duty of the attend- ing physician, as watching for albumin in the urine of a scarlet fever patient; and the terrible results which often follow neglect of the ear symptoms in these diseases, should insure their being promptly treated by an aurist when they first make their appearance. In conclusion I would say, that in this article I have not attempted to enumerate all the diseases of the pos- terior nares which might directly or indirectly affect the Eustachian tubes and middle ear, but I have* tried to show the intimate connection, as regards both pathology and treatment, between the two regions in some of the more common diseases which affect the mucous mem- brane of both of these cavities, and the necessity of keep- ing this in mind when we are called upon to treat either of them. The diseases of which I have spoken do not always originate in the nose or throat, spreading thence to the posterior nares and middle ear. For example, we sometimes find sclerosis of the middle ear without any previous history of trouble in the nose and throat. Nevertheless, in a large majority of cases, such as I have attempted to describe, the trouble in the ears is an exten- sion from the naso pharynx, and it therefore behooves us to examine, and, if necessary, treat this cavity as well as the middle ear. II. L. Morse. 1 St. Bartholomew's Hospital Reports, 1885. TYMPANUM : THE PRESENCE OF AIR IN THE TYMPANUM AS A SIGN OF LIVE-BIRTH. The presence of air in the middle ear as a sign of live-birth, is the subject of a paper by F. Ogston.1 He refers to a series of articles by Dr. Robert Wreden, of St. Peters- burg, on the condition of the ear at, or soon after, birth, in which he directs the attention of medical jurists to the entrance of air into the middle ear, and the disappearance of the gelatinous substance which fills the tympanic cav- ity before and up to the birth of the child. Wreden says that this gelatinous material disappears twenty-four hours after birth; that twelve hours is not sufficient time for the child to have breathed, to cause its complete disap- pearance ; and concludes, from a medico-legal stand- point, that the presence of air in this cavity might be of value as a proof that respiration had taken place. Ogston considers that these statements have been made without sufficient grounds, and that they require modi- fication. He gives the notes of fifteen cases collected partly by Dr. Alexander Ogston and partly by himself, as follows ; Fig. 4224.-Actual Size of Mouth-gag. ferred, Fig. 4224, which is easy to adjust, easy to remove, easy to keep clean, and never out of order." The extracts which I have quoted from the excellent articles by Drs. Blake and Hooper show most conclusive- ly how important it is for an aurist to examine the poste- rior nares for adenoid growths in cases of deafness in children, particularly when they have other symptoms, such as mouth-breathing, which point to the presence of these growths ; and the futility of treating the ears alone and disregarding the symptoms of trouble in the naso- pharyngeal vault. Inflammations of the Pharynx.-In regard to acute and chronic inflammations of. the pharynx, what has already been said in connection with diseases of the anterior nares, namely, that the inflammation often spreads to the mouths of the Eustachian tubes and thence to the tympanic cavity, applies equally well. It is important, therefore, to cut short the disease if possible, and to con- ♦ Made by Codman & Shurtleff, Boston. 364 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES Tympanum. Tympanum. Age of Child. State of Middle-ears. State of Lungs. Cause of Death. Other Facts, etc., to Fix Term of Life. 1 14 weeks. Filled with air. Fully expanded. Smothering. Bronchitis. 2 9 weeks. Filled with air. Fully expanded. Smothering. Bronchitis. 3 2 weeks. Filled with fluid. Fully expanded. Smothering. 4 6 weeks. Right, air-Left, muddy fluid. Fully expanded. Smothering. Bronchitis. 5 1 month. Filled with air. Fully expanded. Smothering. 6 4 weeks. Right, air-Left, air and fluid. Fully expanded. Broncho-pneumonia. ■■ 7 8 days. Filled with air. Fully expanded. Bronchitis. Lungs bulky, emphysematous. 8 3 days. Containing air. Fully expanded. Smothering. ■ 9 2 hours. Fluid and yellow substance. Partly expanded. Apoplexia neonatorum. Breathed feebly two hours. 10 New-born. Containing fluid. Expanded. Smothering. Meconium in lower intestine. 11 New-born. Filled with red fluid. Expanded. Fractured skull. Meconium in lower intestine. 12. New-born. Containing fluid. Expanded. Smothering. Navel-string attached. Me- conium in lower intestine. 13 New-born. Containing red fluid. Partly expanded. ? Meconium in lower intestine. 14 New-born. Containing air. Expanded. Smothering. Meconium in lower intestine. 15 New-born. Containing fluid. Unexpanded. Still-born. - Ogston thinks that he ought to have omitted the first six cases as not bearing directly on the subject, but he thought it better to adduce them, inasmuch as, though most of the ears contained air, yet some of them contained fluid also, and in one (3) they were filled with fluid, al- though the child had lived two weeks and there were no signs of catarrh in the respiratory tract to account for its presence. The fluid was probably catarrhal, but as it was not examined microscopically, Ogston cannot state positively that it was so. The last nine cases, on the contrary, are those in which Wreden's proposed test should be expected to prove useful, but, as we see by the table, in only three (6, 7, and 14) was air found in the middle ears, although the lungs in all, with the exception of a still-born min- iature infant, contained sufficient air to float in water, and from all air could be expressed when they were held under water. The presence of catarrhal fluid in the middle ear might be misleading, but in these cases more or less air would be found along with it, which would tend to prevent its being mistaken for the gelat- inous matter found before birth. Other papers on this subject have been published by Wendt,2 Troeltsch,3 E. Hofmann,4 Blumenstok,5 Zau- fal,6 Moldenhauer,1 Gelle,8 Schmaltz,9 and Lesser.10 Gorham Bacon. 1 Ogston, F. : Presence of Air in the Middle Ear as a Sign of Live-birth. British and Foreign Med. Chir. Review, October, 1875. 2 Wendt: Ueber das Verhalten von Mittelohr-Affection im friihesten Kindesalter. Arch. f. Heilk., 1873, pp. 97-124. 3 Troeltsch : Lehrbuch der Ohrenh,, 5 Aufl., 1874, p. 162. 4 Hoffmann, E.: Ueber verzeitige Athembewegungen in forens. Beziehung. Vierteljahrschr, fur gen. Med., 1873, Bd. xix., p. 217-258. s Blumenstok : Die Wreden-Wendt'sche Ohrenprobe und ihre Bed- eutung in foro. Wiener Med. Wochenschrift, 1875, No. 40 ; and also, Zur Verwerthung der Ohrenprobe fur die Diagnose des Ertrinkungstodes. Friedrich's Bl. fur gen. Med., 1876, p. 289. 6 Zaufal : Lectionen des Gehororgans von Nengeborenen und Saug- lingen. Olsten. Jahr, fur Padiat., 1870, Bd. i.. p. 118. 7 Moldenhauer: Das Verhalten der Paukenhohle beim Fotus und Neu- geborenen und die Verwendbarkeit der Ohrenprobe fur die Ger. Med. Arch. f. Heilk, 1875, pp. 498-415. 8 Gelle: Medecine iegale. Signe nouveau indiquant la respiration du nouveau-ne tire de 1'inspection de 1'oreille. Paris, 1876. 9 Schmaltz: Das sogenannte Schliemhautpolster in der Paukenhohle der Neugeborenen und seine forens. Bedeutung. Arch. f. Heilk., 1877, 3. u. 4. Heft. 10 Lesser: Zur WurdigungderOhrenprobe: Vierteljahrschrift furgen. Med., 1879, Bd. xxx., pp. 26-64. TYMPANUM. TUMORS AND NEW-GROWTHS IN THE. Aural Polypi.-Aural polypi, developed gen- erally during the course of a chronic suppurative otitis media of long standing, most frequently have their ori- gin from the mucous membrane of the tympanic cavity, less frequently from the external auditory canal and membrana tympani. Schwartze says that polypi are found in from four to five per cent, of all cases of ear dis- ease, and twice as frequently in men as in women. Ac- cording to Politzer, " the most frequent starting points of polypi of the middle ear are the inner and superior walls of the tympanic cavity, the covering of the ossicula, more rarely the cells of the mastoid process and the mu- cous membrane of the Eustachian tube. In the external meatus, their roots spring oftenest from the posterior superior wall of the osseous portion near the membrana tympani, or partly from the latter itself, rarely from the cartilaginous portion. On the membrana tympani, the root of the polypus arises mostly from the superior pos- terior section and from Shrapnell's membrane. Very often polypous growths are found at the same time in the middle ear, on the membrana tympani, and in the meatus." Polypi originating from the tympanum and extending into the Eustachian tube have been described by Meissner and Voltolini. Moos and Steinbriigge 1 found that in one hundred cases of polypi examined, seventy-five had their starting Fig. 4225.-Aural Polypi, to. Root; k, body of polypus; p, round ex- crescences growing on polypus. (After Politzer.) points from the outer wall of the labyrinth and twenty- live from the external auditory canal. Occasionally, the ossicles, and more especially the mal- leus, are found imbedded in the polypoid growth. There are great variations in the size of polypi ; they may be as small as a nodule or large enough to com- pletely fill the external meatus, and even project from it. When this latter occurs and there is profuse secretion, quite frequently ulceration takes place at the exposed extremity. They are generally, however, of the size of a pea or date-kernel (Politzer). Polypi have been known in rare cases, by pressure, to enlarge the osseous auditory canal. They may be attached by a broad base or a very slender pedicle. Frequently, a polypus originating by a slender pedicle passes through a small perforation in the mem- brana tympani and appears in the audi- tory canal. Several cases have been reported, in which polypi were found in the tympanic cavity without perforation of the drum- head. A. Eitelberg2 mentions a case of a girl, fifteen years of age, who presented herself at his office, saying that she had been suffering for three days from con- tinuous intense pain in the right ear. Three years pre- viously she had had a stinging sensation in the same ear for about a week, and had been troubled with tinni- tus for two weeks previous to the beginning of the pain. An examination showed that the posterior part of the membrana tympani was bulged out, swollen in toto, partially devoid of epidermis, and of a reddish-gray color. The handle of the malleus was not discernible. In the external meatus, lamellae of epidermis were found Fig. 4226.-Club- shaped Polypus, growing within the tympanum. (AftefPolitzer.) 365 Tympanum. Tympanum. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. in masses, which, of course, were removed thoroughly before inspection of the membrana tympani. With Politzer's method, no perforation noise was heard, no retrogression of the bulging followed it, but the pain was greatly relieved and soon stopped entirely. The bulg- ing of the drum-head persisted ; the operation of para- centesis was performed, and instead of pus, a red tumor appeared in the opening. The secretion for the first few days was slight, but later became profuse, and the per- foration became much enlarged. The growth was then seen to be the size of a pea, and sprang with a broad pedicle from the mucous membrane of the promontory. By means of instillations of a four-per- cent. solution of boric acid, consisting of 10 parts of rectified spirit in 15 of distilled water, the discharge began to diminish in about two weeks and the polypus to shrink. The perforation finally closed, leaving the membrana tympani thickened and of a whitish- gray color, and the place of the para- centesis marked by a dull shining line. The handle of the malleus remained indistinctly visible. The hearing had improved from 0 to 10 ctm. for the watch ; medium loud conversation was heard as far as the full length of the room, 6 metres, when the left ear was closed. The pa- tient then stopped treatment, being satisfied with the result. In ten out of one hundred cases reported by Moos and Steinbriigge, caries was associated with the presence of polypi. A single polypus or several may be found in one ear. Politzer says "that in cases of multiple polypi, long contact may cause the union of two originally separate," and he reports in his Handbook a case of a polypus completely filling the meatus of the ear of a girl, who died from sinus thrombosis, and where one root started from the membrana tympani and was connected with the malleus and incus, while the second and longer root had its origin from the inner and inferior wall of the tympanic cavity. He says that "from the different origins of the two roots, it may with certainty be as- sumed that a polypus of the membrana tympani has united with one of the tympanic cavity, from continued pressure, an incident which has also been observed in other cavities of the body." Polypi vary as to their external form, being either perfectly smooth and club-shaped, or by their papillary structure they may be knobbed and glandular, having the appearance of a raspberry, and a bright red color. When they are smooth and exposed to the air, they are usually pale orpinkish. Schwartze3 says "the papillae are either situated as a compact base of tis- sue, or the whole tumor consists only of branching papillae of all sizes and forms, producing sometimes an appear- ance like condylomata." He further says that " all aural polypi are covered by epithelium, either by a single or multiple layer of cylinder epithelium, the upper layer of which possesses ciliae, or by a multiple layer of pavement epi- thelium, or by a mixed epithelium. In the latter case the base of the tumor is covered by a cili- ated cylinder epithelium, and its external end by a mul- tiple layer of pavement epithelium, arranged as in the epidermis. The transition from the cylinder to the pave- ment epithelium is gradual." There are four varieties of polypi, according to their structure, viz. : I. Mucous polypi (granulations or round- celled polypi). II. Fibromata. III. Myxomata ; and IV. Angiomata, according to Buck. I. Mucous Polypi are most frequently observed and form fifty-five per cent, of all polypi, according to Moos and Steinbriigge. They are identical histologically with nasal and naso-pharyngeal mucous polypi, and are pro- duced by a hyperplasia of the mucous membrane of the tympanum. They consist of a fine delicate and loose stroma of areolar connective tissue, in the meshes of which are found round cells and sometimes spindle- shaped or stellate cells. There are also numerous blood- vessels. These polypi are usually irregular on the sur- face, owing to their papillary structure and the glands which they contain, and which, according to Schwartze, " are tubular inversions of the epithelium into the tissue of the polypus." These growths frequently contain cysts, which are lined by cylindrical epithelium and filled with a mucous fluid, in which are found loose epithelial cells and mu- cous corpuscles. Steudener regards them as retention- cysts, produced from the tubular glands. The epithelium covering the surface of the polypus, which is exposed directly to the external air, is usually of the pavement variety, while on the unexposed, or in- ner surface, there is usually found cylindrical epithe- lium or ciliated cylindrical epithelium. (Fig. 4229.) Fig. 4227.-Papil- lary Aural Polypus resembling Condy- lomata. (After Schwartze.) Fig. 4229.-Cross Section of a Mucous Polypus, covered with ciliated cy- lindrical epithelium. (From a drawing by Dr. Ira Van Gieson.) Politzer says, " by transformation of the round cells into spindle-shaped cicatrix cells, the soft polypus receives a hard fibrous character. This transformation proceeds irregularly from the root to the body of the polypus." Hartmann4 considers that a granulation growth may develop into a fibroma by the cellular elements develop- ing into spindle-cells and connective-tissue fibres, some of the blood-vessels becoming obliterated. J. B. Weydner,8 of Munich, in a paper published, " On the Structure of Aural Polypi," feels justified in as- serting " that almost all aural polypi are generally noth- ing but granulation tumors, whose fate it is to be ulti- mately transformed into connective tissue." " Only a few of the polypi attain, however, any considerable size and undergo the above transformation." The author gives the notes of seventy-three cases of aural polypi, and states that the cause of the polypi in eight cases was otitis me- dia purulenta acuta ; five of these polypi grew from the membrana tympani, two from the meatus, and one from a Wilde's incision. None of these originated in the tym- panum. Otitis media purulenta chronica existed in sixty-one cases, in ten of which the polypus was located upon or near Shrapnell's membrane. Of the remaining fifty-one, twenty-five sprang from the tympanic cavity, thirteen from the membrana tympani, and thirteen from the ex- ternal meatus. Besides these, there were four other cases in which polypi in the meatus arose independently Fig. 4228.-Smooth Aural Polypus, the base covered with smooth pa- pills. (After Schwartze.) 366 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tympanum. Tympanum. of any suppuration, and chiefly, in the author's opinion, from irritation caused by foreign bodies or plugs of ce- rumen. The ages of the patients varied from twenty to thirty years. Ten were under ten years of age ; sixteen between ten and twenty ; twenty-one between twenty and thirty ; ten between thirty and forty ; twelve be- tween forty and sixty ; age unknown in four cases. Forty-four were men ; twenty-seven w'ere women. His- tologically, thirty-three of the polypi were pure granula- tion tumors, composed only of round cells and numerous blood-vessels ; twenty-three contained additionally some connective tissue ; while in only eight of the polypi did mature connective tissue preponderate over the other elements; five were essentially vascular tumors, one a lymphangioma, one a teleangiectasia, and three cavern- ous angiomata ; four of the polypi were epithelial tu- mors, and among them were a small cholesteatoma, a wart from the tragus, a wart-like growth from the cartilagi- nous meatus, and, lastly, an adenoma, which was found polypus existed in the ear of a boy seventeen years of age, and had its origin by a broad base from the tym- panum. It had been extirpated by Schwartze, who says : " From its external appearance it seemed to be perfectly gelatinous. Its epithelial covering consisted of a multi- ple layer of pavement epithelium, into which flat papillae, like those of the cutis, projected. The stroma consisted of a perfectly homogeneous gelatinous tissue, crossed by an anastomosing network of spindle- and star-shaped cells ; very fine fibrillae were also found, which in some parts accompanied the rows of cells, in other parts formed a wide-meshed network through the gelatinous tissue. On the surface of the tumor, and also in the neighborhood of the blood-vessels, these fibrillae were especially numerous, in the former case in layers parallel to the surface of the tumor, in the latter case in layers concentric to the blood-vessels." There were found in the gelatinous tissue, in the meshes of the network formed by the fibrillae and cells, a number of round, granular cells with a simple round nucleus, resem- bling lymph-corpuscles in size and appearance. Schwartze explains the existence of this form of tumor in that "the foetal tympanum contains mucous tissue, w'hich generally undergoes a retrograde metamorphosis after birth. Residues of this tissue, on the occurrence of purulent catarrh of the middle in a case of chronic otorrhoea. The tendency to degenera- tion was marked in forty-six out of the seventy-three poly- pi. In three cases the handle of the malleus was partially or wholly enclosed. II. Fibromata have their ori- gin from the periosteal layer of the middle ear or auditory canal, and their growth is much slower than that of mu- cous polypi. They do not bleed as readily when touched with a probe, the surface of the tumors is smoother, and they are generally paler in color than the granulation growths, owing to the scarcity of blood-vessels. A fibroma is dense and firm, and consists of fibrillar connective tissue, in the meshes of which are interspersed spindle cells. Its surface is covered with pavement epithelium. This variety of polypus does not contain tubular glands and cysts, but small papillae project into the epithelial layer or covering. A fibroma, however, is never distinctly papillary. III. Myxomata are extremely rare, occurring, accord- ing to Hartmann, in five per cent, of aural polypi. The first case reported was that by Steudener, in which a ear, which is extremely common in new-born children, become irritated and increase in size, thus producing a polypoid tumor." IV. Angiomata have been described by A. H. Buck,* who says that Virchow applies the term cavernosum to that variety of angioma which is characterized by the existence of a network of blood-spaces, occupying the place and fulfilling the function of capillaries. Ac- cording to his view, the arteries, in a growth of this kind, pour their blood into these spaces, from which it passes directly into the veins and so back into the general circulation. Buck, in the same paper, gives the history of the following case: George A., aged nineteen years, mechanic, was admitted to the New York Eye and Ear Infirmary, April 2, 1870. He says he has suffered since seven years of age from frequent attacks of earache and an almost constant otorrhoea from both ears. He has also been annoyed by noises of different character. Lately the sound in the left ear has been a pulsating, humming noise; it is continuous, but at regular inter- vals, corresponding to the pulse-beat apparently, it be- comes louder. On waking this morning he found his pil- low, as he states, covered with blood. The haemorrhage, Fig. 4230.-Cross Section of An- giomatous Polypus, as seen un- der a low power. (Buck's case.) From a drawing made by Dr. Ira Van Gieson. 367 Tympanum. Tympanum. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. which came from the left ear and was unaccompanied by pain, continued in the form of oozing throughout the entire forenoon. This was the first time that any blood was noticed as being in the discharge from either ear. The patient's general condition is good. The right auditory meatus half filled with pus ; right mem- brana tympani entirely destroyed. Left meatus filled with blood, partly clotted. After its removal by syring- ing, an oblong, dark-colored body, about the size of a small pea, was found lying, apparently free, on the infe- rior wall of the meatus. At first sight it was supposed to be a foreign body or inspissated cerumen. The poly- pus was found attached by a long and slender pedicle to the stump of the hammer, which could be seen in the background. Dr. R. F. Weir divided the pedicle with the scissors and the growth was removed by syringing. Powdered alum was insufflated. June 25th : The patient returned to-day, stating that about May 15th the noises and discharge both reappeared and have continued ever since. On examination of the left ear a pinkish vascu- lar teat is found hanging to the stump of the hammer and standing out in strong contrast with the pale granu- lations which form the background. He was ordered instillations of tannin, 3 j., glycerine, § j. The entire mass, when examined under a microscope (Fig. 4230), " was found to consist of blood-vessels, radi- ating from an irregularly-shaped central cavity and sepa- rated by a ne t- work of fibrous connective tissue, holding blood-corpuscles in its meshes. In two or three of the sections, a large vein could be followed from the central cav- ity into the remaining stump of the pedicle. In one of these and in other sections, the point of rupture could be distinctly traced from the central cavity to the periphery of the polypus." The patient being asleep at the time of the haem- orrhage, it must be assumed that the rupture took place from natural causes located within the tu- mor itself. Six weeks after the removal of the original growth a second one made its appearance. This occurrence, according to Buck, seemed a " strong argument in favor of Virchow's view that an angioma is an independent new-growth of ves- sels, just as much as an exostosis is an indepen- dent new-growth of bone." Large-sized polypi are occasionally observed hav- ing their origin from the cartilaginous portion of the auditory meatus, as in a case which I recently observed, where large polypoid masses were at- tached around the opening of a sinus in the ante- rior wall of the cartilaginous canal; this sinus ex- tended forward and inward to the squamous portion of the temporal bone, which was necrosed, as was also the bony auditory canal and zygomatic arch. Frequently, granulations which either disappear or develop into polypi, are found at a point in the auditory canal where a furuncle has had its seat. Hedinger, Cassels, and Bezold have reported cases in which osseous deposits were found in the substance of the polypus. Symptoms.-Aural polypi may not cause during a life- time any injury to the health ; more frequently, how- ever, by preventing a free exit for the escape of the se- cretion, they cause more or less pain, a sense of fulness, pressure, or dulness on the corresponding side of the head, with vertigo and tinnitus. The secretion pent up in the mastoid antrum becoming stagnant and developing into cheesy masses, may through absorption occasion disease of the bone and serious com- plications. In a case1 which I reported of a patient with a chronic purulent inflammation of both ears with polypi, severe symptoms developed, viz., nausea, vomiting, un- steadiness in the gait, and marked deafness, together with facial paralysis. After removal of the polypi and dila- tation of the canal, thus allowing the pus to escape freely, there was a marked improve- ment in all these symptoms. Spontaneous cure of the polypus through shrivelling seldom occurs. Schwartze, Toyn- bee, Moos, and others have, on the other hand, reported cases of spontaneous discharge of polypi. Politzer believes that this occurs mostly in the case of large polypi with thin pedicles, and that the death and discharge of the polypus are produced by the tumor becom- ing rotated on its long axis and the blood- supply being thus cut off. The presence of polypi may be suspected in cases of chronic purulent middle-ear disease, especially when the discharge contains blood. Schwartze8 reports a case of aural polypus, which was the cause of hemiplegia of the cor- responding side, together with anaesthesia and ptosis. According to Politzer, an aid to the diagno- sis is the appearance presented by the polypus : "The pale-red, pearl-gray polypi with smooth or moderately rough surface, usually spring from the meatus, while the sodden, red, vascu- lar, raspberry-shaped growths with villiform, papillated surfaces, most frequently arise in the tympanic cavity." Treatment.-The point of attachment of a polypus should first be ascertained by the use of a fine probe, which is introduced into the auditory meatus and carefully passed around the grow'th. When this has been determined, Blake's snare (Fig. 4231) will be found one of the best instruments for the removal of polypi, especially those attached to the middle ear or membrana tympani. Dif- ferent-sized cannulae, with fine iron or steel wire, can be used, according to the situation and size of the growths. In some cases, where the polypi are small and soft and the snare cannot be easily passed around the base of the growth, the sharp curette (Fig. 4232) will be found ex- tremely useful. It is well to instill a solution of cocaine (ten per cent.) into the ear before operating, and in some cases, es- pecially in children, it will be necessary to give ether. Avulsion, by means of forceps, is recommended by some surgeons. The method is to seize the growth by the instrument and to wrench it off by a rotary motion. Considerable dam- age maybe done, however, by removing more than the morbid growth, especially if the polypus is attached to the mem- brana tympani; but when arising from the wall of the canal, the operation is generally successful. Polypi arising from the walls of the canal, may fre- quently be easily snipped off by means of curved scissors, of a form shown in Fig. 4233. In the case of granulations, Politzer mentions in his Handbook the method introduced by Oscar Wolf : " This con- sists in scraping off the proliferations from the promontory or from the acces- sible inferior or posterior wall of the tympanum by means of small, sharp spoons of various shapes. This method, however, is only suitable in cases of sharply - defined granulations, whether single or in groups. The scraping often only partially succeeds, and the remainder of the granu- lations must be cauterized or removed by the instillation of alcohol. In such cases, however, the duration of treatment is very much shortened by this operation." Fig. 4232.- The Sharp Curette. Fig. 4231.-Blake's Snare. Fig. 4233.-Curved Scissors for Re- moving Polypi of the Meatus. 368 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tympanum. Tympanum. Politzer also makes use of a small annular knife (Fig. 4234), constructed on the same principle as Meyer's in- strument for the removal of adenoid vegetations in the naso-pharynx, in cases where it it not easy to remove the polypus with the snare. The in- strument, which is of steel and is here shown in its full size, is 7 ctm. long, and carries on its anterior end a con- cavo-convex ring, whose inner margin is very sharp. The diameter of the larger ring is 3 to 3| mm., and of the smaller one 14 to 2 mm. The instru- ment is attached to a handle and can be turned in different directions ac- cording to the situation of the growth, whether in the tympanic cavity or on the walls of the auditory canal. The ring can also be bent with its convex cutting surface at an obtuse angle to the long axis of the instrument, for the removal of certain polypi. Polit- zer says : " With small round polypi and granulations in the meatus, this instrument is pushed forward to the growth and its convex surface pressed against the latter until a firm base is felt. The instrument is then quickly withdrawn, cutting the growth from its base and bringing it with it on the concave surface of the ring, and so removing it from the meatus. This procedure is suitable not only for polypi and granulations whose size does not exceed the diameter of the annular knife, but also for larger growths. For polypi with a very broad base, the annular knife cannot be used." The galvano-cautery is best adapted, according to Schwartze and Jacoby, to the removal of fibrous polypi, when the snare or knife cannot be used. Politzer con- siders the galvano-cautery to present many advantages over the caustic remedies, in the fact that it causes rapid and thorough destruction of the growth, and also that vio- lent pain is felt only at the moment of its action on the growth, ceasing immediately after the cauteri- zation. After removal of the polypus, the root or base should be cauterized with a satu- rated solution of chromic acid, and this should be repeated until all trace of the growth has disappeared. Politzer recommends tincture of chloride of iron as an application to granulations and to the roots of polypi. Dr. Edward H. Clarke recommended the injection of a solution of perchloride or persulphate of iron into the polypus, and with satisfactory results. Other caus- tics employed are: Vienna paste, potassa fusa, nitric acid, and nitrate of silver in solution or melted in the form of a ball on the end of a probe or wire. When the polypi are small and not easily removed by instruments, alcohol, either ab- solute or diluted, and containing boracic- acid powder in solution or suspension (3 j--§ j-)» will frequently cause these growths, as well as the swollen mucous membrane of the middle ear, to shrink. Before applying it, the ear should be thor- oughly cleansed and dried by means of absorbent cotton. The alcohol, warmed, should then be poured into the meatus and allowed to remain from fifteen to thirty minutes. This should be repeated two or three times a day. In the case of granulations or polypi that persistently return after removal, and when attached to the walls of the meatus, a plug of absorbent cotton, introduced into the canal and pressing against these growths, will fre- quently cause them to disappear. The so-called dry treatment, or insufflation of boracic acid or other powders, is to be recommended in many cases after removal of the morbid growths, and espe- cially in the case of granulations associated with caries or necrosis. Theobald,9 of Baltimore, has used with much success boracic acid and zinc oxide, equal parts, in cases of sup- purative otitis media with granulations. Knapp,10 in a paper read before the American Otolog- ical Society, concludes as follows : "My chief object in speaking of the treatment of aural polypi before this society was : 1. To warn against repeated cauterizations. 2. To express my experience in favor of the alcohol treatment; 3. To recommend letting granulations with a broad base grow until they have become pedunculated ; and 4. To vindicate the old method of avulsion, as being both expeditious and efficient, and no more dangerous than other methods." Fibroma Attached to Chorda Tympani Nerve.-Hinton described a small fibroma which had its origin from the chorda tympani nerve. Professor Koeppe has also seen a gumma with a similar origin. Cholesteatoma, according to Schwartze, "is a name often used for various pathological conditions." In some cases it is used to designate a true new-growth, having its origin from the dermal layer of the external meatus (Toynbee n), from the drum- head (Hinton,12 Kupper,13 Wendt14), or from the bone, similar to cholesteatomata found in other bones of the skull. The tumor is com- posed of a stearine-like substance, glistening, containing principally epidermal cells polyg- onal in shape), and generally small numbers of cholesterine crystals. In the earlier stage of its development there may be no inflamma- tory irritation in the neighboring parts of the growth, but this is shown in a later stage, when suppuration is apt to follow, associated with a destructive tendency. According to Schwartze, then, we may have perforation of the membrana tympani, or the bone of the upper wall of the meatus or of the sulcus trans- versus, with an opening into the middle or posterior fossa of the skull. Lucae found a cholesteatoma developed as a new-growth in the tympanic cavity, where there occurred neither perforation of the drum-head nor inflammation of the middle-ear. Cholesteatoma, however, is a name more frequently given to a collection of inflammatory products, espe- cially in the mastoid antrum, where there is not a free exit for the discharge of pus. The products consist usually of desquamated epithelium and numerous cho- lesterine crystals, besides fatty and caseous pus. These masses have no connective-tissue capsule, and are fre- quently found in cases of purulent discharge of the middle ear with perforated drum-head, where polypi are present blocking up the canal, and thus preventing a free discharge of pus. The watery elements escape, while the more solid products are retained. Cholestea- tomata may cause atrophy from pressure, and sclerosis, as well as caries and necrosis of the bony walls. They may thus burrow into the mastoid cavity, through the walls of the external auditory canal, or into the cranial cavity. These tumors, if not removed, may produce severe head symptoms, as pain, vertigo, fever, vomiting, and meningeal inflammation, and even pyaemia, abscess of the brain, and death. After removal of these tumors, a great excavation in the bone may be found, involving the whole of the mastoid cavity, auditory canal, and tympanum, as well as the labyrinth and pyramid (Schwartze). According to Wendt, a cholesteatoma in the temporal bone is produced by a desquamative in- flammation of the mucous membrane of the tympanum (with or without perforation of the drum-head). Fig. 4234.-Politzer's Annular Knife ; two different sizes. Fig. 4236.- Galvano- cautery Point. Fig. 4235.-Gal- va n o - cautery Snare. 369 Tympanu in. Tympanum. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Exostoses.-These may be found on the walls of the tympanum or on the ossicles. Schwartze says : " On the floor of the cavity and on the lower edge of the promon- tory, they occur as normal formations, like osteophytes, in the form of sharp points and osseous bridges ; but they are also found in these shapes as pathological forma- tions on other parts, as the promontory, the neighborhood of the fenestra rotunda, and the eminentia pyramidalis, where they are the results of chronic periostitis. Osse- ous bridges are sometimes found between the eminentia pyramidalis and fenestra ovalis." The same writer says that " exostoses on the ossicula, the results of ossifying periostitis, without suppuration of the tympanum and without perforation of the drum-membrane, are common on the incus, where the point of preference is on the labyrinth side of the end of the short process ; they are less common on the malleus, and least common on the stapes." Gout and rheumatism, as well as syphilis, ac- cording to some writers, play a most important part in the causation of these bony growths. Hyperostosis.-If the walls of the tympanum are equal- ly involved, the middle ear may become very much con- tracted. Complete closure of the foramen rotundum may occur. Cysts.-Cases of dermoid cysts containing hairs have been described by Toynbee and Hinton.15 Politzer16 mentions the occurrence of cyst-like cavi- ties, having their origin from the mucous membrane of the drum-head. Schwartze17 has described a retention- cyst lined with epithelium and filled with rhombic tables of fat crystals, which he thinks was developed from a tubular mucous gland of the tympanic mucous membrane. Tubercle.-Eschle 18 was the first to make a positive communication as to the presence of tubercle bacilli in the discharge from the ear, in the case of a man with advanced pulmonary phthisis. Hartman, in his Hand- book, says that " we must explain general tuberculosis originating in the ear by the entrance of tubercle bacilli from the outside into the deposits of pus, which find there a favorable soil, spread thence over the body, and thus produce general infection. In cases where the af- fection has existed longer than that of the ear, purulent otitis may be regarded as a localization of the general infection originating in pulmonary tuberculosis. Direct transmission of tuberculosis from the sputum to the mucous membrane of the tympanic cavity may also take place through the Eustachian tube." In a case of Hartmann's at present under observation, in which the lungs have been affected for years, a left- sided otorrhcea developed recently, which has resulted in great destruction. Tubercle bacilli were always found in the sputum, but never in the discharge from the ear. The symptoms of tubercular infection of the ear are commonly non-inflammatory; some deafness and dis- charge usually first attract the patient's attention. More or less destruction of the drum-head follows, as well as of the mucous lining of the tympanum and bony walls. According to Nathan,19 there were bacilli found in twelve out of forty cases of chronic discharge from the ear. Bezold had sent these to him for examination. Pulmonary tuberculosis was diagnosed in eight of these cases. Voltolini20 has also made a communication on this subject. Gessler21 says that he was unable to discover any ba- cilli in the secretion of cases of phthisical otitis media purulenta, examined at the request of Dr. Bezold, but he did not have sufficient material to form any positive con- clusions. Kanzler22 was unable to prove the existence of bacilli in the secretion of two cases of otorrhoea, although they were abundant in the mucus of the inflamed larynx. A. Gottstein23 considers, with some degree of proba- bility, that in cases of otorrhoea the diagnostic value of the bacilli is not very great, and draw's the following con- clusions : " The examination of the secretion, in all sus- pected cases of chronic purulent middle-ear inflamma- tion, for tubercle bacilli is to be recommended. If, however, the result is negative, we are not justified in excluding a tubercular origin." Thomas Barr, at a meet- ing of the Glasgow Pathological Society in 1881, when the pathology of phthisis and tuberculosis was under discussion, suggested, as a possible source of tubercular infection, the softening of caseous masses which had become stagnant and retained in the cavity of the mas- toid. The author says: "Is it not possible that they (cheesy products) may at any time soften, and then be- coming absorbed by the blood-vessels or lymphatics, con- stitute the virus, which reveals itself in a general tuber- culosis or in a local tubercular meningitis ? " This doctrine of self-infection has been taught by many writers, among them Virchow, Buhl, Niemeyer, and others. Vascular Villi of the Tympanic Mucous Membrane.- Moos24 had the opportunity of discovering vascular villi of the inner tympanic wall. The first case was that of a child, which wras born in an asphyxiated condition, but was brought back to life only to die ten days later. The second case was that of a fcetus of four months. These villi, as seen from the sketches, bear the greatest resem- blance to those of the intestines, and appear to confine themselves to a particular locality, and there are rarely more than eight. They rest upon the inner tympanic wall opposite the posterior periphery of the membrana tympani, but on the side of the locality where the fibres of the membrane are inserted into the annulus tympani- cus. They look somewhat like a finger, and measure about 0.2 mm. in length and 0.055 mm. in breadth. They are evidently prolongations or protrusions of the mucous membrane, are composed of the narrow edge of the same, are covered w'ith a single layer of ciliated cylinder epithelium, and bear within them a single vas- cular loop. These loops arise from the vessels of the mucous tissue which underlies the mucous membrane, and is at this time, as is easily to be understood, still extraordinarily increased in thickness. From the loca- tion at which the villi cease to appear, the mucous mem- brane continues to bear for some distance a wavy and al- most papilla-like appearance. Moos has never been able to demonstrate vessels, or loops of vessels, in any of these papilla-like prominences, which, like the villi, are also covered with a ciliated cylinder-epithelium. Further investigations will show whether the occurrence of these villi is constant, or whether they are only present in the foetus and new-born children, and then disappear after respiration has become w'ell established. Gerlach has described microscopic elevations of the mucous membrane of the drum-head, some resembling the papillae of the tongue and some intestinal villi. Ger- lach says the former become large enough to be seen with the naked eye in transmitted light. They are cov- ered by a single layer of pavement epithelium, and are composed centrally of the ordinary connective tissue, but at the periphery of a more homogeneous connective tissue, and contain one or more vascular loops, but no nerves. They are found more frequently on the mem- brana tympani of newT-born children. Malignant Growths.-Malignant growths having their origin in the tympanic cavity are of extremely rare occurrence. Generally the disease, commencing in the auricle, external auditory canal, or some other part of the temporal bone, involves secondarily the middle ear. Cases of primary cancer, originating in the middle ear, have been reported by Travers25 and Wishart.26 A case of osteo-sarcoma of the cavity of the tympanum has been reported by Boke.27 Toynbee, in his "Diseases of the Ear," mentions five cases of primary carcinoma of the middle ear, but only two of these had been under his im- mediate care. He admits, however, that he is not certain of the origin of these tumors. Schwartze, in his " Pathological Anatomy," says : " I myself have seen three cases of primary epithelial cancer of the temporal bone, of which two have been reported, and in all of them the origin of the growths was the tym- panic mucous membrane." Wilde, in his text-book, relates a case of osteo-sarcoma 370 Tympanum, Tympanum. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. in a boy seven years of age, in apparently good health. A small polypus was discovered and removed, but it soon returned. Mastoid disease supervened. Attacks of epilepsy occurred, and death soon followed. At the autopsy there was found an osteo-sarcoma of the petrous and mastoid portions of the temporal bone. He thinks that the disease had its origin primarily in the bone, and that the purulent discharge from the ear and polypus were secondary. A case of sarcoma reported by C. A. Robertson 28 was as follows : Mrs. H., forty years of age, of a nervous temperament and anaemic, said that seven years ago she first had a roaring and rumbling noise in the right ear. Two years later she became deaf, and three years subse- quently an otorrhoea followed, which continues now. The discharge, slight in quantity, yellowish and watery, has recently become sanious and very offensive. About six months ago she developed facial paralysis on the right side. She was first seen in June, 1870, on account of pain in the ear and deafness. An exam- ination showed the presence of a poly- pus, completely blocking the external meatus and almost reaching to the orifice of the canal. Attempts to remove the hard, fibrous growth always caused a copious haemorrhage. This was controlled by a tampon of cot- ton, wet in a solu- tion of persul- phate of iron. Astringent injec- tions were made into the ear of the pa- tient, and persulphate of iron was injected into the growth through a hypodermic syringe. The aggregate of all the portions removed would form a mass as large as a hickory- nut, but on inspection the tumor did not seem to be reduced in size. A microscopical examination showed the tumor to present the appearance of a fasciculated sarcoma. Further notes state that more of the growth was removed, and at the bottom of th^ meatus was a fibrous portion, which did not tend to protrude as at first. The lymphatic glands in front of the meatus and on the side of the ramus of the maxilla below the concha were enlarged. The discharge was less of- fensive. The hearing for the watch was negative, when it was placed against the ear or on any part of the tem- poral bone. Schwartze29 reports a case of epithelioma in a man fifty-five years of age, who had suffered from suppura- tive inflammation of the left middle ear, due to scarlatina, which he had in childhood. Caries of the temporal bone followed ; the mastoid process was opened and scraped. Shortly afterward granulations sprang up from the interior of the meatus, and a tumor the size of a pigeon's egg developed in front of the ear. Post- mortem examination showed that the disease, epithe- lioma, involved the temporal bone, destroying the tym- panic cavity, the petrosa, and the inferior half of the squamous portion. The disease had also involved the transverse sinus and a thrombus reaching to the jugular vein was found. (Fig. 4237.) Harlan30 relates the case of a round-celled sarcoma occurring in the ear of a little girl three years of age. Two months before she came for examination there was a bloody discharge from the ear, attended with pain on swallowing. The face was drawn to the right side, and there was some swelling about the face. A round polypus filled the external meatus. There was also a swelling below and behind the auricle. The polypoid growth was removed several times. Death ensued from exhaustion. At the autopsy, the bone behind the ear at the base of the tumor was found eroded, and the inner wall of the tympanum destroyed. Hartmann 31 has described a case of round-celled sar- coma of the middle ear in a boy three and a half years of age. After two weeks of suppurative inflammation of the ear, there developed in the tympanic cavity polypi, which recurred notwithstanding their frequent removal. The boy died five months later from marasmus. The temporal lobe of the brain was found compressed by the tumor. Arthur Matthewson32 has reported the case of a woman aged twenty-seven years, who had an epithe- lioma of the middle ear. She was first seen November 14, 1876, on account of pain in her left ear, which had commenced three days previously. There had been a discharge from this ear for years ; there was some deaf- ness, and on inspection there was found a perforated Fig. 4237.-Destruction of the Temporal Bone by Epithelial Cancer, a. Median remnant of the pars petrosa ; on the surface of its apex the bone is also destroyed by the new growth : b. porus acusticus internus ; c, foramen lacerum anterius ; d, foramen ovale, enlarged by destruction of its edges to twice its natural circumference; e, foramen spinosum ; f, sphenoid articulation. (After Schwartze.) drum-membrane, with hard, whitish, fibrous granulations projecting through the opening. There was no swelling of the soft parts over the mastoid, nor tenderness on pressure. The granulations were at first touched with a strong solution of nitrate of silver and the ear douched with warm water. The pain did not subside, so that leeches, counter-irritants, and blisters were applied about the ear, but with very little effect. The granulations were then picked away with forceps and touched with nitric acid. No dead bone was detected. March 18, 1877, a free incision was made over the mastoid, though the usual indications of mastoid disease were still absent. There was found very extensive necrosis of the mastoid, and the probe passed readily through a considerable opening into a large cavity in the bone, filled with fetid pus. The relief was but temporary ; 371 Tympanum. Tympan u m. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. pieces of bone were removed from time to time. May 24th, as the former incision was inclined to heal, a freer opening was made behind and above the meatus, and many pieces of dead bone and a large mass of granula- tions were removed. Fluids syringed into the opening passed freely out at the meatus. The pulsation of the intra-cranial vessels could be plainly seen. There were no symptoms of cerebral disturbance. No relief obtained, except by opiates. The disease gradually extended and on July 27, 1877, the patient died of exhaustion. A short time before she became unconscious her hearing on the affected side remained such that she could under- stand ordinary conversation at the distance of eight or ten feet. Autopsy : On removing the brain, there was found projecting from the floor of the skull, just over the petrous portion of the temporal bone on the left side, a whitish tumor about the size of a large hazel-nut, soft to the touch. It made a depression on the under sur- face of the tempero-sphenoidal lobe of the brain. The dura mater covering the whole temporal bone and ex- tending back to the occipital, and down into the foramen magnum, and over the wing of the sphenoid and sella turcica, presented an opaque, dull, soaked appearance, and was partly detached from the bone. The periosteal surface of the dura was covered with the new growth, varying in thickness at different points, but greatest over the ear. The bones of the labyrinth appeared to have been detached en masse, as they were found in the midst of the growth, held in place by the auditory nerve. The whole mastoid and petrous portions of the temporal bone were gone. The Gasserian ganglion and fifth nerve were involved in the new growth. The brain was normal. The growth was an epithelioma. The most interesting points in the case, from a pathological stand-point, were the absence of neuralgia of the fifth nerve, and of all symptoms which are characterized as Meniere's disease. The growth must have had its origin in the middle ear and extended to the dura mater, and as it progressed and involved that portion lining the mastoid, the nu- trition of the latter was interfered with and slow death of the bone brought about; and this appears to be the reason why the ordinary symptoms of inflammation were not present. A case of cancerous disease reported by Delstanche33 (fils) was as follows: A growth started from the right tragus and involved the tympanic cavity, the Eustachian tube, posterior part of the frontal bone, the wing of the sphenoid bone, and the posterior orbital wall. The dis- ease extended to the dura mater and caused death. Lucae34 reports a case of epithelioma which occurred as a polypus and persisted after removal. The patient was a man thirty-seven years of age, who had suffered from otorrhoea since childhood. He died ten months later from general exhaustion. A post-mortem examina- tion showed involvement of the right temporal bone, perforation of the petrous bone to the cranium, as well as purulent meningitis and a cerebral abscess. Politzer (Handbook) mentions a case of epithelioma pro- ceeding from the middle ear and invading the cochlea. Pomeroy35 has reported a case of myxo-sarcoma, which originated probably in the Gasserian ganglion and ner- ves in its vicinity, with partial destruction of the petrous and other portions of the temporal bone, and the soft parts within them. The patient, a girl six years of age. was brought for treatment on account of a convergent squint in the left eye, which had existed for ten weeks. In the right ear were symptoms of middle-ear catarrh, while in the left there was a minute granulation pro- truding through a perforated membrane. The granula- tion was removed by forceps. After the first week there was pain in the left eye and ear, darting to- ward the throat. The patient steadily grew worse, the growth in the left ear returned, and it was decided to be a case of malignant growth in the tympanum or its neighborhood. The ear filled up quickly again with a new growth, and this was soon followed by a tumor just behind the lobule and one beneath the tragus. These tumors grew very rapidly ; the child died from inanition and exhaustion. A case of epithelioma of the middle ear was reported by C. J. Kipp,36 as follows: H. K., aged fifty, Ger- man, came in June, 1880; she had suffered from an of- fensive otorrhcea from the right ear since birth, and, until a year ago, had never had an earache. About three months ago a fleshy mass appeared in the external meatus, and has since then gradually increased in size. For the past month she has suffered from intense pain in the head and car. For three days she has been unable to close the lids of the right eye, and the whole of the right side of the face is paralyzed. A red, spongy, rasp- berry-like polypus, sprouting from all sides of the meatus, was removed to a certain extent, and a considerable quan- tity of offensive, sanious pus escaped. The middle ear was likewise filled with a similar growth, but this was not touched. The walls of the external auditory canal were carious. The mastoid process was swollen, but no fluctuation was detected. The part in front of the auri- cle was also considerably swollen, but no pus was de- tected. The ear was deaf to all sounds. The eyes were examined, but nothing abnormal was found. The growth in the meatus returned ; pain was excruciating ; an inci- sion was made over the mastoid, but only a few drops of blood were evacuated. The swelling consisted of a fungoid mass. The disease gradually spread. The pa- tient had convulsions, followed by coma, and died six months after she was first seen. No autopsy was ob- tained. The microscopical examination of the fungoid masses removed from the external auditory canal showed that they were composed of large epithelial cells with large and distinct nuclei, arranged in cylinders, which contained also many pearly globules. The cylinders were held together by scant connective tissue. The out- line of many of the cells was serrated. In J. Orne Greene's 37 case of round-celled sarcoma of the ear, unfortunately, the primary origin of the growth could not be determined, as when the patient was first seen the meatus, tympanum, and mastoid were all in- volved. No autopsy could be obtained. In a paper on " Malignant Tumors of the Middle Ear," A. Rasmussen and E. Schmiegelow38 have given the his- tory of a case of endothelioma (sarcoma endothelioides, Rindfleisch) where the tumor, as it seemed to the writers, developed in one of the cavities of the petrous portion of the temporal bone, probably the tympanum, and grew from here partly outward through the external meatus, and partly inward and upward through the dura mater into the temporal lobe of the brain. The cerebral symp- toms were not prominent the first year ; facial paralysis appeared two years before death. The case seemed re- markable on account of the considerable local destruc- tion. " Such malignity," according to the writers, "is suggestive of its perhaps being the result of a combina- tion of two kinds of tumors. In this case, the combina- tion of two per se quite benignant forms of tumor has re- sulted in a malignant and very destructive growth." F. Kretschmann39 has written an exhaustive paper en- titled "Carcinoma of the Temporal Bone." He reports two new cases and gives a resume of fourteen cases which have already been published. He prefers the name of carcinoma of the temporal bone, from the fact that in many cases'it is impossible to tell where the new- growths had their origin. Of the two new cases which he mentions, one was that of a man seventy-two years of age. There was always at times a discharge from the right ear without causing any pain, and as long as the patient can remember he has never heard w'ith that ear. At the beginning of 1885 there was a more copious dis- charge from the same ear ; the pus was mixed with blood at times. There were pains also, producing sleeplessness and loss of appetite. He complained also of dizziness. An examination showed slight facial paralysis of the right side. There were two sequestra of bone in the canal. One was removed by forceps. There was no oedema over the mastoid, but it was a little sensitive on pressure. The watch and speech as well as the tuning- fork were not heard in that ear. The following day, the remaining sequestrum was removed, and then granula- tions could be seen, filling the deeper portion of the mea- 372 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tyinpanum. Tympanum. tus. There was found a sinus in the posterior wall of the auditory canal, leading to the antrum. The mastoid was opened and a large cavity, filled with granulations, was laid bare. These granulations and those from the canal were removed. The patient was much improved by the operation and the pains ceased. The disease was found to be carcinoma of the epithelial variety. After eight weeks the wound of the mastoid healed and the patient returned to his home. The disease, however, re- turned, and in January, 1886, the pains were severe ; in February a large sequestrum was removed. The dis- ease steadily progressed, and the patient died March 16th ; there was no autopsy. The following case40 of carcinoma came to my clinic at the New York Eye and Ear Infirmary in the summer of 1887. The disease undoubtedly had its origin in the tympanic cavity or in the mastoid antrum, as the follow- ing history will show. The patient, Mrs. M., a widow, fifty-six years of age, says that she has always been healthy ; no history of syphilis nor rheumatism ; she has had seven children. A year ago she first noticed deaf- ness in the right ear, with some tinnitus. There was no discharge until March, 1887, but since then there has been a slight watery oozing. Three weeks ago she no- ticed some swelling in front of the ear, and the pain, which before occurred only occasionally, has now become steady. What alarms her and has brought her here for treatment, is the facial paralysis which followed the swelling. An examination shows considerable indura- tion and swelling of the tissues in front of the right auricle, and extending toward the orbit and upward. The swelling also extends below the ear toward the angle of the jaw. There is more or less tenderness on pressure just in front of the external auditory meatus, and she complains of a steady, boring pain at a point slightly above and in front of the commencement of the helix. This pain is worse at night, not allowing her to sleep. The facial paralysis is not complete. There is a slight sero-purulent discharge from the auditory canal; the walls of the latter are so indurated and swollen that a view of the membrana tympani cannot be obtained. A probe introduced carefully, enters to the usual depth, causing no pain but considerable haemorrhage. Wet- cups were applied, and she was directed to syringe the ear frequently with hot water. She was also given hydrarg. bichlorid., gr. and potass, iod., gr. x., three times daily. August 23d. The swelling about the ear seems less and the pain has almost disappeared. August 26th. The pain has recommenced and is as se- vere as before. The swelling remains the same as when first seen. There being some indication of fluctuation, an exploratory incision, one-half inch long and one and one-fourth inch deep, was made under cocaine, just in front of the external meatus. No pus was found and very little bleeding ensued. August 30th. The incision has completely healed. September 13th. She has a severe erysipelatous ulcera- tion of the right leg. No change in other symptoms. A lead wash was given for the leg. October 1st. Since September 13th she has been at her home in New York State. She feels badly and thinks while there she overworked. The leg healed quickly. She sleeps only little at night, but dozes during the day. The bottom of the external auditory canal was seen to-day for the first time, and found to be occupied by two dark, bleeding vegetations. The mixed treatment was discontinued, as she was suffering from diarrhoea. October 25th. The facial paralysis has been complete for the past two weeks. The swelling has increased and the pain is intense. Poultices have been applied over the temporal and mastoid regions. Antipyrine has been tried in doses of twenty grains at night, with but slight and doubtful effect. Dr. Muzzy treated the patient up to this time. I saw her for the first time about November 2d. She could then hear loud voice with the right ear, and the tuning- fork, when placed on the vertex, was also referred to the same ear. She heard the tuning-fork louder when placed on the mastoid process than by aerial conduction. The left membrana tympani dull, retracted, and thickened ; cone of light small. The tissues over the mastoid pro- cess were indurated, and on making firm pressure over the apex of the mastoid there was some deep-seated pain. I made a Wilde's incision about one and a half inch long, and found denuded bone and an irregular opening about one-fourth inch in diameter leading to the mastoid cells. • There were found no sequestra of bone nor pus; the cells seemed covered by a spongy tissue, but a thorough examination was impossible, as probing caused consider- able pain. A poultice was then applied over the mastoid process, the ear was syringed, and morphine was given to alleviate the pain at night. The patient entered the Infirmary as an inmate, Novem- ber 8th, as the pain continued to be severe and the swell- ing remained the same. Dr. A. H. Buck and Dr. R. F. Weir saw the case in consultation with me, and it was decided best to postpone any operation on the mastoid at present, as a Wilde's incision had already been made and an opening established to the mastoid cells. Although the possibility of its being malignant disease was consid- Fig. 4238.-Carcinoma of the Temporal Bone. From a photograph. ered, it was thought more probable to be a case of exten- sive caries, involving the mastoid cells and auditory- canal, with chronic inflammation and induration of the surrounding tissues. At the time of the examination the probe passed into the mastoid process toward the antrum to the depth of two inches. The probe entering the tympanic cavity also revealed carious bone. The canal was still very much contracted, and the introduction of the probe into the middle ear at this examination, as be- fore, caused considerable haemorrhage. There being some cheesy material in the tympanum, it was deemed best to syringe the ear and the mastoid cells with a solu- tion of boracic acid several times a day, in order to keep the parts thoroughly clean, and to continue the morphine to relieve the pain. This treatment wras carried out for from ten days to two weeks. As the pain continued and there was no change in the induration of the tissues, etc., with Dr. Buck's concurrence, I decided to explore more thoroughly the mastoid cells. Operation.-Ether was given by the house-surgeon, Dr. Whiting; and assisted by Drs. Richards and Muzzy, 373 Tympanum. Ulcer. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. I enlarged the incision which I had previously made, by extending it upward to a level with the upper border of of before the operation, at a point close to the com- mencement of the helix, seems to be less now. The in- cision made behind the ear is healed, except where the drainage-tube enters, and the entire mastoid cavity is tilled with hard tissues, with the exception of the canal maintained by the tubing, which enters forward and in- ward for a distance of one inch and three-fourths, at the lowest extremity of which is observed a slight pulsation. The entire auricle is now indurated except the helix, the fossa of the helix, and the lobule. The cicatrix behind the ear is bluish in color, as 'well as the meatus and concha. The meatus is contracted still, and a probe passed in for a distance of two inches, causes considera- ble haemorrhage. H. D. watch, R. E.=0; L. E.=14". When the watch is placed on the right temple she hears it slightly. The tuning-fork, when held in the same re- gion, is likewise heard faintly with the right ear, but is not heard when placed on the mastoid process or other parts of the cranium. She hears slightly raised voice with the right ear, when the left is closed, and the tones of a Galton whistle are heard fairly well at a distance of three feet. Left ear ; she hears the tuning-fork better by aerial than by bony conduction. She has been up, walking about the room, for the past fortnight, and to- day left the Infirmary for her home. February 22d. Dr. Muzzy sent me to-day the following additional notes of the case : The patient has not left her bed since going home. The pain is now great in the up- Fig. 42-39. -a, Bone trabeculae ; b, mastoid sinuses ; c, carcinoma. the pinna and downward as far as the lower extremity of the lobule. The incision was made half an inch be- hind the insertion of the pinna. The tissues divided were as dense as cartilage. The mastoid was found ex- tensively diseased, containing loose sequestra of bone and soft tissue. These sequestra and soft tissue were re- moved and the cavity scraped with a sharp spoon, so that I was able to introduce easily the little finger into the mastoid cavity. I cut off a slice of the cartilage-like tissue over the mas- toid process, for microscopical examination. The mastoid cavity was then thoroughly washed out with a solution of carbolic acid, the water, when syringed in, passing readily through the antrum and escaping by the external meatus, and vice versa. Iodoform powder was insuf- flated and a bandage applied. The patient stood the operation well. December 15th. The wound was dressed on the second day after the operation and a drain- age-tube inserted into the mastoid cavity. The syringing with carbolic acid solution has been carried out twice a day and iodoform powder insufflated. There has been much difficulty in preventing the sinus from closing. She has been taking pills of iron, strychnine and qui- nine, besides milk and a nourishing diet. Since the operation the pain has been much less severe, but morphine at night has been necessary. The slice of the indurated tissue removed at the operation was examined by Dr. Richmond Len- nox, pathologist to the Infirmary, and pro- nounced carcinomatous without any possibility of doubt. He says in his report: " It is of the fibrous or scirrhous variety, and as yet the groups of cells characteristic of such growths are small. But it is very distinct, and although in some places there is a moderate amount of cellular infiltration (leucocytes), there seem to be no signs of any breaking down." December 20th. The patient has been sitting up during the past week or ten days. The in- duration about the ear has increased until at present it extends upward two inches, and for- ward to the orbit two and a half inches ; also behind the auricle two inches and downward, just below the angle of the jaw, where there is some en- largement of the glands. The pain that she complained Fig. 4240.-a, Mastoid sinuses ; 6, carcinoma ; c, bone trabeculae. per temporal region and vertex. The pinna has become swollen to a great size and is of a black color. The ine- 374 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tympanum. Ulcer. atus is dilated. The cut behind the ear is nearly healed. A large swelling now exists below the ear on the neck. She swallows with difficulty only strained oatmeal. She has hemiplegia of the right side. Her speech is affected and her mind wanders. The mass of the tumor is soft to the touch. April 20th. I received information to-day that the pa- tient died March 24th. For three weeks before death she experienced great difficulty in swallowing, as the disease extended to the neck, and she suffered greatly from nausea and vomiting. Death was due to asthenia. There was no autopsy. Figs. 4239 and 4240 are from drawings made from a section of the bony tissue, removed during the operation from the mastoid cells, for which I am greatly indebted to Dr. George C. Freeborn. Gorham Bacon. 1 Moos and Steinbriigge: Zeitschr. f. Ohren., vol. xii., p. 43. 2 A. Eitelberg: Archives of Otology, vol. xvi., No. 3. 3 Schwartze : Pathological Anatomy. 4 Hartmann : Diseases of the Ear. 6 J. B. Weydner: Archives of Otology, vol. xiv., p. 49. 6 A. H. Buck: Transactions Amer. Otol. Soc., 1876. 7 Gorham Bacon : Archives of Otol., vol. xiii., No. 1. 6 Schwartze : Arch. f. Ohren., Bd. iv., S. 147. 9 Samuel Theobald: Trans. Amer. Otol. Soc., vol. ii., part v. 10 H. Knapp: Trans. Amer. Otol. Soc., vol. iii., part i. 11 Toynbee : Medico-Chirurg. Trans., vol. xliv. 12 Hinton : Arch. f. Ohren., ii., S. 151. 13 Kupper: Arch. f. Ohren., xi., p. 18. 14 Wendt: Arch, f, Ohren., xiv., Heft 6. Toynbee and.Hinton: Trans. Pathol. Soc., xvil., p. 274. 76 Politzer: Arch. f. Ohren., v., S. 216. 17 Schwartze: Arch f. Ohren., i„ S. 205. 18 Eschle : Dent. Med. Wochenschr., No. 30, 1883. 19 Nathan : Inaug. Dissert., Munich, 1884. 20 Voltolini: Dent. Med. Wochens., No. 2, 1884. 21 Gessler : Deut. Med. Wochens., No. 34, 1883. 22 Kanzler: Berlin. Klin. Wochens., Nos. 2 and 3, 1884. 23 A. Gottstein : Archives of Otol., vol. xiii., Nos. 2 and 3. 24 Moos : Third Internal. Congress, Basel, Sept. 3,1884, Arch, of Otol., vol. xiv., No. 1, p. 46. 25 Travers: Froriep's Notizen : Bd. 25, No. 22, S. 352. 28 Wishart: Edinburgh M. and S. Jour., vol. xviii., p. 393. 27 Boke : Wien. Med. Zeitung, Halle, 1863, Nos. 45 and 46 28 C. A. Robertson : Trans. Amer. Otol. Soc., 1870. 29 Schwartze: Arch, of Ohrenh., Bd. ix., S. 208. 30 Harlan : Phil. Med. Times, December, 1873. 31 Hartmann: Zeit. f. Ohren , viii. 32 A. Matthewson : Trans. Amer. Otol. Soc., 1878. 33 Delstauche (fils): Arch. f. Ohren., xv. 34 Lucae : Arch. f. Ohren., xiv., S. 127. 35 O. D. Pomeroy: Amer. Jour. Ot»l., April, 1881. 36 C. J. Kipp; Trans. Amer. Otol. Soc., 1881. 37 J. Orne Green : Arch, of Otol., xiii., No. 2. 38 A. Rasmussen and E. Schmiegelow : Arch, of Otol., vol. xv., Nos. 2 and 3. 39 F. Kretschmann : Arch. f. Ohren., 24 Bd., 4 Heft. 40 Gorham Bacon & A. T. Muzzy : Arch, of Otol., vol. xvii.. No. 1 1888. UKIAH VICHY SPRINGS. Location and Post-office: Ukiah, Mendocino County, Cal. Access.-By the San Francisco & North Pacific Rail- road to Cloverdale, thence by stage thirty-two miles to the springs. Analysis.-I. Hewson, Jr. One gallon contains : Grains. Carbonate of soda 197.75 Carbonate of lime " " ' '' 17.'85 Carbonate of magnesia ' " " " 22.64 Chloride of sodium 27.51 Chloride of potassium trace Sulphate of potassa and soda trace Iron and alumina trace Silica 6.86 Total 272.61 Therapeutic Properties.-These watersare very sim- ilar in composition to the famed Vichy of France. They are alkaline, and are indicated in certain forms of indi- gestion. These springs are located among the hills of North- western California, two miles from Ukiah, the county seat of Mendocino County ; the scenery is beautiful and the climate charming. There is a good hotel, and facil- ities are offered for bathing. George B. Fowler. ULCER, ULCERATION. The word ulceration is used by medical writers with two very different significations. Some apply it to the occurrence of a large number of ulcers, or an extensive ulcerating surface in any region, as ulceration of the rectum, ulceration of the pharynx. Others restrict the word to the process by which an ulcer is formed or extends. Undoubtedly the latter is the bet- ter use of the term, and it is the one which we shall adopt. The history of the study and treatment of ulcers is a reflection of the history of the progress of medicine, so well has the ignorance or knowledge, the false or the true views of each epoch, been represented in the attitude of the profession toward these forms of disease. But we must confine ourselves to the more practical aspects of the subject. From the earliest times, when there was an idea that an ulcer had an independent existence of its own-was, so to say, an entity-a great diversity of opinion has pre- vailed as to what really constituted an ulcer, and what limitations should be placed upon the term. In our own time the difficulty has increased rather than diminished. Billroth defines an ulcer as a loss of substance with no tendency to heal. Others define ulceration as a molecu- lar gangrene, or a suppuration of superficial parts, with a tendency to spread into the surrounding tissues. Both of these definitions are manifestly incorrect, for the moment that an ulcer began to heal, or even to remain sta- tionary, it would cease by these definitions to be an ulcer, and yet we do not change the name of the lesion when it begins to heal. "A healing ulcer" is a legitimate ex- pression. Petit defines an ulcer as a loss of substance which has passed the time when it can heal by first intention, a defi- nition which corresponds more nearly with the accepted opinion than that of Billroth. Golding-Bird ("Guy's Hospital Reports," xxiv., 1879, p. 271) gives an excellent definition of an ulcer from a pathological point of view, namely, "a limited area of granulation-tissue upon a surface of the body." Perhaps a better clinical definition would be as follows : An ulcer is a superficial loss of sub- stance, or a solution of continuity, upon any of the free surfaces of the body, which will not admit of repair by primary union. This definition includes all granulat- ing wounds, ulcerative processes, or losses of substance from suppuration or gangrene, situated upon the skin, mucous membranes, or endothelial surfaces. Some may object to including all granulating wounds as ulcers. But it is certainly impossible to distinguish, either in description or in fact, between a granulating wound and an ulcer in process of repair, and there seems to be no longer any need of making the attempt to distinguish between them, now that we have passed the period when ulcers were looked upon as an independent disease, and have come to consider them as local lesions due to some external injury, or internal pathological cause. Al- though our definition includes all ulcers, we must con- fine ourselves to those of the skin and mucous mem- branes. We leave the rest, and even some forms of ulcers of the latter tissues, to be described with the vari- ous diseases of which they constitute some of the le- sions. Ulcers may be classified in various ways. Classifying them by their appearances we have three large classes : 1. Granulating-a, healthy; b, exuberant; c, feeble. 2. Indolent-a, with small scanty granulations ; b, covered with a surface resembling mucous membrane ; c, raw. 3. Progressive-a, by molecular gangrene, true ulcera- tion ; b, by sloughs of considerable extent (gangrenous or phagedenic). If we classify them by their causes, we find the fol- lowing varieties : I. Ulcers due to local causes : (1) traumatic; (2) infectious (septic, primary lesion of syphilis, tuberculous, lupoid, dysenteric, etc.); (3) vari- cose ; (4) malignant; those caused by (5) sloughing from the pressure of benign tumors, (6) embolism, or (7) local- ized neuritis and trophic changes. II. Ulcers due to constitutional causes: (1) secondary and tertiary syphi- litic ; (2) typhoid ; (3) diphtheritic ; (4) leprous ; (5) scor- butic ; (6) scrofulous ; (7) gouty ; (8) diabetic ; (9) those due to certain skin diseases (pemphigus, ecthyma) ; (10) 375 Ulcer. Ulcer. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. or the mineral poisons ; (11) the ulcers of the duodenum secondary to extensive burns of the skin. Both methods of classification are necessary, for an ulcer due to various causes may present any of the appearances mentioned above. Both methods are also practical, for in the treatment of an ulcer both its cause and its present condition must be taken into considera- tion. Etiology.-Among the ancients, and even until quite recent times, ulcers were treated with more respect than at present, and much vain study was expended in elaborating theories as to their causes, and in construct- ing complicated systems of classification. Of the older theories we need only mention those of Hunter, who supposed ulceration to be a process similar to the pro- cess of absorption by which various foetal structures are made to disappear as the organism develops, but differ- ing from it in that ulceration was accompanied by the formation of pus. Bell (1778), and J. M. Langenbeck (1823), supposed that ulcers were caused and maintained by the contact of irritant discharges, which had the power of destroying the tissues, and were in turn pro- duced by the tissues as they were destroyed-a theory which can be said to be correct even to-day, but with the understanding that bacteria are the cause of the ir- ritation produced by the discharges. J. N. Rust (1835), on the other hand, thought that the discharge was pre- servative, not destructive, and that it was itself the best local application for promoting healing; and he also looked upon the ulcer as a newly formed secreting organ. The introduction of the new ideas as to the causes and processes of inflammation swept away all these old theories, and created our modern views on the etiology of ulcers. But even before that time, Bell ("A Treatise on Ul- cer," Edinburgh, 1778) succeeded in making a classifica- tion of ulcers which is still looked up to as an example in the construction of systems of classification, although it is no longer possible to accept it in all its details. He divided ulcers into those due to purely local causes, and those which wrere symptomatic of a constitutional vice or infection. This division must be placed at the foun- dation of every attempt to study the etiology of ulcers. But the distinction is not always easy to make, and the list of varieties in each class requires constant revision as our knowledge of pathology extends and our opinions alter. There may also be something of a conflict of opinion upon the proper meaning of some of the terms in use. Thus Billroth includes the ulcer caused by lu- pus among the symptomatic ulcers, because its origin is from a growth within the tissues, not from an external cause ; and yet it is due to a limited local infection, even if we grant the possibility of subsequent generalization as tuberculosis ; and such ulcers should certainly be in- cluded among those due to a local cause. It is, as yet, not proven whether cancer is a purely local disease, or whether it is due to a constitutional vice; although the weight of evidence at present is in favor of the former theory, unless the latter is also to be admitted as a sort of predisposing cause. In fact, many forms of ulcers are due to a combination of a local with a constitutional cause, and the two classes cannot be very sharply distin- guished, although it is necessary to divide them as far as possible for a proper clinical and pathological study of the subject. We may say, then, that ulcers may be due to purely local causes, either external (traumatism), or internal (infection); or they may be due to constitutional causes, with local lesions (secondary syphilis) ; or, finally, they may be due to a combination of the two, the constitu- tional cause predisposing to ulceration, the local cause determining its occurrence and its situation (varicose veins, or traumatism, in a feeble, gouty, or tuberculous individual). Simple Ulcers.-The number of idiopathic or so-called simple ulcers grows continually smaller, as our patho- logical and diagnostic knowledge increases, and we are enabled to refer one variety after another to its proper cause. But many still remain unclassified. Schreider (These de Paris, 1883) investigated a large number of these cases of ulcer, and found in the great majority of them evidence of atheroma, varicose veins, chronic bronchitis, skin eruptions, heart affections, headache, joint troubles, ribbed nails, and other symptoms of that peculiar constitutional vice known as gout or lithiasis by English writers, and termed herpetisme by Lancereaux ("Traite de Herpetisme," Paris, 1883). The cause or causes which produce this inveterate disorder of the sys- tem are as yet but poorly understood. But the extensive trophic changes which it occasions in all the tissues of the body, form a very reasonable basis for the hypothesis that it may also be responsible for the nutritive changes upon which depends the occurrence of ulceration, in cases in which no more definite cause can be detected. Age, Sex, Occupation.-The influence of age, sex, and occupation has often been invoked in the etiology of ulcers. Old age is undoubtedly marked by many retro- gressive tissue-changes and by a diminished vitality which should predispose to ulceration, and yet statistics show only a slight increase in the frequency of ulcers among the aged. Statistics, on the other hand, show a proportion of three men affected by ulcer to one woman, a difference which is probably due to the greater ex- posure of men to traumatism, syphilis, and alcohol. Occupation also, probably owes its influence to the vary- ing amount of exposure to traumatism, but statistics are unreliable upon this point, for they seldom include a wide enough territory to give a fair proportion to the various occupations. But the great predisposing causes to ulceration are neglect and filth, and these matters de- pend upon personal habits, which generally correspond to the social station of the individual. Therefore, the greatest number of ulcers is to be found among the laboring clashes, who have not the means, and often lack the intelligence necessary to the proper care of the ulcer when it first appears and can be readily cured. As for the situation of the ordinary ulcer of the skin, it is most frequently found upon the leg, for the circulation is most at a disadvantage in that part of the body, and the exposure to traumatism is the greatest. Traumatism.-Traumatism is one of the most fre- quent causes of ulcers, at least of the acute variety, a part of the skin or mucous membrane being entirely re- moved, or so destroyed that its existence is no longer possible, and the deficiency is left to heal by granulation. Even an incised wound may leave a gaping interval be- tween its edges, to heal by granulation, and it seems more logical to call all such superficial granulating sur- faces ulcers, than to try to distinguish them from ulcers in the process of healing, with which they are identical in appearance and character. The degree of traumatism necessary to produce these results will vary with the peculiarities of the individual constitution, for the tis- sues of the young and the robust will resist an injury sufficient to cause the death of the tissues in the aged, the feeble, and those afflicted with some constitutional vice such as gout, tuberculosis, diabetes, or syphilis. The frequent occurrence of bed sores in enfeebled patients long confined to one position, is a familiar illustration of this truth, for in such cases the mere weight of the body so greatly disturbs the nutrition of the parts which sus- tain it as to occasion their death. Septic Infection.-Many ulcers, and especially the gan- grenous forms of ulceration, are due to an infection of the skin by septic germs from without, through some minute wound, or from within through the circulation, causing suppuration and gangrene. Probably that form of gangrene known as noma originates in this way, but it is generally fatal before the slough falls ; therefore ulcers due to this cause are rare. Common instances of septic infection are the chancroid (unless we are to hold to the old idea of a specific virus) and the "dissecting wound." In some cases progressive gangrene will ap- pear in an ulcer already formed, and extend into the deeper tissues and into the surrounding parts, apd the ulcer is then termed phagedenic. This form of gan- grene is apt to attack the subcutaneous tissue first, under- mining the skin, and involving the latter secondarily. 376 Ulcer, Ulcer. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Phagedena is most frequent in chancroidal ulcers and hospital gangrene, and especially in hot, moist. cli- mates. Syphilis, Chancroid.-Undoubtedly the most constant and prolific cause of the formation of ulcers is syphilis. Beginning with an ulcer of a particularly indolent and persistent character in the primary lesion, and marked throughout its secondary stage by extensive ulceration, especially of the mucous membranes, in its tertiary stage no part of the body is free from its attacks. The chan- croidal ulcer, although more destructive than the primary lesion of syphilis, is generally easily subdued by proper treatment. But if it is long neglected it may furnish us with some of the largest ulcers of which we have any knowledge, the chronic chancroid, which may involve the genitals, both groins, and even a large part of the surface of the thighs, buttocks, and abdomen. Tuberculosis.-Tuberculous ulcers are most frequent on the mucous membranes, especially in the throat, in- testine, and genital tract. But tuberculosis may also in- vade the skin and produce ulcers by the breaking down of the tuberculous deposit. The skin is generally at- tacked by extension of the disease from some neighbor- ing tubercular process (ulcers of the mucous membranes, a fistula from an osteitis, or an abscess), but it is also oc- casionally found as an independent deposit secondary to some distant tubercular focus, and even as an entirely primary infection. Lupus has long been considered by some to be a tubercular infection of the skin of a more strictly local type, and of slower development than the ordinary tuberculous affections of the skin ; and now the evidence in favor of this view is growing so strong that the majority of dermatologists have adopted it. Conse- quently the peculiar ulceration of lupus is to be consid- ered as the result of tubercular infection. Neoplasms.-A very frequent cause of ulceration is the infiltration of the skin, or mucous membranes, or the un- derlying tissues upon which they depend for their sup- port, by the growth of neoplasms, most commonly of some of the malignant forms, and especially of epitheli- oma. In these cases the healthy tissues are replaced by the cells of the new-growth, and the latter die because of their low vitality, or because of the interference with nutrition caused by the pressure of the tumor upon the blood-vessels supplying the part, and an ulcer is the re- sult. ' These malignant ulcers are sometimes very formi- dable and destructive, eating with great rapidity through all the underlying tissues, for even the bone itself is un- able to withstand their ravages, and sometimes present- ing surfaces of vast extent before the patient succumbs. As will be seen later, the slow-growing but inveterate rodent ulcer is to be classed among these, as an ulcer due to epitheliomatous growth. Benign tumors may also cause ulceration by projecting from below and pressing upon the superficial parts-thus cutting off their blood- supply, and exposing them to greater traumatism. But the benign tumor itself seldom ulcerates. Embolism.-Some ulcers are undoubtedly due to embo- lism of small vessels of the skin or mucous membranes, the affected area sloughing and leaving granulating sur- faces when the slough has fallen. The embolus may be a simple clot of blood, but not infrequently it is a mass of bacteria, or at least contains a large number of micro- organisms, and the gangrene results from subsequent in- fection of the anaemic tissue by their growth. The ma- jority of ulcers of the stomach and duodenum probably owe their occurrence to embolism or thrombosis, with subsequent digestion of the anaemic parts by the gastric and intestinal juices. Varicose Veins.-There is an undoubted relation of cause and effect between varicose veins and ulcers of the leg, but authorities are divided as to the exact con- nection between the two. The fact that most persons with varicose veins in the leg escape without ulcers, at least for many years, would seem to show that there must be some additional cause. Some have sought for this additional cause in the presence of oedema, but ul- cers are not always present even when oedema has long been an accompaniment of the varicosity. From Schrei- der's work, already alluded to, we extract the following table as evidence upon these points : Cases. Varicose veins. (Edema. Ulcers. I At 21 years of age. " 20 " .. 15 <. " 54 " " " 25 " " " 23 " " " 30 " " " 30 " At 30 years. " 30 " " 30 " " 61 " " 30 " " 23 " At 65 years. " 40 " " 40 " " 63 " " 59 " " 24 .. " 44 " " 50 " II Ill IV V VI VII VIII Schreider, as we have seen, seeks the missing link of connection between the ulcer and the varicose veins in the gouty diathesis, the disease both of the veins and of the skin depending upon that common cause. But this theory still leaves unexplained why some cases of vari- cose veins are exempt from ulceration. The presence of varicose veins must interfere with the circulation of the blood in the skin, and with its nutrition, and it is not unreasonable to suppose that this interference may be •very different in degree in different cases, even when the apparent changes in the large veins are equally ad- vanced. There is certainly a marked contrast in the color of the skin in different cases, which would seem to show that, although the main veins are as large and probably as degenerate in both sets of cases, yet the pro- cess does not extend far enough into the smaller vessels to seriously impair the circulation in those cases in which there is a natural color of the skin. Many ulcers in cases of varicose veins are due to small abscesses caused by phlebitis. In other cases there is a history of injury, but often of an injury too slight to have had an effect upon normal skin. Quenu, as we shall see farther on, refers all cases of varicose ulcers to changes in the nerves, sec- ondary to the disease in the blood-vessels. Trophic Changes.-In some forms of ulcer and gan- grene we are forced to assume that some trophic change has taken place in the skin, due perhaps to a neurosis of the vaso-motor nerves, perhaps to an affection of some nerves controlling more directly the actual cell-life. Some forms of multiple spontaneous gangrene of the skin are due to this cause. Catarrhal Ulcers.-The existence of the so-called catarrhal ulcer of the mucous membranes has long been a matter of dispute. As generally understood, the path- ological changes of catarrh are limited to the epithelium, except some congestion of the deeper layers of the mu- cous membrane, and many limit the term ulcer to a loss of substance extending more deeply than the epithelium, calling the lesser lesions erosions or abrasions. These two facts explain the discrepancies often found among authorities. But it is an undoubted clinical fact that ulceration involving the subepithelial tissues is found with catarrh, and is probably due to the infection of some superficial wound, or even of an erosion by bac- teria. Their entrance and persistence is also dependent upon the existing inflammation of the mucous mem- brane. Hence there appears to be good reason for rec- ognizing the catarrhal ulcer clinically, even if it is not solely and entirely the result of the pathological changes of the catarrhal inflammation. Hamorrhagic Ulcers.-The so-called vicarious ulcer, by which is meant an ulcer which bleeds at the time of the menstrual molimen, especially when there is no normal menstruation, is very rarely seen, and if the symptom of periodical hajmorrhage is observed in any case, it is cer- tainly no indication that there would be danger to the patient in endeavoring to heal the ulcer. Mercurial Ulcers, etc.-Besides the local corrosive ac- tion of chemicals, the introduction of certain metallic poisons into the system will cause ulceration of the mu- cous membranes, such as the ulcers of the intestine caused by bichloride of mercury, and the stomatitis caused by mercury and its salts. These ulcers are due to a selective action of the poison upon the tissues, and extravasation of blood not infrequently precedes the ul- ceration. 377 Ulcer. Ulcer. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Typhoid Ulcers, etc.-Certain diseases are accompanied by ulcers upon the mucous membranes, such as the ul- cers of the intestine in typhoid fever, and those of the air-passages in diphtheria ; and it is still a question how far the local lesion is due to the constitutional affection, or how far the general symptoms are caused by the local lesions. For a discussion and description of these ulcers we must refer to the various articles, Typhoid Fever, Diphtheria, Dysentery, Leprosy, etc. "Fissures."-One variety of ulcer remains to be men- tioned, the linear ulcers, which are the cause of those two troublesome affections, fissure of the anus, and sore nipples in nursing women. In both the form of ulcer is the same, being linear, and one of the causes is the same, the presence of irritating substances in the sore, the Pathology.-Formation.-The pathological processes involved in the formation of ulcers differ according to the causes which lie at their foundation. When the ulcer is caused by constant irritation of some spot by mechanical or chemical means, congestion and oedema first take place, with a thickening of the epithelial layer, and increased growth of its cells, but accompanied by a diminished hardening of the outer layers, so that they fall off more readily, and thus the papillary layer is ex- posed. The latter, already inflamed and full of leuco- cytes, is attacked by suppuration, and the defect contin- ually spreads in depth and width. But the irritation may act in a different way and result in the collection of serum beneath the epithelial layer, lifting it from the parts beneath, and forming a blister or pustule. When the covering of the latter is removed, a superficial loss of substance is left, and an ulcer of the skin or mucous membrane is the result. (Kaposi and some others limit the term ulcer to those cases in which the corium of the skin has been involved, calling the lesser lesions, abrasions, or excoria- tions.) If a slough has formed in the skin or mucous membrane by any form of gangrene, embolism, or traumatism, the slough is separated from the healthy tissues by an area of inflam- mation and suppuration, and when the slough has fallen an ulcer of corre- sponding depth remains. When an abscess or gumma has burst, or been incised, the opening enlarges by the melting away of the skin, and the cavity fills up with granulations until it is quite superfi- cial, and thus an ulcer is formed. Simple Ulcer.-A microscopic sec- tion through the edge of a simple ulcer of the skin, in its stage of increase (see Fig. 4241), presents a thickening of the Malpighian layer as we approach the ulcer from the healthy skin, an in- crease in the size of the papilla;, an enlargement of the blood-vessels, some oedema of the connective tissue, and an infiltration of the latter with small round cells, which grow more numer- ous until they fill the entire tissue, and pus-cells are produced. The base of the ulcer presents various structures according to its depth, from the deeper layer of the skin to the bone itself, but all altered by inflammatory changes. When the ulcerative process has ceased to extend, at least with any marked progress, some organization of the products of inflammation begins to take place, and new connective tis- sue forms, especially around the blood- vessels. This new tissue condenses and contracts as it grows older, producing that dense fibrous layer which surrounds and underlies the chronic ulcer, unless the healing process sets in sufficiently early to prevent the formation of large quantities of this connective tissue. Under the best of circumstances, the scar resulting from an ulcer will be a sort of sclerosed skin, without glands, and thickened with connective tissue. The changes in ulcers of the mucous membranes are similar to those just described as occurring in the skin, except that there is less tendency to the production of connective tissue, and entire regeneration of the membrane is more frequent than that of the skin. Changes in Other Tissues.- Varicose Ulcers.-Quenu {Revue de Chirurgie, 1882, p. 877) has made a very care- ful microscopic study of ulcers and of the other tissues in cases of chronic ulcers of the leg with varicose veins Fig. 4241 Represents a Section through the Edge of an Ulcer, the sketch being divided into two parts at B, for convenience of printing. A, Healthy skin; C, border of the ulcer ; D, its base. a, papillae ; b, the same, cut obliquely ; c, layer of cornified epithelium ; ff, granulation tissue; 1', dilated blood-vessels. (From Nouv. Diet, de Med. et de Chir. Prat., Paris, 1885. Article " Ulceration.") shape of which renders it very difficult to cleanse. But the fissure of the anus also owes its obstinacy to the fact that it is situated directly over a muscle which leaves it no rest, and thus the irritation is constantly continued. Ulcer of the Rectum.-Ulcer of the rectum is a com- mon disease, and yet its etiology is doubtful. Accord- ing to Allingham ("Diseases of the Rectum"), two- thirds of the cases are instances of late syphilitic disease, and some of the remainder are tuberculous ; but a large proportion are of unexplained origin. He claims that they do not arise from chancroid, careful observation having convinced him that they very rarely extend so low down as the anus, which would certainly be the case if they were caused by chancroid. Kelsey (New York Med. Record, 1886, xxx., 625) agrees with him, and we may accept their decision even against that of Gosselin and Mason. 378 Fleer. Fleer. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. -the specimens being obtained post mortem or by am- putation. In the skin he found changes similar to those given above, with a deposit of pigment which appeared to come from extravasated blood. The veins were vari- cose, dilated, and surrounded by new connective tissue, which was forming and condensing at the same time. The arteries were affected by endarteritis and atheroma, and occasionally there was thrombosis of large branches. In the muscles there was interstitial chronic myositis, with degeneration of the muscular fibres. In the nerves there was a new growth of connective tissue, beginning around the dilated capillaries, and surrounding the nerve- fibres, which afterward degenerated on account of the pressure exerted by this tissue as it contracted. These alterations were found in nerves at a long distance from the point of ulceration, and even in those nerves which were not distributed to that part of the leg. He thinks that the changes began in the vessels, then attacked the nerves, and finally caused trophic alterations and ulcera- tion of the skin. He believed himself able to exclude an ascending neuritis secondary to the inflammation of the ulcer. The bones are also affected by the presence of an ul- cer upon a limb, although rarely attacked by the ulcera- tive process in any of the simple forms of ulcer, for the periosteum thickens so rapidly under the influence of the approaching ulceration that it forms an efficient bar- rier. But a chronic periosteitis with osteitis is set up, which results in hypertrophy of the bone, or in the pro- duction of osteophytes and exostoses; and, in the leg, the tibia and fibula have been found united in one bony mass (Reclus, Progres Medical, 1879, p. 955). The new bone is generally of the medullary variety, not compact. If the epiphyses have not yet joined the shaft, the bones may also be increased in length. Syphilis.-The primary ulcer of syphilis shows, on mi- croscopic examination, that the tissues surrounding and underlying the loss of substance are thickly infiltrated with small round cells, which lie in a close net-work of fine connective-tissue fibres. This infiltration invades the blood-vessels, which show the lesions of endarteritis, and are further occluded by the pressure of the new tis- sue which surrounds them. The newly discovered ba- cillus of Lustgarten can be found in small numbers in the tissues-but its significance is not yet proven. The sec- ondary, and superficial tertiary ulcers of syphilis, both in the skin and mucous membranes, do not differ from simple ulcers in their microscopic structure, except in the greater amount of small-celled infiltration, and the slighter tendency to suppuration. The gummatous ul- cers, however, begin with the deposit of gummatous material, a thick infiltration of small round cells replac- ing and crowding aside the normal tissues, until by their pressure upon the blood-vessels they shut off their own supply of nutriment and die. The product is a firm red- dish or cheesy mass, becoming softer with time, and even fluctuating, but never forming pus. Inflammation is caused in the surrounding tissues, and this may result in suppuration. If the gumma lies near the surface, ne- crosis or ulceration of the overlying tissues sets in, and continues until all the abnormal tissue breaks down and is eliminated. Chancroid.-The microscopic appearances of a chan- croidal ulcer are those of an inflammatory lesion-dilated vessels, serous exudation, infiltration of the tissues with large quantities of round cells which tend to form pus, and abundant infection of the whole with septic and pus- forming bacteria. Tuberculosis.-True tuberculosis of the skin is rare. When it does occur, the skin is infiltrated with the tu- berculous material in the form of " granulations" with small round cells and giant cells, and these may coalesce and result in necrosis and ulceration, the latter being co- extensive with the amount of tubercular deposit. More frequently, tuberculous ulcers of the skin are the result of the bursting and discharge of a tuberculous abscess or suppurating gland, or they surround some fistula which has been open and discharging for a long time. Tuberculous ulcers are more frequently seen upon the mucous membranes, where they are formed by a similar process of infiltration and subsequent ulceration. The bacillus of Koch can frequently be detected in these lo- cal deposits of tuberculous material. Including lupus under the head of tuberculosis, we find that here, too, the ulceration follows upon an infiltration of the skin and mucous membrane with lupus material, consisting of crowded small round cells, with occasional giant cells forming nodules ; but the ulceration is usually not so ex- tensive as the deposit, and the border of the ulcer is thickened, everted, and surrounded with a zone of nod- ules of considerable extent. A few observers have been fortunate enough to detect the bacillus of tuberculosis in lupus material, but it is rarely found, and in small num- bers. Neoplasms.-Ulceration accompanying benign tumors is generally the result of upward pressure from the pro- jecting tumor, thus exposing the surface to greater trau- matism, and at the same time cutting off its nutrition by pressure upon the blood-vessels. But in the case of ma- lignant tumors, necrosis results from the overgrowth of new cells, which have invaded and replaced the normal tissues, and which die from their lack of vitality, and by cutting off the nutrition of the central parts by their own pressure. For the minute structure of the malignant ulcers we must refer to the articles upon Carcinoma, Sar- coma, etc. Transformation of Simple Ulcers into Epithe- lioma.-It is very important to note the fact that simple ulcers may be changed or may develop into epithelioma, usually as the result of irritation and neglect continued for many years. In such cases the microscopic changes would first be found in the skin at the edges of the ulcer, its edges being generally thickened by infiltration of round cells, and deposit of connective tissue. The ap- pearances would be those of beginning epithelioma. Even sarcoma has been observed as a sequel of a chronic ulcer of the leg (Prewitt: St. Louis Courier of Medicine, 1884, xi., p. 518). Symptoms and Course.-In describing an ulcer we must direct our attention to its base, its edges, and its discharge. Simple Ulcer.-A simple granulating ulcer, such as would be caused by an abrasion or superficial wound of the skin or mucous membrane, presents a base covered with granulations of a healthy red color, and medium size, for very large or very small granulations indicate a lack of vitality. Unless the original loss of substance was very deep, the base should be level with the sur- rounding surface, and its discharge should be scanty, white, or yellowish pus, with very little serum. The edges should lie even with the surrounding parts, with- out any induration, and they should be marked by the white line of advancing epidermis or epithelium in cica- trization. There should be just a trace of increased vas- cularization in the parts beyond. When the ulcer has become chronic and indolent, as in cases of simple chronic ulcer of the leg, its appear- ance is generally very different, although in some cases the only difference is in the smaller size and paler color of the granulations, in the more profuse and thinner dis- charge, and in the slightly thickened edges. But as a rule, the chronic ulcer will be found with a very pale base, without granulations, presenting a shining surface which looks very like mucous membrane, or covered with a thin layer of necrotic white tissue. Sometimes the underlying tissues are completely exposed and raw, so that fibrous tissue and muscle can be distinguished in the base of the ulcer. The discharge from these ulcers is usually very scanty, and of a serous character, contain- ing very few pus-cells, because there are no granulations to supply them. The base lies below the surrounding parts, and this depression appears to be greater than it really is, because the edges are so thickened that they stand above the neighboring skin, like a wall around the ulcer. These thickened edges rise in a gradual slope, both from the base of the ulcer and from the skin. Sometimes, however, they are sharply cut on the side toward the ulcer, but they are never undermined unless 379 Ulcer. Ulcer. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. some fresh necrosis, or traumatism, has reawakened the active ulceration. The edges usually present a regular curve, seldom being ragged or worm-eaten, and they are usually of a uniform height on all sides of the ulcer- not nodular, or uneven. Their color is generally pale, and there is no increased vascularization of the surround- ing skin, but occasionally they are livid and blue, or even slightly reddened. There is no white line of ad- vancing epidermis, and the whole picture speaks of an entire absence of any vital reaction, either reparative or inflammatory. If such an ulcer as we have described becomes in- flamed by neglect or unsuitable treatment, fresh sloughs form in the base and along the edges, some ill-condi- tioned granulations may spring up, free serous discharge with a greater number of pus-cells appears, the thicken- ing of the edges increases and extends into the surround- ing skin, which may become oedematous and congested, and even brawny, with inflammation. Under more chronic irritation the inflammation takes a somewhat different form, and the base of the ulcer becomes red and angry, but continues raw and without granulations, and its discharge is a very scanty serum, while the edges grow very thick with oedema and congestion. Both these con- ditions are usually accompanied with pain, although the ordinary chronic ulcer is nearly devoid of feeling, and both its base and edges may be cut and cauterized until healthy tissue is reached, almost without sensibility. One form of chronic ulcer is, however, very painful, prob- ably because some nerve-filaments, which have become involved in the abundant cicatricial tissue which forms under the base and around the edges, are rendered pain- ful by the constant contraction, as is the case with pain- ful cicatrices in any part of the body. Epitheliomatous Degeneration.-It is the chronic ulcer which is liable to develop into epithelioma, and in the transition stage it is exceedingly difficult to tell when the epitheliomatous growth has begun. The visible changes begin in the edges, which become nodular and uneven, and at the same time thicker and harder than before. The thickening and induration extend into the surrounding skin beyond the true edge of the ulcer. Toward the ulcer, on the other hand, irregular, pale, hard, but friable, and easily bleeding granulations spring up from the edge and spread over the base, filling it with irregular nodules like massive granulations, until the whole ulcer is transformed into a typical, ulcerating epithelioma. The formation of new tissue may exceed the destruction by ulceration, and then the depression will be replaced by a tumor projecting above the level of the surrounding skin, but still ulcerating upon the sur- face. In doubtful cases the microscope will assist in the diagnosis, but it is useless to employ minute pieces cut from the granulations for microscopical examination. In order to make the diagnosis reliable, a vertical slice must be cut, passing through the edge of the ulcer, in- cluding the granulations at one end and the healthy skin at the other, and including also the dense fibrous tissue below. Thin microscopic sections from a slice of this kind will generally allow a positive answer to the ques- tion as to the presence of epithelioma. Varicose Ulcers.-The ulcer which occurs with varicose veins of the leg may begin as a simple ulcer (that is, without any perceptible cause or pathological change), or it may be caused by traumatism, or may be the result of necrosis of the skin due to thrombosis of the small ves- sels, or to a low grade of phlebitis and cellulitis. If of idiopathic or traumatic origin, it differs in appearance from the ordinary ulcer only in the dark-blue color of its base and edges, the readiness with which venous ooz- ing takes place from its surface, and the pigmented skin in its neighborhood. But if the ulcer is the result of thrombosis or phlebitis, it is of small size, with under- mined, sometimes sloughing, edges, which are often very thin and livid, and its base is made up of tissue infil- trated with blood, and sloughing. Often there are sev- eral of these small ulcers close together, separated by narrow strips of livid, undermined skin, which may be left like bridges, the sloughing process having extended under the skin from one ulcer to the next. A consider- able area of the skin may be honeycombed in this way, something like a carbuncle, but ultimately the strips of skin melt away, and the entire region becomes an ulcer of considerable size, and similar in appearance to the form first described. The loss of blood from varicose ulcers may be considerable, but it is readily controlled by pressure. The ulcers are seldom deep, usually in- volving only the skin and the cellular tissue immediately beneath. Besides the ulcer, in various parts of the leg, hard, red nodules will often appear, due to the low grade of inflammation in the veins or in the cellular tissue around them, or sometimes occasioned by an extravasa- tion of blood, or by a small slough. Very frequently these are absorbed without breaking down, or the skin over them bursts and a little bloody serum oozes out, and then the swelling disappears. But pus may be formed, and if it is not removed by a free incision the skin may be undermined for a considerable distance, and healing may be very much delayed. Phagedena.-Septic inoculation of the skin will often result in sloughing and subsequent ulceration, and the sloughing process may spread very rapidly, more rapidly than the sloughs can be cast off by granulation. In less rapid cases, the slough may be extending at some parts of the ulcer, while at others there is a tendency to simple ulceration, or even to reparative granulation. The true cause of the gangrene or phagedena, which generally makes its beginning in some ordinary ulcer, most fre- quently in a neglected chancroid, is not very well under- stood, but it is probably some septic micro-organism, very virulent locally, but without much tendency to gen- eral invasion of the body. Phagedena is most commonly seen in connection with hospital gangrene, which is for- tunately so rare in modern surgery. Syphilis, Chancroid.-The primary lesion of syphilis is described in this work under the head Chancre, as is also the chancroid, therefore we need only mention them here. Secondary and tertiary syphilitic ulcers of the skin and mucous membranes occur as a consequence of any of the papular, pustular, or tubercular eruptions. Accordingly they present the distribution and other characteristics of these eruptions, being often symmetri- cal on the two sides of the body, often arranged in cir- cles or segments of circles, or in a serpiginous form. The appearance of these ulcers varies, but usually they are multiple, small, circular in shape, with more or less sharp-cut edges, as if punched out. The bases are apt to be white and sloughing, and the discharge is thin and serous, with a tendency to form scabs. Sometimes large patches of ulceration are produced by the coalescence of smaller ulcers, and these patches may spread at one border while they cicatrize at the other, thus producing circles and segments of circles. The ulcers are generally very indolent. Recovery usually results in a depressed cicatrix, which is often pigmented in the case of cutane- ous ulcers. Syphilitic ulcers of the mucous membranes are most frequently situated in the mouth, nose, pharynx, larynx, rectum, and upon the genitals. The ulcers of the secondary stage are often painful, and easily irritated by neglect and improper applications. Gummatous ulcers are found in the later stages of syphilis, both in the skin and on the mucous membranes, and present large ragged cavities, of a circular or oval form, with deeply depressed sloughing bases, thin, semi- purulent discharge, and undermined, bluish, and slough- ing edges. Their appearance is easily deduced from their pathology, for they are formed by the bursting of a softened gumma, and hence preserve its form in their early stages, until the edges gradually melt away, and the whole material of the gumma sloughs out of the cavity. The latter gradually fills with granulations, cicatrization sets in, and healing becomes complete, but a depressed cicatrix is usually the result. The gumma- tous process frequently involves some superficial bone, and may even perforate it, as in the perforating ulcers of the palate or nasal septum, and a permanent opening may be left when the ulcer has healed, the edges becom- ing covered with mucous membrane. 380 Ulcer. Ulcer. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tuberculosis.-Tuberculous ulcers are more frequently found upon the mucous membrane than upon the skin, and upon all the mucous membranes. They form shal- low, irregular ulcers of various sizes, with uneven bases, covered with thin, white, or yellowish sloughs, or with pale, often exuberant, granulations, and occasionally they are of a dark-red color from extravasated blood. The edges are irregular, as if worm-eaten, and are gen- erally thickened, rather soft, and everted, although they are not infrequently undermined. There may be a slight inflammatory areola. The discharge is scanty and se- rous. When situated in the intestine they may be due to the bursting of a gland infiltrated with tuberculous ma- terial, and they then assume a crater-like shape. Tuberculous ulcers of the skin appear in three forms : the so-called scrofuloderma, the true tuberculosis of the skin, and lupus vulgaris, which must now be recognized as a tubercular process. Scrofuloderma appears as a shallow ulcer of varying size and shape-circular, lin- ear, or irregular. The edges are thin and bluish, under- mined and irregular, but sometimes they are smooth and regularly curved. The base is covered with pale granulations, which are very small, or hypertrophied, or oedematous; or it may present a white or yellow slough. These ulcers are generally found where a tu- bercular abscess has been discharging. True tuberculo- sis of the skin results in round shallow ulcers, which are most commonly seen at the junction of the skin and mucous membrane. The surrounding skin is red and inflamed. The base is covered with pus, and the edges are irregular, elevated, everted, and not undermined. The base and edges may be hard or soft. Small grayish- yellow nodules may be seen in both the base and the edges-the tubercular " granulations." As an aid to the diagnosis of this rare lesion, it may be noted that epithe- liomatous ulcers are harder ; and gummatous ulcers have smoother edges, which are not inflamed, but are undermined. Both epithelioma and gumma are of more rapid growth than the tuberculous ulcer. (Neumann : " Atlas der Hautkrankheiten." Wien, 1886.) In lupus vulgaris the skin becomes infiltrated with reddish-brown or yellow nodules, from a pin-head to a split pea in size, situated below the epidermis, soft or moderately hard, occurring in groups and irregular patches. Ulceration most frequently begins at several points at once (unlike epithelioma), and the ulcers then coalesce (unlike syphilis), producing superficial ulcers with reddish granulating bases, irregular edges, not hard or everted, and a scanty discharge. Lupus is most fre- quently found on the face and fingers. Diseases of the Skin.-Ecthyma, herpes, pemphigus, and lepra are the forms of skin diseases in which ulcera- tion is most commonly observed, and we refer the reader to the articles upon those subjects. In herpes of the gen- itals, the ulcers may closely resemble those of chancroid, being small, circular, superficial ulcers, with white or gray bases, and reddened edges. On the lips, the ulcers of herpes form the familiar "fever sores." The ulcers caused by malignant pemphigus and circumscribed gan- grenous dermatitis (that is, spontaneous gangrene, proba- bly due to some neurosis of the vaso-motor nerves) are very rare-in appearance they present the usual charac- teristics of a superficial limited slough of the skin (in pemphigus preceded by a bleb), which leaves a granulat- ing ulcer when the slough falls. Neoplasms.-We have already seen that the ulcers caused by tumors are of two kinds. In benign tumors, and occasionally in sarcoma, the ulceration is simply a sloughing of the tissues under the pressure of the tumor as it rises from below, but in some cases (especially in cystic fibroma of the mamma) the tumor protrudes in a fungous mass from the opening thus formed. The tumor itself only ulcerates after it has thus been ex- posed, and then but moderately. In the malignant tumors, however, the superficial tissues, including the skin, are replaced by the new- growth, and then this ulcerates, either in large slough- ing masses, or by a slower molecular death and disin- tegration. The ulcers thus formed may be very large. When situated upon the head, they may cover the entire scalp, or destroy-all the features of the face ; and upon the broader surfaces of the body, such as the back, they may attain a diameter of several inches. The largest ulcers are most commonly found in epitheliomatous growths, for the other malignant tumors generally prove fatal before the ulcers formed by them have attained such a size. These epitheliomatous ulcers present a very uneven base, with immense nodules projecting from it, like huge, hard granulations, pale in color, but bleeding at the slightest touch. The discharge is serous, sometimes abundant, sometimes scanty, and generally very fetid. The edges are uneven, irregular, as if worm- eaten, very much thickened, and densely hard. Fre- quently they are everted, as if the new-growth immedi- ately belowr them were pushing them upward. Large sloughs are seen in these ulcers, both in the base and along the borders, but the progress of the ulceration is often very slow, lasting for ten, fifteen, even twenty years. There is usually not much pain, and there is no constitutional infection or cachexia until very late in the disease. The earliest stages of epithelioma of the face are sometimes in the form of a small superficial ulcer, covered with an adherent scab, progressing very slowly, painless, with no inflammatory reaction. The base of these ulcers is pale red, or yellow, or simply raw, as if a piece had been ground out of the skin with a grindstone. The edges, although hard, are not very perceptibly thickened, and they do not project beyond the surface of the surrounding skin. When this condi- tion lasts for years without the development of any dis- tinct tumor, it forms the disease known to the older Eng- lish writers as "rodent ulcer," and even microscopically there is so little newly formed tissue, so little cell-growth, that some still claim that this disease is distinct from epithelioma. In its earliest stages the disease appears as a "flat-topped wart, or chronic pimple." The lymphatic glands are seldom enlarged. The incurability of the disease, except by complete extirpation, its frequent re- currence, and its limitation to old and middle-aged per- sons, show its clinical resemblance to ordinary epithe- lioma, and the microscope has set the matter beyond doubt. (Hutchinson: "Illustrations of Surgery,"vol. i., p. 13; Warren: "The Anatomy and Development of Rodent Ulcer " (Boylston Prize Essay), Boston, 1872 ; Thiersch : " Der Epithelialkrebs," Leipzig, 1865.) The ulcers due to other malignant tumors (carcinoma, sarcoma) present uneven, sloughing bases, hard or soft according to the character of the neoplasm, sometimes covered with unhealthy granulations, sometimes deeply pigmented, generally bleeding freely at the slightest touch. The edges are uneven and undermined, or thick and everted. The discharge is serous, thin, and bloody, contains flakes of sloughed material, and has a peculiar fetid odor. The course of ulcers due to malignant tu- mors is naturally that of the tumors themselves. Perforating Ulcer of the Foot.-Perforating ulcer of the foot is a peculiar form of ulcer, beginning upon some part of the plantar surface of the foot which has been most exposed to pressure, as a small thickened patch, at first of a white color, later turning dark, infiltrated with blood, and gangrenous. When this slough falls, it leaves a deep funnel-shaped ulcer, with sloughing edges, which extends through all the underlying tissues, and attacks the bone itself. Often the ulcer is so deep and narrow as to form a fistula rather than an ulcer. There is no pain felt at any time, and the surrounding skin is anaes- thetic. The course of the ulcer is slow, but unaffected by any ordinary treatment. A similar form of ulceration is sometimes met with in the hand and fingers. In most cases, profound local or general changes are found in the nerves, and the disease is looked upon as a disturbance of nutrition dependent upon nervous disease-a tropho- neurosis of some sort. In some cases locomotor ataxy was present, and syphilis also. Endarteritis obliterans is a frequent accompaniment of the perforating ulcer, and probably has some etiological connection with it. Dia- betes, too, has been found associated with the disease, and may be considered as at least a predisposing cause, 381 Ulcer. Ulcer. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. for cases have been cured by treatment directed to the diabetes. It is possible that there may be more than one form of pathological lesion included under the somewhat vague description of this ulcer. (Despres : Gaz. des Hopi- taux, 1880, p. 1019; Bruns: Berlin. Klin. Wochenschr., 1875, No. 30; Terillon: Bull. Soc. de Chir., Paris, xi., 408 ; Jeannel : Rev. de Chir., 1886, No. 1.) Scorbutic Ulcers.-Scurvy has been mentioned above as a cause of ulceration, and although it is rarely seen at the present time, it requires passing notice. The ulcers form after the familiar brawny induration has invaded the skin and subcutaneous tissue. They are of an un- healthy color, with swollen edges, and covered with an adherent, dark, fetid crust. Haemorrhage follows the re- moval of this crust, and it is rapidly formed again. The base has a tendency to produce fungoid granulations. Intestinal Ulcers Secondary to Burns.-Ulcers of the in- testine are caused by burns of the skin, in some manner as yet unexplained. They are generally situated just be- low the pylorus, and are indolent in appearance, showing no trace of inflammatory action around their edges. The latter are slightly everted. These ulcers occasionally perforate the peritoneum, or cause death by opening some blood-vessel large enough to result in fatal haemorrhage. As a rule, they give no symptoms which allow of a diag- nosis during life, unless one of these accidents is threat- ened, when intense pain or bloody stools give a warning of the approaching disaster. Ulcers of the Rectum.-Ulcers of the rectum can be recognized with the finger, as a rough spot upon the otherwise smooth surface of the rectal mucous mem- brane, beginning about an inch from the anus, some- times higher up, and extending up beyond the reach of the linger or speculum. To the eye they present a sur- face covered with granulations, healthy or anaemic, ac- cording to the condition of the patient. The discharge in the early stages is mucus, sometimes mingled with blood ; later, it becomes more and more puriform. This discharge gives rise to the most characteristic symptom of the complaint-a desire, on first waking in the morn- ing, to go to stool, and the passage of mucus, and per- haps a loose stool, but without entire relief, so that the patient has several stools in the course of an hour. Then lie goes through the day without much difficulty, unless the case is severe or far advanced, when the same fre- quent stools are passed again in the evening. There may be a feeling of pain, or at least of heat and discomfort, in the rectum, as if it were not completely empty. Weakness of the sphincter is a very constant symptom of the later stages, and stricture is the usual sequel. Pendjhe and Anam Ulcers.-Two forms of ulcers re- cently described require a short notice : the "Pendjhe" ulcer, named after the district of that name in Russian Asia, and the "Anam" ulcer, found in Tonquin. The latter is probably simply a form of phagedena such as is common in hot countries. It begins by an inflammation starting from a small abrasion of the skin, generally on the foot and leg, with sloughing of the inflamed skin, producing a sharp-cut ulcer, which spreads slowly, pre- ceded by an area of inflammation. Its course is remark- ably slow, and its resistance to treatment obstinate. Syphilis, anaemia, etc., are necessary as predisposing fac- tors. (Morand : Gaz. med. de l'Algerie, 1887 ; Le Dantec : Arch, de Med. Navale, 1885 ; Ranking: Lancet, 1887, ii., 413.) The "Pendjhe" ulcer appears to be strictly limited to that district. It begins with a red papule, which changes into a small pustule, bursts, and produces a small round ulcer which penetrates the entire thickness of the skin. Similar spots appear near by, and a large ulcer is formed by their coalescence, the surrounding tissues being also inflamed and swollen. Nodules appear in the skin in the course of the lymphatics, but without any reddening of the skin. The ulcer is found most fre- quently on the ankle and wrist, around the waist, and upon the neck and face, but may be seen in other situa- tions, perhaps by self-inoculation. It is supposed to orig- inate in the bites of some insect. The course of this ulcer is also very chronic and obstinate. (Ssuski, Lju- bezki, Welitschkin : Vratch, 1886, Nos. 9, 18, 19; Hey- denreich : " The Pendjhe Ulcer," St. Petersburg, 1888.) Complications.-We have already spoken of phag- edena, which is perhaps not so much a complication of ulceration as a peculiar form of the morbid process. Like all open wounds, ulcers are liable to septic infec- tion, and when one considers the character of their dis- charge, and the neglect which is generally shown in their treatment, it is a matter of surprise that they are not more often attacked by some septic process. Their usual freedom from this complication is probably to be referred to the property which granulations possess of resisting the entrance of septic infection. Erysipelas is the most frequent form of sepsis which attacks ulcers, and it is most common among the poor and most igno- rant persons. It is often of considerable extent when brought before the surgeon, and consequently it may easily have a fatal result. Another form of sepsis is an adenitis resulting in extensive suppuration, and this may lead to death by exhaustion, hectic fever, and amyloid degeneration of the liver and kidneys. The suppuration of the ulcer itself can scarcely be sufficient in any case to result in these disastrous consequences. The most important complications of ulcers are those which result from the perforation of some important viscus or cavity of the body by extension of the ulceration. These complications are found in venereal ulcers of the penis or vagina perforating the urethra, those of the vagina perforating the bladder or rectum, tuberculous or malignant ulcers of the bladder, rectum, or vagina perforating the neighboring viscera, or malignant or syphilitic ulcers perforating the palate, the nasal septum, or the cheek. Most important of all are ulcers of some of the internal organs-the stomach, the intestine, the gall-bladder, or the urinary bladder-which perforate the peritoneal cavity, or some neighboring organ which has become adherent. Nature endeavors to prevent this catastrophe by the irritability of the peritoneum, which becomes congested as the ulceration approaches it, and throws out an effusion of fibrin and young cells which organizes upon the outside of the diseased viscus, thus thickening its walls under the base of the ulcer. This same plastic inflammation is excited also in the peri- toneum lining the internal surface of the abdominal walls, or covering some adjacent organ, so that the sur- face of the diseased part becomes adherent to the ab- dominal wall, or to the organ in contact with it, and thus the ulcer attacks them next in turn, without open- ing the peritoneal cavity. Peritonitis is the inevitable consequence when the perforation has taken place too rapidly to allow proper occlusive adhesions to form beneath the base of the ulcer, or when such adhesions have formed, but some sudden movement or other vio- lence, such as distention, or excessive peristalsis, causes a rupture of the base of the ulcer, and a yielding of the adhesions at the same time. Haemorrhage is a very important complication of ulcers. When the ulcer is on any of the external surfaces of the body the haemorrhage is seldom serious, except from malignant tumors, or varicose veins of the leg. In these cases, it may be so severe as to endanger life, resisting pressure, impossible to control by the ligature, owing to the character of the tissues in which the bleeding vessels are placed, and necessitating the application of the ligature at a distance from the bleeding point. In ulcers of the internal surfaces of the body, being altogether in- accessible to surgical treatment, it is very frequently fatal. Further complications are those which result as a sequel to the healing process, and the contraction of the scars left by the ulcers. These scars may cause great deformity, distorting the face, causing curvature of the spine, anchylosis of the joints, and in many ways affect- ing the organs of the body which have suffered from ulceration. But it would carry us too far to enter into details as to these consequences. Prognosis.-From what has been said, it is evident that the prognosis of an ulcer, both as regards danger to life, and as regards curability, depends upon many fac- 382 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Ulcer. Ulcer. tors, and chiefly upon the nature and cause, the situation and complications of the ulcer, and the age and condi- tion of the patient. An ordinary ulcer of the skin, of traumatic or idiopathic origin, may be said to present no danger to life unless septic infection take place. Its curability will depend upon the nutritive condition of the skin in its neighborhood, its situation, and the care which it is likely to receive in treatment. Thus, an ulcer situated upon a leg with varicose veins, which has existed for some time and presents the peculiarities of the indo- lent ulcer, has a bad prognosis as to curability, and even if cured, will probably return. Ulcers of the stomach and intestine, if not tuberculous, excite grave fears for life during their existence, but the majority do not prove fatal, and they are generally curable within a reasonable time. Tuberculous ulcers can be cured but rarely, wherever they are situated, and the progress of the same disease in the lungs or intestine almost invari- ably terminates life sooner or later. The prognosis of ulcers in malignant tumors is the same as that of the neoplasm in which they occur-an early and complete extirpation affords the only hope of saving life. Treatment.-The treatment of ulcers must, in most cases, be both local and general. Local treatment con- sists in rest, cleanliness, topical applications, dressings, cauterization, incision, excision, transplantation of skin, and amputation or resection of the affected limb. Ulcers are generally more or less inflamed when brought before the surgeon, and his first duty is to re- duce this inflammation by appropriate antiphlogistic measures, before endeavoring to awaken proper growth of granulation and epidermis ; in fact, the latter cannot be expected to take place so long as inflammation is present. To reduce this inflammation, the surgeon must secure rest to the parts, remove all irritating materials, diminish congestion, and, if necessary, relieve pain. Rest is secured by putting the patient to bed, and in severe cases the diseased limb should be secured upon a splint which will immobilize the joints above and below the affected part, or at least the nearest joint. All irritating material, such as dirt, improper applications, and the discharge and crusts of the ulcer, must be removed, and the entire neighborhood cleansed, first with soap and water, and then with some mild but efficient antiseptic solution. If there is much hair in the neighborhood this should be shaved off, for hair is the favorite lurking place of filth and septic matter of every kind. When the parts have been thoroughly cleansed and disinfected, the diseased limb or portion of the body is placed on a higher level than the rest of the body, by resting it upon a pillow or inclined plane, or by means of a simple suspension apparatus made of a board hung by cords from some strong support above. The best local application which can be made is some weak anti- septic solution, most simply applied in the form of com- presses, made of pieces of linen or gauze dipped in a 1 to 100, or 1 to 50 solution of carbolic acid, or a 1 to 5,000 solution of bichloride of mercury, or a solution of acetate of alumina. (A one per cent, solution of acetate of alu- mina is prepared by adding twenty-four grams (3 vj.) of alum and thirty-eight grams ( 3 jxss.) of sugar of lead to one litre (Oij.) of water, allowing it to stand for twenty- four hours, and then filtering.) This last solution is en- tirely unirritating and non-poisonous. The compresses are most conveniently applied at about the temperature of the room, and then moistened, not removing them until the discharge from the ulcer has penetrated them. But the solutionscan be made with ice-water, if preferred, and the compresses changed as often as they grow warm, or an ice bag can be applied over the compresses. It is seldom necessary to employ cold, for the rest, elevation, and moisture will generally suffice to render the patient comfortable. Poultices are not to be advised unless it is impossible to use antiseptic compresses, and if they are employed, they should be boiled before use, applied very hot, and frequently changed, and the old ones should be thrown away if there is any discharge whatever from the ulcer. If these precautions are not taken, the poultice is a dan- gerous application, for it furnishes the most perfect con- ditions for the growth of septic germs. If poultices or wet compresses are employed too long, the parts become sodden and have their vitality impaired, therefore this treatment should not be continued for over two days at a time. If it is advisable to secure a more decided effect, per- manent irrigation may be employed by placing a water- proof cloth, or some sort of tray, under the limb, cover- ing the latter with a few layers of gauze, and allowing the antiseptic solution (which should be only one-half of the strength indicated above) to trickle slowly upon the gauze. This method requires careful watching, for the brisk evaporation of the solution may produce a dan- gerous reduction of temperature. The permanent bath (Kaposi : " Hautkrankheiten," Vienna, 1883, p. 362) has also been employed with great success for ulcers, espe- cially those of considerable extent, or involving parts of the body to which the application of compresses would be difficult. The temperature of the bath should be regulated by the feelings of the patient, and by watching the effect upon the temperature of the body as indicated by the thermometer. It is best to begin with a tempera- ture of 98° to 100° F. No antiseptic should be used in these baths, but great care should be exercised in pro- curing pure water, or sterilizing it by boiling, and in constantly changing it by adding fresh water and allow- ing the surplus to escape. If the entire body is to be immersed, the bath-tub should be fitted with a false bot- tom of boards with hinged joints at the level of the hips and knees, so that some change of position can be given to the patient, who rests on this platform upon several thicknesses of woollen blanket, in such a position as to remove all pressure from the diseased parts. If only one limb is to be immersed, a sort of trough just large enough to contain it, is made of boards or sheet-metal, and the limb rests upon folded compresses, or is sus- pended by strips of bandage secured to the edges. In these partial baths very wreak antiseptic solutions may be employed. Excellent results have been obtained by these baths, but they are very irksome to the patient, and except in such cases as extensive burns, or gangren- ous ulcers of the trunk and genitals, they do not present any advantages over wet compresses or irrigation. In addition to these antiphlogistic measures, any ab- scesses or suppurating glands must of course be opened, and if there is general cellulitis of the part free incisions must be made, so as to provide abundant drainage for the pus. If erysipelas is present, it should be treated by any of the approved methods-compresses wet with carbolic acid, or bichloride solution, marginal injections of car- bolic acid, scarification and subsequent application of antiseptic solutions, painting with nitrate of silver, ap- plications of ichthyol in ointment or solution, etc. If the ordinary methods for reducing inflammation do not relieve the pain of the inflamed ulcer, the compresses may be wetted with solutions of lead and opium, or chlo- ral (five or ten grains to the fiuidounce), or cocaine. But these applications are more likely to be required for the so-called irritable or painful ulcer, than for ulcers which are simply inflamed. Local Applications.-After the inflammation has been subdued, local applications must be considered. The most important applications are those designed to stimu- late the reparative processes. If inflammation has been reduced, and if rest and cleanliness can be maintained with simple antiseptic dressings, a large proportion of ulcers will heal like ordinary granulating wounds. But as the majority of patients are unwilling, or unable, to submit even to a short confinement to attain this result, the ulcers cannot be treated under such conditions as to give them the opportunity to heal by their own powers, and hence they require to have the latent force of their vitality brought out, as if by whip and spur. A complete list of the supposed stimulating applica- tions would embrace almost every drug and combination known to the pharmacopoeia, and we shall readily be excused in limiting ourselves to a few substances which possess undoubted merit. The precise action of these 383 Ulcer. Ulcer. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. stimulants upon the tissues is not thoroughly under- stood. Most of them act by merely increasing the blood- supply of the parts by simple irritation. Others appear to have a direct action upon the individual cells. This action is most easily understood in the case of nitrate of silver, for when this is applied very lightly to the granu- lations next to the advancing line of cicatrizing epider- mis, it is followed by an immediate advance of the epithelial cells. It is probable that the light contact of the caustic upon the superficial cells partially contracts and coagulates them, thus facilitating their transforma- tion into epidermis. This change only takes place at the edges, in immediate contact with the epithelial cells already formed, and the probable explanation of this fact is that the true epithelial cells have already extended beyond the white line which marks the limit of the cornified layer. The granulations next to that line can- not be distinguished from the rest, but they are already formed of epithelial cells, not yet cornified, but soft, corresponding to the deeper layers of the rete Malpighii, and the transformation of granulation cells into epi- thelium has already taken place. The contact of the caustic with these soft cells produces an immediate cornification, thus saving a delay of several hours, and enabling the deeper parts of the skin to advance beneath their protection more rapidly than would occur if the growth were left to nature. Other substances appear to have some occult influence upon the cells of granulation tissue, aiding their growth, but the exact mode in which this influence acts is not yet understood. According to Unna (Berlin, klin. Wochenschr., 1883, 533), carbolic acid, bichloride of mercury, and salicylic acid favor granulation, but hinder cicatrization, as is shown by the eczema which they cause so frequently ; while iodoform and boric acid favor both. He has found that pyrogallic acid, sulphur, and especially ichthyol, fa- vor cicatrization. He believes that all substances with reducing properties will favor the growth of epithelium, as well as all dehydrating substances, such as tannin, alum, and nitrate of silver ; while the oxygenating sub- stances, among which must be reckoned the ordinary an- tiseptics, delay it. The stimulating substances which seem most worthy of mention are balsam of Peru, nitrate of silver, alum, permanganate of potash, nitrate of mercury, sulphate of copper or zinc, chromic acid, quinine, salicylic acid, anti- pyrine, and ichthyol. The oldest of these applications is the balsam of Peru, and it is a capital stimulant for exciting the growth of granulations, especially when there is no active cause for their poor growth, only a little atony, as in the case of granulating wounds or chronic ulcers which have begun to heal in poorly nourished individuals. Nitrate of silver has three distinct uses in the treat- ment of ulcers : the destruction of granulations, the stim- ulation of the base of the ulcer, and the assistance given to the cicatrizing epidermis described above. For the first purpose it should be used in the stick form and firmly applied. For stimulating the base of an ulcer, the stick may be merely brushed lightly over the surface, so as to leave a hardly perceptible eschar, or its point may be bored into the dense cicatricial tissue, so as to make a sort of punctate cauterization of the entire sur- face. Solutions of nitrate of silver, from five grains to the fluidounce upward, are also frequently employed to stimulate ulcers of the mucous membranes. Alum is an old-fashioned application, used in solution or as a powder, acting partly by its irritant property, partly by its astringency. Permanganate of potash is not a bad stimulating application for a chronic ulcer, in a solution of five to ten grains to the fluidounce, but in some cases this will prove so painful that weaker solu- tions must be employed. Solutions of sulphate of cop- per, or of zinc, of about the same strength, are also good stimulants. For secondary syphilitic ulcers of the mu- cous membranes, and especially in the mouth, a solution of chromic acid, ten grains to the ounce, is a remarkably good application, and will sometimes cause them to heal even without constitutional treatment. Quinine, salicylic acid, and antipyrine are remedies of similar character, being irritant and antiseptic. They owe their healing power in about equal degree to both qualities, but they are often painful applications, and must therefore be employed with due regard to the sen- sibility of the ulcer. They are used in powder. Great claims have been made for salicylic acid, especially as an application for chancroids, but it is certainly very far from being equal to the generally employed iodoform. Of the well-known antiseptics, carbolic acid, bichlo- ride of mercury, and boric acid, we need say nothing, as their powers are so well known. They are somewhat irritant and undoubtedly promote the growth of granu- lations, but, as we have already seen, Unna considers the former detrimental to the growth of epithelium. Ichthyol, a compound of sulphur, was first introduced to the profession by Unna (Monatsheft f. Prakt. Derma- tologic, 1882, p. 328), who claimed that it particularly favored the growth of epithelium. According to the ex- perience of many, it has a remarkable power in stimu- lating the growth of granulations as well, as can be tes- tified to by the writer, who has employed it in all sorts of ulcers-chronic, varicose, and syphilitic-as well as in deep tuberculous sinuses. It may be employed in a ten per cent, aqueous solution, but most conveniently in a twenty-five per cent, ointment. Among the blander applications, the writer must con- fess his preference for the old-fashioned oxide of zinc ointment, but it is best suited for those cases in which there is not a very profuse discharge, and no septic con- dition. A ten per cent, ointment of boric acid is prefer- able when the discharge is very free, as it does not cake and interfere with the absorption of the discharge by the dressing. When there is much sloughing, nothing is equal to iodoform, and it is, in fact, indispensable in such cases, if the surgeon wishes to apply a dry dressing. The iodide of bismuth, which was introduced to sup- plant it, appears to be more irritating, and although this renders it somewhat stimulating, still it will often be found to be very painful. Subnitrate of bismuth and calomel answer very well for small ulcers with moderate discharge, when it is possible to heal them under a scab- such, for instance, as herpes of the genitals, and chan- croids which have been thoroughly cauterized. Under the head of local applications must also be con- sidered the use of the carbolic spray, as recommended by G. de la Tourette (Revue de Chirurgie, 1886, vi., 575). This author employed strong solutions of carbolic acid, one to twenty, or even one to ten, and exposed the ulcer to the spray for from half an hour to an hour and a half at a time, twice a day. In the intervals the ulcer was dressed with boric acid vaseline. He states that ulcers with very thick and indurated edges require incisions also. It is difficult to see how this method surpasses the customary use of carbolic acid on compresses, unless in the greater strength of the solution, and the shorter time it is left in contact with the sore. Perhaps we should include among the bland local ap- plications the dressings with peptonized cod-liver oil, suggested by Dr. W. B. Hopkins (Therapeutic Gazette, 1885, May, p. 303). In the case of a man very much ex- hausted by long-continued suppuration from a superfi- cial granulating wound, he applied the peptonized oil directly to the granulations, and while the contact of the oil did no injury to the ulcer, the general strength im- proved. The ulcer itself improved secondarily to this gain in the general condition. Among the stimulating applications for chronic ulcers must not be forgotten the use of a blister. The blister should cover the entire surface of the ulcer, and also its edges, for a large part of its good effect lies in its power of melting down the cicatricial tissue which renders the latter so thick and hard. Galvanism.-Electricity has often been recommended for the stimulation of chronic ulcers, but it has never been popular. Perhaps not enough patience has been devoted to the study of this method of treatment. Late- ly Meyer and Blackwood (Philadelphia Medical Times, 1887, xvii., 499) have reported successful cases treated by 384 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Ulcer. Ulcer. galvanism. But as one of Meyer's cases required nearly two hundred applications of ten to fifteen milliamperes, the results cannot be said to be brilliant. Dressings.-For the proper treatment of ulcers, the form of dressing to be employed is more important than the local applications, and second in importance only to rest and cleanliness. There is a great variety of dress- ings in use, and we must again confine ourselves to those which have proved themselves of value. These are the adhesive-plaster strapping of Baynton, the rubber ban- dage of Martin, the cotton dressing of Volkmann, and the boric-acid dressing of Lister. Baynton published his method of treating ulcers by compression in 1797, about twenty years after Bell's fa- mous work on ulcers was published. From that time to this, strapping has maintained its position among the most reliable methods of treating ulcers, and the idea of continuous support and compression (which was appre- ciated even by the ancients) is the foundation of every useful method of dressing ulcers. The plaster is cut into strips, lengthwise of the cloth (otherwise it stretches unequally), from three-fourths of an inch to an inch and a fourth in width, according to the size of the limb to be strapped, and long enough to encircle the limb. After heating the plaster, the strip is passed behind the limb and its centre applied to the posterior surface of the lat- ter, and then the two ends are brought forward on each side and crossed in front, with just sufficient tension to make equable, firm compression. The first strip is ap- plied just below the lower edge of the ulcer. The next strip is applied just above this, and overlapping it for a third to a half of its width. Each strip must be so placed as to follow the curve of the limb and to lie perfectly flat, and the application of the strapping is an art requir- ing considerable practice. If there is fear that the circu- lar strips will interfere with the blood-supply, or that they will prevent proper contraction of the edges of the ulcer in healing, the method may be varied by making the strips so short that they will surround only two-thirds of the circumference. A layer of cotton, to absorb the discharge, and a bandage from the toes or fingers up, to prevent swelling and keep the cotton in place, complete the dressing. The cicatrization of the epidermis appears to extend under the smooth surface afforded by the plas- ter more rapidly than by any other method. The plaster should be allowed to remain in place for twenty-four to forty-eight hours, and even longer if the discharge is slight, for the less the parts are disturbed the more quick- ly they will heal. Similar in principle, but more perfect in its mechani- cal action, is the rubber bandage of Martin, first pub- lished in 1877 (" Transactions of the American Medical Association," xxviii., p. 589). The bandage is made of the purest rubber, so as not to irritate the skin, and is proportioned in length and width to the size of the limb, an ordinary leg bandage being ten and half yards long and three inches wide. The bandage is applied like the ordinary roller bandage, but with very slight tension, for the contractility of the rubber maintains the tension first given it. The ulcer is carefully cleansed and disinfected, and the bandage applied the first thing in the morning, while the patient is still in bed. It is removed at night, thoroughly cleansed, allowed to stand in water, and then wiped dry before being applied again. No ointments should be used with it, as they spoil the rubber. It is necessary for the patient to wear the bandage for some time even after the ulcer has healed, and if there are varicose veins it must be worn perma- nently, or replaced by an elastic stocking. Martin sup- poses that the contact of the rubber with the skin forms part of the remedial action, but in some cases it will be found that the skin will not tolerate the confinement of the rubber, the profuse perspiration which it causes re- sulting in eczema. Sometimes the use of a similar band- age, but perforated with small holes, will remove this difficulty. Volkmann, in 1862, recommended the application of the occlusive cotton dressing, already in use in surgery, to ulcers of the leg (Arch. f. Klin. Chir., iii., 272). The ulcer was covered with sufficient absorbent cotton to take up all the discharge, after the ulcer and the skin had been thoroughly cleansed, and a firmly compressing bandage applied overall. The cotton was made so thick that pressure directly over the ulcer was no more pain- ful than elsewhere. The dressing was allowed to re- main until the discharge found its way through, or the bandage became loose. In the second case another bandage was applied ; in the first case, more cotton was added outside of the first dressing, without disturbing it, and another bandage. If any odor of decomposition was detected, the entire dressing was renewed. Volk- mann states that he has frequently seen extensive ulcers heal in a week under this dressing. In more modern times surgeons would hardly disregard the odor of stale pus, of which Volkmann wrote as " familiar " to all sur- geons, and not indicative of decomposition, and there- fore the method of occlusion suggested by Lister is more likely to find approval. It is certainly safer, and it is but very little more troublesome. Lister's method is briefly the following : The limb is thoroughly washed with soap and water, and a 1 to 20 solution of carbolic acid, and the ulcer itself cleansed with a saturated solution of boric acid. A piece of pro- tective, cut to correspond with the shape of the ulcer, but a little larger, so as to extend for a fourth of an inch beyond it on every side, is laid upon the ulcer- having first been soaking in the boric-acid solution for ten or fifteen minutes. A thick layer of borated cotton is then placed over the ulcer, and the entire limb wrapped in a thick layer of ordinary cotton, and sur- rounded with a firm bandage. In an extensive expe- rience, this method of dressing idcers has given excellent results in the hands of the writer (New York Med. Jour., 1884, ii., 514). The dressing was varied a little by em- ploying a piece of thin rubber tissue instead of the pro- tective, and a wet starched (crinoline) bandage applied instead of the ordinary bandage. The dressing was changed once a week, but some patients wore it for three weeks and even a month, while going about their ordi- nary work. Various local applications can be made to the ulcer under the borated cotton, such as a dry powder dressing of iodoform, stimulation with balsam of Peru, or the ichthyol ointment. On the leg it was found that the cotton need not be carried below the ankle, and while the crinoline bandage was begun there, a muslin bandage was put on the foot, so that the ordinary shoe could be worn. The important advantages of this method are complete antisepsis, absorption and steriliza- tion of the discharge, uniform compression, and rest to the parts secured by infrequent dressing. The protec- tive, or rubber tissue, is useful for distributing the dis- charge through the cotton, and thus preventing the lat- ter from caking upon the surface of the ulcer, as it is so apt to do. All dressings and other treatment of ulcers of the leg act best when the patient is in bed, but after a few days' rest, and when the ulcer shows some disposition to heal, it is probably better to have the patient moving about upon his feet with some compressive dressing, for if a cicatrix has been obtained by treatment in bed, it is very apt to break down when the patient resumes the upright position, even if it is protected by strapping. When ulcers are treated in a fixed position of the limb, the natural movements of the limb may cause the cicatrix to break down later by the tension which they exert upon it, but this evil can be readily avoided by changing the position of the limb at each dressing. Relaxing Sutures.-We have already seen how the edges and base of a chronic ulcer become surrounded with dense cicatricial tissue, which prevents further cicatrization and contraction by its attachment to deeper parts, and thus prevents the ulcer from drawing upon the freely movable skin around it, as it would otherwise do. This tissue also cuts off the blood-supply, as the contracted ring in a " bark-bound " tree cuts off the sap. Before this cicatricial tissue has formed, the neighboring skin can be drawn toward the ulcer by strapping, and if an ulcer extends for any distance around a limb, the 385 Ulcer. Ulcer. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. strapping can be arranged with a weight, so as to make permanent extension, like the dressing for Huck's exten- sion in fracture of the thigh. In the case of small ulcers, relaxing sutures (Gaff ky : Berlin. Klin. Wochenschr., 1878, p. 667) can be passed through the skin just above and be- low the ulcer, either mattress sutures or lead-plate sutures (a silver wire with a small lead plate at each end) being employed, and a fold of skin raised, bearing the ulcer upon its apex and relieving it of all tension. The sutures are allowed to remain a couple of days, under an anti- septic dressing, to avoid the danger of septic infection, and then removed, and the ulcer dressed as usual. Incisions.-But when this cicatricial tissue has once formed it is necessary to resort to the knife, either foi* incision or excision. The incisions may be made in various ways. A very old method consists in making radial incisions through the edge of the ulcer into sound skin, and deep enough to divide all the cicatricial tissue at that point, the incisions being made about a fourth of an inch apart, around the entire circumference of the ulcer (see Fig. 4242, a). An excellent method is the crossed incision, the prin- ciple of which seems to have originated in Liston's " starring " of the ulcer (Lancet, 1853, i., 568) revived by Hardie (Lancet, 1884, i., 879) and lately described, in variation, by Harbordt (Spaeth : Centralblatt f. Chirur- gie, 1888, 249). Liston carried two deep incisions, at right angles to each other, entirely through both edges and the base of the ulcer. Hardie followed the same method, but laid great stress upon the neces- sity of going entirely through the cicatricial tissue, no matter what its extent and depth, even if it is almost an inch thick. Harbordt makes a series of inci- sions about half an inch apart, and crosses them with a second set at right angles, like the " cross-hatching " of en- graving, both sets being carried entirely through the cicatricial tissue un- derlying the base, and into healthy skin at the edges (see Fig. 4242, b\ The writer has employed these incisions with capital results, but has found that where the cicatricial tissue is not very thick, it is well to place the incisions nearer, gauging their separation by the thickness of the cicatricial tissue and the base of the ulcer, so that when the incisions are made the entire base of the ulcer shall be divided into cubes, adherent to the healthy tissues by the lower side only. Haemorrhage may be severe, but is easily con- trolled by pressure. Antisepsis must be scrupulously observed, and to secure disinfection of the base of the ulcer it should be dressed with moist antiseptic com- presses for twenty-four hours before the operation. An incision through the skin along the edge of the ulcer, just outside of the cicatricial tissue, so as to allow the latter to contract still further by relieving it of the tension of the surrounding skin, is an ancient method of treating ulcers. Nussbaum has advised (Bayer. Aerztl., Intelligenzbl., 1873, No. 14) continuing this incision completely around the ulcer. The French refer this cir- cumscribing incision to Dolbeau. A very useful modi- fication of it has been given by Hodgen (" International Encyclopaedia of Surgery," ii., p. 288), the ulcer being cir- cumscribed by several short, overlapping incisions, in- stead of a single continuous one, so as not to cut off the circulation entirely (see Fig. 4242, c). The circumscribing incisions must be carried down to the fascia, including the entire thickness of the skin, and if they do not gape they should be plugged with lint. In ulcers entirely surrounding the limb, this incision has been made in its wdiole circumference, like the incision for a circular am- putation. It is to be remembered that these lateral incis- ions must be made through healthy skin, for they will give no relief if carried through cicatricial tissue. Excision and Cauterization.-For still more obstinate ulcers, and whenever there is suspicion of a change into epithelioma, there remains extirpation with the knife, or destruction by caustics or the actual cautery. The latter is seldom employed. The best chemical caustics are fuming nitric acid, sulphuric acid mixed with willow charcoal so as to make a paste, Vienna paste (equal parts of caustic potash and unslaked lime), chromic acid, lac- tic acid, arsenic (in a paste of two parts arsenious acid and eight parts of some indifferent material), chloride of zinc in concentrated solution, and liquor hydrargyri nitra- tis-but the last may cause mercurial poisoning if used too freely. It has been claimed for some caustics-for instance, chloride of zinc for cancer, and lactic acid for tuberculosis-that they show a selective action, attacking the morbid growth and leaving the healthy tissues. But this is true of most caustics, for they attack more readily those tissues which have low vitality, and the curette will show the same difference, most of these tissues be- ing less resistant than the healthy tissues. But since the introduction of anaesthesia, caustics have been much less employed than formerly, for the anaes- thetic protects the patient from the pain and dread of the knife ; but there is no way of overcoming the long-con- tinued pain of cauterization. Moreover, the knife or cu- rette is just as efficient, and leaves a healthier wound for healing. When excision is resorted to, it will generally be necessary to com- plete the healing of the large loss of substance occasioned, by some form of grafting or transplantation of the skin. But a small ulcer may be excised if the neighboring parts are healthy and the skin movable, and the edges of the wound united with sutures. Even when the edges cannot be brought quite to- gether, the wound may be lessened in size and recovery hastened. Skin-grafting.-The best method of skin-grafting is that of Reverdin, as modified by Thiersch (Plessing: Arch. f. Klin. Chirurgie, 1888, xxxvii., 53). The meth- ods of obtaining the epidermis by scraping the sole of the foot, or by slicing corns, although recommended by Hodgen, do not offer any advantages over Reverdin's method, and grafts taken in this way do not possess the vitality of those from healthy skin. Grafts have also been taken with success from amputated limbs, and even from the cadaver. Reverdin's method consisted in cut- ting thin small slices from the superficial layers of the skin with a sharp knife, and applying them to the gran- ulations. Within a short time the grafts are found to have become attached, and then they begin to increase in size by a new growth of epithelium around their edges. Thiersch introduced the important modification of re- moving the superficial granulation-tissue by the scalpel, the curved scissors, or the curette, until the firm fibrous tissue beneath is exposed, and using the latter as the ba- sis for applying the grafts. He showed by microscopic examination {Arch. f. Klin. Chirurgie, 1874, xvii., 323) that the fine blood-vessels of the superficial granulation- tissue ran vertically to the surface, and those of the next layer ran horizontally, and that the former layer was constantly melting away by necrosis and contraction, while the lower layer was permanent, and offered better nutrition to the grafts. By this improved method it is possible to make very large grafts adhere at once. The patient is anaesthetized, and the granulating surface pre- pared by removing the granulations. Then the skin and soft parts of the arm or leg, where the skin is healthy, are drawn tense by the left hand placed beneath it, while Fig. 4242.-The central space represents the ulcer, the shading around it the sur- rounding induration, and the lines the various incisions. 386 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Ulcer. Ulcer. with a large sharp razor a slice is cut from the upper sur- face, from one-half to one inch wide, and as long as can be made. The skin and the razor must be kept wet, as in cutting microscopical sections, with a 6 to 1,000 solu- tion of common salt. The sections thus obtained will include the entire rete Malpighii, the papillae, and a por- tion of the corium. These slices are then transferred to the prepared surface, when the haemorrhage from it has been stopped by pressure. The entire ulcer is covered with these slices, placed side by side, so as to overlap each other and the edges of the ulcer, like shingles on a roof. The grafts are then gently pressed down with a bunch of wet cotton, and a piece of protective or thin rubber tissue wet with the salt solution is applied over them, extending to the edge of the ulcer. A mass of cotton, also wet with the salt solution, is laid over the protective, about half an inch thick, and extending some- what beyond the grafts on every side. Over this is placed another layer of rubber tissue covering the whole, so as to keep it moist; the entire limb is then wrapped in cotton, and a firm bandage is applied. The dressing is changed in twenty-four hours. No antiseptics are em- ployed, as it is thought that they interfere with the vital- ity and taking power of the grafts. Very large surfaces have been covered with epidermis by this method at one sitting. The skin of animals, especially that of the frog and the domestic fowl, have been successfully employed for grafting by Reverdin's method. In making these grafts, the entire thickness of the skin must be employed, down to the cellular tissue. In other respects the method does not differ from the method with human skin. Skin-transportation.-Lefort (" Manuel de Medecine Operatoire," Paris, 1888, tome i., p. 182) and Wolfe {Medical Times and Gazette, 1876, June 3) have revived, apparently independently, a new method of grafting skin, said to have been formerly practised in the East. Esmarch (Verhandl. XIV. Congress Deutsch. Chirurg., 1885, I., p. 107) further elaborated the method. A piece of skin is cut from any part of the body, and all the fatty •and cellular tissue trimmed from its under side, leaving only the skin itself. This piece is then secured by a few sutures upon the ulcer, after the granulations of the latter have been removed, and an antiseptic dressing is applied. Plastic Flap Operations.-In some cases, and especially where a great deal of cicatricial tissue has formed about a joint, it will be better to use the transplantation of a freshly dissected Hap with a pedicle, as done by Graefe and Maas (Arch. f. Klin. Chirurgie, xxxi., p. 559 ; see also V. Hacker, Ibid., xxxvii., 1888, p. 91). These flaps can be taken from the adjacent skin, but then always in such a way as to leave a bridge of sound skin between the wound from w'hich the flap is taken and the surface upon which it is applied. The surface of the ulcer is to be prepared as in Thiersch's method. The flap can also be taken from another limb or from the trunk, when- ever the part which bears the ulcer can be brought into close contact and retained for a week or ten days by suitable dressings. Thus a flap for the heel would be obtained from the side of the opposite leg. If no symp- toms appear requiring earlier interference, the dressing remains for a week or ten days, then it is removed, and the pedicle of the flap is divided. Some very remarkable results have been obtained in this way, the flaps becom- ing firmly adherent and presenting all the elasticity, softness, and other qualities of healthy skin which are so important in the neighborhood of joints. Sponge-grafting.-When there is a very deep cavity to be filled up, the method of sponge-grafting introduced by Hamilton (Edinburgh Medical Journal, 1881-82, xxvii., 385) may be employed. A piece of sponge is decalcified by soaking it in nitro-hydrochloric acid, then washed in an alkaline solution, and preserved in a one to twenty solution of carbolic acid. When required, it is cut to the exact shape and size of the cavity to be filled, and applied after a thorough disinfection of the ulcer and its sur- roundings. The discharge is very profuse and the anti- .septic dressings require frequent renewal, as decomposi- tion is very apt to occur. The granulations spring up and fill all the interstices of the sponge, and when they reach the surface bury the latter from sight, and are then covered in by the epidermis. The sponge tissue is slow- ly absorbed. Although some excellent results have been obtained, the sponge is very liable to act as a foreign body, cause suppuration, and slough out even after it seems as if success were assured ; therefore great care is required, and failure is not uncommon. Probably deficient antisepsis is the usual cause of the failures, although incomplete decalcification of the sponge will explain some. In one case Hamilton grafted a mass of sponge nearly an inch thick and five inches in diameter, and saw it completely absorbed. Amputation and Resection.-When every effort has been made to heal the ulcer, but without success, and when the disease remains an insupportable evil in spite of careful and intelligent dressing, and the patient is entirely disabled, the surgeon should not hesitate to resort to more energetic measures for the removal-we cannot call it the cure-of the ulcer. Amputation is not always necessary when an ulcer of the leg becomes epi- theliomatous, for thorough curetting and excision will often effect a cure. Amputation may also frequently be replaced by a resection of part of the bones of the limb, which will allow the soft parts to be brought together and cover the defect. Probably the resection of the heel, according to the method of Mikulicz-Wladimiroff, will be most frequently resorted to, for ulcers of the heel are common and particularly obstinate, and the result of this operation is far better than that of an amputation of the foot or leg with an artificial support. In this method the os calcis and astragalus are removed, the articular surfaces of the bones of the leg and of the tarsal bones in Chopart's joint sawed off, and the two fresh surfaces joined by placing the foot in a position of equinus. Jasinski (Gazeta Lezarska, 1886, No. 51) and Martel (France med., 1886, No. 17) have lately reported cases of incurable and extensive ulcers of the leg, in which they removed a portion of both bones above the malleoli, united the ends, and secured a useful limb. Choice of Methods of Treatment.-In chronic ulcers especial attention must be given to the cicatricial tissue, inducing its absorption by blisters and incisions, and then stimulating the growth of granulations. Very painful or neuralgic ulcers may be relieved by dividing the nerve which supplies that part of the skin at some point above the ulcer. Varicose ulcers require compression chiefly ; even when hard inflammatory nodules appear in the skin they may be treated by simple compression, and if they break they may be allowed to ooze so long as their con- tents are merely bloody serum. But if the presence of pus or of a slough is suspected, a free incision must be made through the little mass, and the cavity made to heal up from the bottom. An ichthyol ointment is an excel- lent application for hardening the skin when it is puffy and full of dilated capillaries. For syphilitic and tuber- culous ulcers nothing is equal to iodoform as a local application ; and it is the best dressing for all sloughing ulcers, whatever their origin. One of the best methods of treating lupous and tuberculous ulcers is the free use of the curette, removing all the infected tissue. Fissures of the anus can sometimes be induced to heal by rest in bed, careful cleansing, keeping the faeces soft by diet laxatives and enemata of oil, the use of iodoform ointment locally, and occasional stimulation with nitrate of silver. But very often a thorough stretching of the sphincter under an anaesthetic, or division of its fibres with a knife, will be found necessary. Ulcers of the rectum are generally very obstinate. They should be treated by rest in bed, fluid or very light diet, keeping the faeces soft, cleansing enemata of warm water, and injections of nitrate of silver. The latter in- jections may be begun with a strength of two or three grains to the ounce, and gradually made stronger. Oc- casional stimulating applications of nitric acid, made through a speculum to the ulcerated surface, will be of advantage. Of course other topical applications, such as bismuth in powder, iodoform, or sulphate of copper, will 387 Ulcer. Umbilical Cord. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. be tried when these routine methods fail. If there is any tendency to stricture the rectal bougie must be used at intervals. Constitutional Treatment.-The constitutional treat- ment of ulcers must be adapted to the special needs of each case, and should be directed especially to correct the foundation, or predisposing causes, of the disease. When- ever any general disorder or taint of the system can be de- tected, it must be attacked by appropriate remedies, even if it is not certain that it is the cause of the ulcer. Syph- ilis will, of course, require its specific treatment, which must often be assisted by tonics. Tuberculosis must be treated by measures designed to support the strength of the patient, by rest, and change of climate. Anaemia and diabetes must be looked for and treated, as they are fre- quently predisposing causes of ulcer. The gouty dia- thesis, or any form of lithsemia, must be especially sought for, as we have seen how frequently it is associated with varicose veins and a tendency to vascular changes and ulceration of the skin; but in most cases it will not be easy to be sure of its existence, and still harder to affect it by treatment. In fact, in most cases of chronic ulcer little or nothing definite can be found to show what the predisposing cause of the ulceration may be, and no con- stitutional treatment is indicated beyond hygienic direc- tions, a tonic, or an occasional laxative. B. Farquhar Curtis. UMBILICAL CORD. The subject is treated in two parts : 1st, Structure of the Cord at Birth ; 2d, Develop- ment of the Cord. The Cord at Birth.-The human cord is a long, twisted rope of tissue, whitish in color, and attached by one end to the navel of the embryo, by the other to the surface of the placenta. Its dimensions are extremely variable at all periods; at birth it is usually about fifty-five centimetres long and twelve millimetres thick ; it is said that cords only fifteen centimetres long as one extreme, and over one hundred and sixty centimetres long as the other extreme, have been observed. Its surface is smooth and glistening, except at the constricted foetal end, where the epidermis stretches about one centimetre on to the cord. The placental end expands to fuse with the chori- onic membrane. The placental insertion is generally ex- centric, that is, the cord joins the placenta at a point between the centre and margin of the latter organ ; usu- ally the excentricity is well marked, and not infre- quently is so great that insertion becomes marginal ; in still rarer cases the cord joins the chorion outside the region of the placenta (insertio velamentosa). Occasion- ally the cord forks before joining the chorion (insertio fareata). The twisting of the cord is always well marked exter- nally, at the time of birth, by the spiral ridges, within each of which a large blood-vessel runs. I have ob- served the number of spirals to vary from three to thirty- two ; the turns, beginning at the embyro, go usually from left to right, but sometimes from right to left. The cause of the twisting, which begins about the mid- dle of the second month, has been much and very un- profitably discussed. Of the many theories on the sub- ject which have been advanced, there is not one, so far as I know, having the slightest claim to acceptance. These vagaries have been collated by Hyrtl,6 and also less fully by Lawson Tait,11 who adds to them. All we can say is that the vessels grow faster in length than the cord as a whole, and therefore assume the spiral disposi- tion ; the cause of this inequality is as completely un- known to us as the causes of all the other inequalities of growth which occur in the embryo. One point must be specially mentioned, namely, that there is no reason to suppose that the cord as a whole actually twists any more than that the spiral intestine of a shark is formed by twisting ; many writers having falsely assumed the occurrence of this twisting motion, have dissertated at no little length on the revolutions of the embryo in utero. There is no evidence that such revolutions occur, nor have we any ground for assuming that the twisted appearance of the cord is due to an actual twisting like that of a rope ; if a long rubber tube forms a coil within a short glass cylinder, it does not indicate that the cylin- der has been twisted. The cord is covered by a layer of epithelium, which is continuous at the distal end with the epithelium of the amnion. Its interior consists of a peculiar embryonic connective tissue known as Wharton's jelly, which is described below ; in this jelly are found at birth three large blood-vessels, and usually a few degenerated r e m - nants of the epithe- lium of the allantois. There are no capilla- ries except close to the navel, and in spite of the opinion of some writers, it ap- pears safe to say that there are no lymph- vessels* and no nerves in the distal part of the cord. Schott8 claims to have followed branches of the he- patic plexus along the vein three or four centimetres into the cord, and branches of the plexus of the colon and uterus an equal distance along the arteries. Valentin has found nerves even further (8-11 ctm.) from the navel. As Kolliker remarks in his larger text- book,6 p. 347, the absence of nerves in the distal portion of the cord and in the chorion is of no little physiologi- cal interest, since the blood-vessels are so contractile. In a cross section (Fig. 4243), as usually obtained, the vessels are found contracted, the arteries, A, A, with their cavities almost obliterated. The vessels have thick walls composed of a muscular coat and a rudimentary intima, but without any special external connective-tis- sue layer. The vessels differ from adult vessels of simi- lar calibre in many respects ; there is no elastic tissue, so far as I have observed, in any jjart; the muscle-cells are short, fusiform, loosely arranged, and run in various directions ; next the intima the fibres are longitudinal in trend ; in the rest of the coat they are grouped in lami- nae, which have the fibres obliquely in one direction or another, thus giv- ing rise to the ap- pearance of alter- nating spiral coats, noticed by Lawson Tait11 (p. 434, and Plate xiii., Figs. 17 and 18). The muscular coat pass- es over without any sharp demarcation into the surround- ing tissue, known as Wharton's jelly, which consists of scattered anasto- mosing cells (com- pare Fig. 4247), and a muciparous matrix with very numerous connective-tissue fibres. The cells and fibres tend to arrange themselves in concentric lines around the blood-vessels and parallel to the surface of the cord (Fig. 4243), so that we may speak of four systems ; within each system the cells tend to an elongated form, but where the systems approach one another the cells become more tri- angular (as seen in sections, Fig. 4247), and show three or four main processes. These triangular cells form, of Fig. 4243,-Cross Section of an Umbilical Cord at term. X about 12 diameters. K, Remnant of the allantois; F, om- phalo-mesaraic vein; A, A, umbilical ar- teries. Fig. 4244.-Diagram of a Cross Section of the Bauchstiel of a Human Embryo, md, Me- dullary groove ; Am, amnion ; V, umbilical vein ; coe, coelom ; A, umbilical artery ; All, allantois. * Wandering cells occur in the intercellular spaces of Wharton's jelly, and it is possible that there are \ym\A\-channelii in the matrix, though no vessels. Compare particularly Koster's paper. 388 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Ulcer. Umbilical Cord. course, long columns, which are more or less distinct from the tissue encompassing the vessels ; to these columns the name of chorda funicula has been applied by Hyrtl; they are said to have been noticed by Woortwyck over a century ago. The external covering of the cord is a stratified epithelium, of which the outer layer is distinctly corneous ; sometimes there are spaces without cells, separated off on the dorsal side, the vitelline stalk is en- closed by the down-folding somatopleure,* and the right umbilical vein aborts. In cross-sections we have now the disposition shown in Fig. 4245, A. The coelom, Coe, is a large cavity and contains the yolk stalk Ys, with its two vessels, and its entodermic cavity entirely oblitera- ted ; near the embryo the coelom may become much en- larged, and is often found during the second month, and even later, to contain a few coils of the intestine ; above the body cavity is the duct of the allantois, All, lined by entodermal epithelium ; and in this re- gion are situated the two arteries and single vein ; the section is bounded by ectoderm.f The further development of the cord depends upon three factors: 1, the growth of the con- nective tissue and blood- vessels ; 2, the abortion of the coelom yolk stalk and allantois duct, in the order named ; 3, differentiation of the connective tissue and of the ectoderm. The growth and differentiation of the mesoderm pro- ceed rapidly-encroaching upon the coelom, which is ob- literated (early in the fourth month). At first the connec- tive tissue (Fig. 4246) is composed merely of numerous cells embedded in a clear substance ; the cells form a com- plex net-work, of which the filaments and meshes are ex- tremely variable in size ; the nuclei are oval, granular, and do not have always accumulations of protoplasm which have been regarded as true lymph stomata (Kos- ter and also Tait); the middle layer is composed of clear cells, and the basal layer of granular cuboidal cells ; in section the appearances are closely comparable to those of the embryonic epidermis from parts where there are no hairs, and at the time when the horny layer begins to appear. As there is no differentiated connective-tissue layer beneath the epithelium, the covering of the cord is best described as embryonic skin. According to cur- rent descriptions the cord is said to be covered by the amnion, but this is obviously an error, as shown by His' observations upon the development, and my own upon the histology of the cord. There is usually to be seen in sections of the cord at term, according to Kblliker,8 p. 344, especially in sections from the proximal end and middle region, a small group of epithelioid cells, with distinct walls, irregularly granular contents, and round nuclei; around the cells (Fig. 4249) there is a slight conden- sation of the connective tissue, to form as it were an envelope. This structure has been regarded by some, writers as the persistent yolk stalk, as, for ex- ample, by Ahlfeld (Arch. fur Gynak., viii., 363). Kblliker,6 p. 344, considered it to be the remnant of the allantoic cavity, a supposition which my own observations confirm. Development of the Cord.-His4 has shown that in the very young embryo the posterior part of the body is prolonged out to be attached to the chorion. To this prolongation His applies the term Bauchstiel. It is the direct continuation of the em- bryo itself; upon its dorsal surface the medullary groove is continued for some distance (Fig. 4244, md); the groove disappears completely very early ; from its sides the somatopleure arches over to form the amnion, Am; below it contains the hindmost prolongation of the entodermal canal, the epithelial tube, All, known as the allantois or allantoic duct; it also carries two veins, V, V, and two arteries, A, A, the former the direct prolongation of the cardi- nal veins, and the latter of the forked dorsal aorta. It is therefore clear that the Bauchstiel is morphologi- cally the hindmost end of the embryo, the differen- tiation of which is arrested in order that it may be con- verted into the allantois stalk, and ultimately into the umbilical cord. By the bending down of the somatopleure, just as in the body proper, the amnion becomes separated off and the coelom closed in. During this process the end of the embryo curls over toward the head, the tail proper is Fig. 4245.-Sections of Umbilical Cord. A, Embryo of 21 mm.; B, foetus of sixty-four to sixty-nine days. Fig. 4246.-Connective Tissue of the Umbilical Cord of an Embryo of 21 mm.; X 540 diameters ; stained with alum, cochineal, and eosine. about them, forming main cell bodies.:}: I notice also a few cells, which I suppose to be leucocytes, but see no * Compare the article Yolk-sac ; also Fig. 1276, vol. iii., p. 192, which shows the yolk stalk within the umbilical cord. + The ectoderm is often wanting, owing to its frequent destruction post mortem. J It is possible that the reticulum here described as cellular is, in part, at least, composed of remnants of an early matrix, which shrinks up and is replaced by the clear matrix here described : my observations do not settle this question of the nature of the reticulum. 389 Umbilical Cord. Uraemia. REFERENCE HANDBOOK OF T'HE MEDICAL SCIENCES. other structures. By the end of the third month the cells have assumed nearly their definite form ; the proto- plasm has increased in amount and forms a large cell- body around each nucleus (Fig. 4247). The net-work has become simpler and coarser, the mcshesbigger, and filaments fewer and thicker; in the matrix are numer- ous connective-tis- sue fibrils, not yet disposed in bun- dles except here and there ; as they curl in all direc- ti o n s, many of them are cut trans- versely and there- f o r e appear as dots. In older cords there is an obvious increase in the number of fibrils, and they form wavy bun- dles. In the cord at term the matrix contains mucin, and may be stained by alum luema- toxylin ; at what period this reac- tion is first de- veloped I have not ascertained. I have observed nothing to indi- cate the presence of special lymph- channels in the cord at any period, but I have not investigated the point. Tait's lymph- channels are merely the intercellular spaces. The ectoderm is at first a single layer of cells, a con- dition which is permanent over the amnion; in an em- bryo of three months I find the two-layered stage (Fig. 4248). The outer layer is granular, and in some parts each cell protrudes like a dome; * the inner layer con- sists of larger, clearer cells. By the fifth month the stratification of the epithelium becomes more evident the true epidermis reaches by, perhaps, the fourth month ; on the other hand, it differs entirely from the amniotic epithelium. The blood-vessels steadily enlarge, and acquire thick muscular walls. In the cord of an embryo of 21 mm. (Fig. 4245, a) the arterial muscu la- ris is well marked, the venous muscu- laris just begin- ning to show. At sixty-three days I find the coat thick- ened on all the vessels; there is a gradual passage from the muscle- cells to the sur- rounding connec- tive tissue, so that one wins the im- pression that the connective - tissue cells are being di- rectly metamor- phosed into mus- cle-cells. By the fifth month the demarcation o f the muscular coats is quite sharp, and it is probable that the further growth of the layer depends upon the growth of the elements it already contains, and not upon the accretion of new ones ; that the muscle-cells do actually become bigger is easily ascertained by direct observation.* The obliteration of the coelom goes on rapidly during the second and third months, and by the beginning of the fourth is nearly or quite completed. The vitelline duct persists longer, but seems to disappear by the sixth month ; for a time it is distinguishable as a shrunken remnant in the midst of the connective-tissue cells of the cord. The allantoic duct occupies usually a position be- tween the two arteries; it attains its maximum diameter about the fifth week, ■when it is a small epithe- lial tube, Fig. 4249, of irregular width, as which it remains for some time without no- ticeable altera- tion ; during the third month it loses this charac- ter and becomes solid by the en- largement of its epithelial cells; the duct persists up to birth in this form, though losing, according to K61- liker, its complete continuity; after it becomes solid Fig. 4247.-Connective Tissue of the Umbilical Cord of a Human Embryo of about Three Months. X 511 diameters. Stained with alum, cochineal, and eosine. Fig. 4248.-Epithelial Covering of the Umbilical Cord of an Embryo of Three Months; X 545 diameters. Fig. 4249.-Cross-sections of the Allantoic Duct. X 340 diameters. and cornification begins. The ectoderm (Ec) therefore develops like the epidermis proper, although much more slowly, so that it never gets beyond the stage which * From the investigations of Dr. J. T. Bowen, on the development of the epidermis, which he has been carrying on in the histological labora- tory of the Harvard Medical School, it seems to me probable that this ex- ternal layer is homologous with the epitrichium. * This offers another example of the rule that growth and cell multi- plication may be distinct processes. Compare Merk's remarks, Denk- schr. IFien Akad., liii., pp. 34-41, 1887. 390 Umbilical Cord. Uraemia. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. there is a slight condensation of tissue around it. Fig. 4249. Charles Sedgwick Minot. 1 Ahlfeld, F. : Ueber die Persistenz des Dotterstrangs in der Nabel- schnur, Arch. f. Gyniik., ix., 1876, .325. 2 Ahlfeld, F.: Die Allantois des Menschen und ihr Verhaltniss zur Na- belschnur. Arch. f. Gynak., x., 1876, 117, Taf. iii. 3 Ahlfeld, F. : Ueber die Persistenz der Dottergefasse nebst Bemer- kungen uber die Anatomiedes Dotterstranges, Arch. f. Gyniik., xi., 1877, 184-197. 4 His, Wilhelm: Anatomie menschlicher Embryonen, iii., Zur Ges- chichte der Organe. Leipzig, 1885, 260 pp. Tafn. ix.-xiv. 6 Hyrtl, Joseph : Die Blutgefiisse der Menschlichen Nachgeburt in normalen und abnormalen Verhaltnissen. Wien, 1870, pp. viii., 152, xx. Tafn. 8 Kolliker, A. : Entwicklungsgeschichte des Menschen und der Ho- heren Thiere. Leipzig, 1879, pp. xxxiv., 1031. 7 Koster: Ueber die feinere Structur der menschlichen Nabelschnur. Wurzburg, 1868. 8 Schott, J. A. C.: Die Controverse liber die Nerven des Nabels- tranges und seine Gefasse. Frankfurt a. M., 1836. * Schultze, B. S. : Die genetische Bedeutung der velamentosen Inser- tion des Nabelstranges. Jena Zeitschr. iii., 1867, 198-205. 10 Schultze, B. S. : Ueber velamentale und placentale Insertion der Nabelschnur. Arch. f. Gyn., xxx., 1887, 47-56. 11 Tait, Lawson : Preliminary Note on the Anatomy of the Umbilical Cord. Proc. Roy. Soc. of London, 1876, 417-440, Pl. xi., xiv. UREMIA. The term uraemia is derived from oipov, the urine, and a^ua, the blood, and signifies a condition of the blood in which certain of the urinary constituents are re- tained in it. These substances, consisting of the urinary salts, the urea, and other products of tissue-metamor- phosis, are normally removed by the depurative action of the kidneys ; but in some morbid states of those or- gans they are unable to perform their function properly, and the excrementitious matters consequently remain in greater or less amount in the blood. The question is, perhaps, not perfectly settled yet whether the physio- logical action of the kidneys consists in a separation by the renal epithelium of the preformed urea from the blood, or in the conversion by this epithelium of some antecedent substance into urea. This question cannot be discussed within the limits of this article ; but, which- ever view be the true one, clinically the results are the same when the function of the kidney is interrupted. There will be in consequence of such interruption an ac- cumulation of excrementitious material in the blood, and this is the state termed urcemia. The uraemic symptoms are perhaps in part due to the retained salts, but mainly to the urea or its antecedents. And this view is not nega- tived by the fact that large quantities of urea may be administered to healthy animals without the production of such symptoms, and with no other effect than an in- creased passage of urea from the kidneys ; for this shows only that in health the kidneys can accomplish the re- moval of an amount of urea much beyond what is nor- mal. Causes.-The morbid states of the kidneys which orig- inate uraemia are the various forms of Bright's disease. Among these affections it occurs probably in a larger proportion of cases of acute congestive nephritis, or acute Bright's disease, than in any other one form ; but the most numerous cases are met with in the different chronic forms, because these are of more frequent occur- rence than the acute. Uraemic symptoms occur in both chronic tubular and chronic interstitial nephritis, but they appear earlier and more frequently in the latter variety, and indeed sometimes constitute in this very insidious form the first indication of disease. In any form of kidney disease when uraemic symptoms occur there is at the time either suppression of urine or a dim- inution of the amount passed, or, if the bulk of urine be normal it is of low specific gravity, thus showing deficient elimination. Sometimes it happens that even with great diminution or actual suppression of urine no uraemic symptoms result; and this is in consequence, probably, of vicarious elimination taking place through the bowels or skin. Symptoms.-The symptoms termed uraemic are all referable to the nervous system, but manifest themselves in various organs and parts of the body. They are headache, stupor, nausea, and vomiting, with other forms of gastric derangement, oppression of breathing, irregular action of the heart, impairment of vision, con- vulsions, and coma. Some of these symptoms may oc- cur in the course of Bright's disease and yet be due to other causes than uraemia. Thus the oppressed breath- ing may be caused by pleural effusion or pulmonary oedema, which are forms of dropsy like those occurring in other parts of the body. Irregular action of the heart may be due to endocarditis or pericarditis occur- ring incidentally. But independently of these causes, and in the absence of any discoverable structural change in the lungs or heart, the functions of these organs are often disturbed by the action of the vitiated blood on the nervous system. The pulse is sometimes very slow, being reduced to fifty in a minute, or even less ; and in other cases, especially at the time of a convulsion, it is very frequent and weak. Dyspnoea is often observed in the subjects of Bright's disease, and when not ac- counted for by actual change in the chest organs it is of the character known as renal asthma. In advanced stages the respiration often assumes the Cheyne-Stokes type. Again, impairment of vision occurring in Bright's disease is frequently due to albuminuric retinitis as shown by the ophthalmoscope ; but in some cases com- plete blindness occurs with no change discoverable in the retina, and is apparently caused by the action of the uraemic elements on the centres of vision. In such cases, unattended with changes in the retina, the vision sometimes returns perfectly in a few days. Among the most common and severe symptoms of uraemia are uraemic convulsions, which are probably occasioned by the irritant action of the morbid sub- stances in the blood on the motor centres, which then evolve nerve-force without regulating its discharge. In appearance such convulsions are like those of an epi- leptic attack, consisting in clonic contractions of the muscles of the face and extremities. The attacks are apt to occur at short intervals, the patient being uncon- scious between the convulsive seizures. Sometimes a first attack terminates fatally, but often the convulsions cease for a time and return as the disease progresses. In some instances with little or no preceding convulsive action profound coma sets in, lasting for a variable time and sometimes ending in death. Occasionally the intel- lectual functions of the brain are affected, the patient becoming delirious or melancholic. Some uraemic symptoms are of especial interest as indicating appar- ently an effort at the elimination of urea. Thus the vomiting of uraemic patients, though sometimes cerebral in origin, is in other cases apparently brought about by the action on the mucous membrane of the stomach of urea, or the carbonate of ammonia into which it is de- composed, these substances being found in the ejected matter. In like manner, the urea in the blood may oc- casion a diarrhoea by its irritant action on the mucous membrane of the bowels. It has been shown further that perspiration which may be excited artificially by diaphoretics for vicarious elimination, at times occurs spontaneously, with the ef- fect of removing urea by the sweat-glands, a fine deposit of urea appearing on the surface in scales after the watery portion of the sweat has evaporated. All the symptoms of uraemia taken together may be divided into the acute and chronic forms, the acute consisting chiefly of convulsions, coma, sudden loss of sight, and urgent dyspnoea; the chronic of headache, nausea, and vomit- ing, diarrhoea, oppression of the breathing, and irregular action of the heart. Treatment.-The treatment of uraemia comprises two measures, apart from those addressed directly to the un- derlying and causal disease of the kidneys. These are, first, the elimination of the morbid agents from the blood, and, secondly, the abatement of irritability of the nervous centres so as to render them more tolerant of the presence of the urea. The first indication is accom- plished best by restoring or increasing the action of the kidneys, or establishing a vicarious action of other elim- inative organs. In acute uraemia with suppression of the urine, a most important measure is the application of wet or dry cups over the kidneys, the abstraction or derivation of blood in this way relieving the congestion 391 Uraemia. Lretlira. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. of the organs and thus enabling them to resume their function. This measure is often applicable in acute con- gestive nephritis, but is not generally admissible in the chronic forms of the disease. Further aid may be given to the kidneys by the use of digitalis which promotes the flow of urine by its action on the heart without pro- ducing any irritant effect on the kidneys themselves. It should be given in full doses of ten to twenty drops of the tincture, or from two to four drachms of the infusion every three hours until some response is afforded by in- creased action of the kidneys. The skin and the bowTels may also be acted upon to produce a vicarious elimina- tion of urea. Free diaphoresis may be brought about very promptly by the use of the hot air or hot vapor bath. The former of these may be readily extemporized by placing an alcohol lamp at one end of a tin tube, the other end of which is introduced under the patient's bed- clothes, so that a current of heated air is brought into contact with the patient's body. The vapor-bath may be applied by placing the patient, enveloped in a blanket, in a chair, beneath which is a vessel of hot water kept at the boiling-point by an alcohol lamp. The heat of the steam-charged air must, of course, be carefully watched and regulated. Of diaphoretic drugs the most efficient is pilocarpine, which in the dose of one-eighth or one-sixth of a grain of the nitrate or muriate may be administered hypodermically, even when the patient is unconscious from convulsions or coma. The writer has many times found the most prompt and strikingly good effect from this drug thus used ; and it has been shown that the se- cretion excited by its use contains an appreciable amount of urea, and that a true vicarious elimination is thus ac- complished. It is, however, sometimes depressing in its action on the heart, and should therefore be used with caution and conjointly with stimulants if there be much weakness. The second indication for treatment is to lessen the sensibility of the nervous centres, and prevent or restrain convulsions by rendering these centres more tolerant of the retained urea. For this purpose various agents have been employed. The inhalation of chloro- form appears sometimes to do good, but in general its effect is only transient, and when its influence passes off the convulsions are liable to return and the coma to be rendered more profound. The bromides are powerless to relieve uraemic convulsions, but there is reason to believe that they lessen the frequency of attacks when they have once begun to occur. In such cases they may be given every night in the dose of from twenty to thirty grains of one or other of the bromide salts. To relieve the con- vulsions when already present, or to prevent their recur- rence, much the most potent neurotic agent is morphine administered hypodermically. It has been supposed that since coma is a frequent result of uraemia, and the convulsions are apt to terminate in coma, there would be danger of aggravating this condition by giving morphine. But so far is this from being true that there is reason for the belief that a direct antagonism exists between the uraemic state and this drug, so that the effects of urea on the nervous centres are best counteracted by it. Again, an apprehension has been felt by some that morphine would interfere with the eliminative action of the kid- neys by checking their secretion ; but this also has been shown to be groundless, the amount of urine not being at all lessened and sometimes apparently even increased under the use of morphine. The muscular spasms of uraemia are certainly arrested more promptly by the hy- podermic use of this drug than by any other means ; and besides this effect it may aid the other agents spoken of in producing free diaphoresis and increasing the renal secretion. It should be given at first in the dose of five or six minims of Magendie's solution, which may be re- peated every two hours if the convulsions are not arrested or if they recur. This use of morphine acts in uraemic convulsions by relieving the morbid excitability and ir- regular action of the nervous centres on which they de- pend. In actual coma it would not be advisable, the best measures for this condition being pilocarpine and the hot air and vapor baths as already described. Samuel C. Chew. URETHANE. By the simple title 'urethane is under- stood, in medicine, the body ethylic urethane (ethylic carbamate) NH2.COOC2H5. This compound occurs in colorless tabular crystals, soluble in water, alcohol, and ether. It has no odor and but a mild ethereal taste, pro- ducing a sensation of coolness to the tongue. Urethane operates upon the animal system as a quite pure, though not overpowerful hypnotic, without effect upon the peripheral sensory apparatus, and without untoward effects of any kind. It is used in medicine to procure sleep, and is found fairly efficient in the more tractable conditions of insomnia. Doses of 1.00 Gm. (fifteen grains) commonly suffice, but the drug may be required in two or three times this quantity, and such large doses have been perfectly well borne. The remedy has also been administered by hypodermatic injection. Urethane is not so potent a hypnotic as paraldehyde, but has the advantage over the latter medicine of not being offensive to taste. It may be prescribed in simple aqueous solu- tion. Edward Curtis. URETHRA, IMPACTED CALCULUS IN. Urethral calculi are usually of renal or vesical origin, although they may be formed in a diverticulum just behind a stricture, or exceptionally in a urethra previously healthy ; they are most frequently found in the deeper parts of the urethra, but occasionally in the penile portion ; they may also be found just outside the urethra, in a sac which communicates with it by a small opening. When they are of renal or vesical origin, they are usu- ally composed of uric acid or oxalate of lime ; when formed in the urethra they are phosphatic. They may be formed about a nucleus that has been introduced from without, has found a resting place in the urethra, and has then taken on a covering of phosphates ; or a uric acid or other calculus from the bladder, being de- tained in the urethra, will there form a nucleus for a fur- ther deposit of phosphates. In size they may vary from a few grains up to several hundred grains. Mr. W. H. Brown, assistant surgeon to the Leeds General Infirmary, reported in the Lancet of September 24, 1887, the removal from the penile urethra of a stone weighing 265 grains'. They are often round, sometimes elongated, and rarely spindle-shaped. Two or more may be present in the same urethra, when their attrition gives rise to facets. Six separate stones from one urethra, so arranged as to occupy nearly the whole extent of the canal, are pictured by Voillemier. Dr. H. Sentex reported to the Society de Chirurgie, through Dr. P. Reclus, an interesting case of multiple cal- culi in the urethra. The patient, thirty-five years of age, expelled many stones following attacks of nephritic colic, passing fourteen in three months. lie had a stricture, not very tight, and after this had been forcibly dilated, the sound was felt to pass over solid bodies. The rectal touch made out in the prostatic region an elongated cylinder, hard and irregular, pressure upon which gave rise to a sort of crepitation. A perineal incision allowed the re- moval of thirty-two facetted calculi weighing together fifty-two grammes. There were no calculi in the blad- der ; recovery was perfect. Calculi in the urethra may occur at almost any age, but are perhaps rather more common in children than in adults. They occur with greater frequency, of course, in the countries where vesical calculi are most frequent. In those cases in which the stone enters the urethra from the bladder, the symptoms may come on suddenly, and consist of severe pain and difficulty in passing water, or even complete retention. The shape and size of the stone will determine the character of the symptoms ; if the stone is smooth and round, and of a size to just fill the urethra, the patient may not be aware of the cause of his inability to pass water. If the stone is irregular, as when the calculus is a fragment left over from a litho- trity, the pain may be very great, even if the retention is not complete. In adults there are usually some previous symptoms due to the presence of the stone in the bladder, or a renal colic may have preceded the passage of the 392 Uraemia. Urethra. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. stone through the urethra. In children the sudden check to urination and complete retention is often the first intimation of the presence of a stone. In the case of an adult, who afterward passed his stone spontane- ously, and came into my hands for the removal of a sec- ond stone which completely closed the urethra, the pa- tient claimed that the first stone lay for some time in the urethra in the perineum, and caused him no difficulty except when he sat down. Unless relief is given, extra- vasation is liable to follow, with all its dangers; this is so common a result in children that Bryant says, "Every case of urinary extravasation which I have seen in chil- dren has been due to an impacted urethral calculus," and he reports a case in a child of fourteen months. The symptoms usually indicate clearly the fact that a calculus is arrested in the urethra, and it can commonly be felt by the finger from the outside. In recent cases a metallic instrument will pass down to it and indicate the character of the obstruction by the sound and by the sensation transmitted to the fingers. When the calculus has lain long in the urethra, and the history is obscure, it may not be so easy to recognize it by an instrument in the urethra. If the foreign body has become lodged in a dilatation, or has made for itself a pocket by ulceration, the sound may pass over without touching it. In such cases the pocket usually communicates with the urethra by a comparatively large opening, and may be entered by a sound slightly bent at the end as one bends a probe to follow a sinus. When the stone is not discharged spontaneously through the urethra, it may ulcerate through the tissues and be discharged, leaving behind it a particularly ob- stinate fistula. The following history illustrates the cases of calculi formed in the urethra. It occurred in the service of the late Dr. C. D. Homans, at the Boston City Hospital, in the spring of 1886 ; the patient entered the hospital May 19th, and gave the following history : Fifteen years ago he was kicked at the seat of the present trouble and passed blood for several days; a lump was noticed soon after which gradually increased ; he never passed any gravel, and there is no history of anything like renal colic; his stream was smaller than normal for three years, but six months previously it became very small, and at times his urine was voided by drops ; a blue spot (sloughing) was noticed eleven days before admission to hospital; four days before entrance urine began to come through a small hole in the swelling. On admission there was found, on the left side of the penis, near the peno-scrotal angle, a sloughing ulcer, the size of a silver dollar, on a raised and reddened base, through which the urine came on micturi- tion. On the second day after entrance, while the wound was being washed, a part of the sloughs came away,and with them a hard substance which had been felt in the swelling ; this proved to be a calculus, which was about the size of a pigeon's egg, weighing two hundred and twenty-six grains ; after this all the urine came through the fistula. Several attempts were made to close the fis- tula, but without success. Stones in the urethra grow more slowly than in the bladder. When they have remained a long time in the urethra in contact with the stream of urine at each mictu- rition, they may show a groove along which the water has passed. Urethral calculi often coexist with stones in the bladder. Urethro-vesical calculi are sometimes found, the stone projecting into the bladder while fixed in the membran- ous and prostatic urethra. Prostatic calculi deserve men- tion under a separate head. If the stone can be made to pass the urethra without too severe manipulation, it ought to be extracted by the meatus, which may be incised to make room. When the calculus is situated near the meatus some of the older writers, Fabricius de Hildanus and others, rec- ommended suction by applying the lips to the glans, and the method was said to be very successful. Voillemier suggests that the pressure of the lips was probably of more service than the suction. Occasionally the stone may be discharged with the urine, if its position is changed by an instrument passed down to it. Possibly the injection of oil would assist. A patient of my own, with retention from impacted cal- culus, passed his urine, and with it the stone, as soon as he was etherized with a view to an operation. Usually it will be necessary to seize the stone with a long, slender pair of forceps. Various forms of urethral forceps are made for such cases, but any forceps may be used. Of course, all instrumentation should be done with the greatest care to avoid injuring the urethral mucous membrane. A very ingenious articulated curette is that which bears the name of Leroy d'Etiolles. It is so con- structed that it may be introduced as a straight, instru- ment and its extremity passed beyond the stone, when by a screw the extremity is bent at right angles to the shaft. Whatever instrument is used within the urethra, very valuable assistance may be rendered by manipula- tions from without. Occasionally it may be necessary to break the stone within the urethra. This may be done by a stout pair of forceps, but straight lithotrites for use in the urethra exist. If the stone is situated in the perineum, it is a simple matter to remove it by a perineal urethrotomy. If the stone has but recently taken up its abode in the urethra the wound ought to heal without difficulty. It is only when it is allowed to ulcerate its way out that permanent fistula in the perineum need be feared. Dr. Dunlap, of Danville, Ky., reports a case in which perineal urethrotomy was done three times in little more than two years, for stones impacted in the urethra, in a boy aged eleven years at the time of the first operation. When the first stone was extracted others were found in the bladder, but the parents would not permit their re- moval. 1 When the stone is deeply seated in the urethra the wisest course is often to push it back into the bladder and crush it there. Abner Post. 1 American Practitioner, 1882, vol. xxvi., p. 341 ; Annul, des Mal. des Org. g6n. urin., i., p. 261. URETHRA, STRICTURE OF THE. A stricture of the urethra is simply a diminution in the calibre of the urethral canal in a limited portion of its extent. The calibre of the urethra may be diminished by various mor- bid conditions, as by external growths that press upon the canal, and by abnormal growths in the prostate ; but such cases are not to be considered as stricture in the or- dinary use of the term. Strictures are described as spasmodic, organic, and traumatic, according to their causation. A spasmodic stricture is the partial or total closure of the canal by the spasmodic action of the muscular fibres surrounding certain parts of the urethra. An organib stricture is the result of inflammatory ac- tion. A traumatic stricture is a diminution in the size of the canal as the result of injury to the urethral walls. Spasmodic Stricture.-A temporary contraction of the urethra may be the result of a purely reflex act, un- controllable by the will, and sufficient to absolutely pre- vent the escape of urine. It is always met with in the deeper portion, where the muscular bands are most num- erous. As an isolated event in a healthy urethra it is probably rare. It is usually a result of some local lesion which acts as an exciting cause of spasm. Spasm is also said to be the explanation of the varying size of the ure- thra in patients with organic stricture. Otis and others believe that stricture of the anterior portion of the urethra is often accompanied by persist- ent spasmodic narrowing in the deeper portions. Such a condition is often mistaken for organic stricture near the bulbous portion, if a small amount of narrowing near the meatus has been overlooked and only the spasmodic contraction discovered. Spasmodic strictures ought to disappear at once under ether. In looking over the accumulated notes of many cases of stricture at the Boston City Hospital, it is noticeable that quite a large number of the cases have, early in their history, had a retention which was called spasmodic, 393 Urethra. Urethra. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. which allowed the use of a fair-sized catheter. This connection of spasm with a slight contraction, which af- terward becomes a marked contraction, is illustrated by a case of Thompson's.3 A policeman, with a slight or- ganic stricture, habitually went on duty early in the morning, and in winter suffered from cold ; at that part of the day his stricture was most troublesome. When he became warm his trouble vanished. After a time he had an attack of complete retention on one of these cold mornings, and his stricture became permanently nar- rower. Spasmodic contraction of the urethra, causing reten- tion, is particularly common after any sudden injury in the neighborhood of the anus, especially after operations for piles. Organic stricture is the only variety of urethral oc- clusion to which the name of stricture is applied by many writers ; it represents a permanent contraction, the result of inflammatory action. The forms of organic stricture, as seen from within the urethra, vary very much. One of the simplest is that of a single fold of mucous membrane obstructing a segment of the canal. Occasionally a free band extends from side to side. These are generally supposed to be formed by a band of lymph which has glued together the oppos- ing walls of the urethra and afterward stretched. Sir Henry Thompson suggests that some, if not all, of these bands are detached portions of mucous membrane due to the passage of an instrument beneath-in fact, short false passages made by the penetration of an instrument beneath the mucous membrane, and its return to the urethra almost immediately. Examples are found in which the stricture presents such an appearance as would be shown had the canal been encircled by a cord. Such strictures are called annular strictures. In most cases of confirmed stricture the coarctation is surrounded by, or rather is due to, more or less indura- tion of the spongy tissue. The opening of the urethra is not always central, the induration being in some cases greater on one side than it is on another. Not infre- quently the opening is not at the lowest point of the canal, but is situated at one side of the urethra, a blind pouch existing below it. This condition is often, if not always, the result of instrumentation, the instrument missing the opening gradually produces the cul-de-sac beyond. In very rare cases a cicatrix may be found, around which the mucous membrane is puckered in lines radiating from it, the amount of contraction correspond- ing with the previous loss of substance. Stricture is seldom the result simply of cicatrization. It is usually due to the formation of a new product of a slowly contracting nature in the deeper, that is, the sub- mucous, tissues. The corpus spongiosum immediately around the stricture may be converted into a fibrous mass, in which there may remain hardly any appearance of spongy tissue. This new product is seen during life in external operations on strictures in the perineum. When the peri-urethral tissues surrounding a stricture in the perineum are cut through, a dense fibrous structure, which resists stoutly under the knife, is divided. This fibrous tissue is seldom so deposited as to make the dim- inution in the calibre of the urethral canal abrupt. The coarctation gradually approaches its tightest point, so that its conformation resembles somewhat that of an hour glass-an enlargement on each side of a constriction. Behind the stricture the urethra is often much dilated. Sometimes this enlargement is sufficient to be quite noticeable when the patient passes water. Sir Benjamin Brodie relates a remarkable and exceptional case, in which the urethra was so dilated that a tumor as large as a small orange presented itself in the perineum when the patient passed water, a condition which may occa- sionally be taken advantage of, when a stricture is im- passable to instruments, to open the urethra behind the obstruction. The mucous membrane behind the stricture often pre- sents a number of longitudinal folds which converge toward the stricture. Superficial ulceration is also com- mon at this point, but is not invariably present. It is from this portion of the urethra that the gleety discharge that accompanies stricture is derived. The pouching and ulceration are both to be attributed to the pressure of the urine, which, hindered in its passage by the nar- rowing in front, expends its force upon the urethra be- hind the obstruction. Stricture of the urethra of long standing is almost in- variably followed by hypertrophy of the bladder-walls. This is a true hypertrophy rather than dilatation, though dilatation is sometimes present. There is usually a dim- inution in the size of the bladder, its capacity being often reduced to a very small amount. The bundles of mus- cle on its inner surface are hypertrophied, and stand out like the column® carne® of the heart. Sacculi in the bladder-walls, formed by protrusions of mucous mem- brane between the bundles of muscular fibres, are not un- common. In cases of long continuance, in which the hindrance to the escape of urine is marked and partial retention re- sults, the bladder is affected with chronic inflammation of its mucous membrane. Post mortem, its mucous membrane is thickened and of an ashy-gray color. The swelling of the mucous membrane, and the hypertrophy of the muscular fibres, block the orifices of, and cause important changes in, the ureters. They become tortu- ous or pouched and greatly dilated, and these changes extend to the pelves of the kidneys. The urine in these diseased ureters and pelves is ammoniacal and horribly fetid. Changes in the kidney are caused by the back- ward pressure of the urine dammed up in the pelves, ureters, and bladder. The kidneys are softened and en- larged, the calyces dilated, the pyramids flattened, and the cortical substance thinner than in the healthy organ. Any septic process set up in the bladder is sure, sooner or later, to be transmitted along the dilated ureter, and as a consequence free suppuration is set up in the calyces and pyramids, until in many cases the latter are almost completely destroyed and the whole organ is converted into an abscess (pyelonephritis). Cardiac hypertrophy and dilatation is a well-known sequence in chronic renal disease of non-vesical origin. Mr. E. Hurry Fenwick finds in the post-mortem records of stricture cases at the London Hospital ' ' a frequent correspondence in the de- scription of the pathological conditions of the muscles of the bladder and heart. Thus, ' Bladder : hypertrophied and dilated ; ureters : dilated and thickened ; heart: hy- pertrophied and dilated.'" The vesicul® seminales are also found dilated in cer- tain cases. In the autopsy records of the Boston City Hospital I find one case in which the vesicula on the right side was enlarged to the size of a filbert, that on the left to the size of an English walnut. The larger one showed trabecular walls and contained a muco-puru- lent fluid. The internal sphincter ani may become enormously hy- pertrophied as a result of the effort to prevent the escape of f®ces during the violent expulsive efforts made to ex- pel the urine. The recto coccygeal muscles may also be enormously developed. External and internal piles may be present in certain cases.1 Traumatic Strictures.-When the urethra is lacer- ated or in any way wounded, it seldom, if ever, heals without some diminution in its calibre. Probably the only exception to this rule occurs in the case of clean, straight longitudinal incisions, such as are made by the surgeon in lithotomy or urethrotomy. Of course the character of the coarctation depends upon the severity of the injury, but, as a rule, traumatic strictures constitute the most difficult class. The urethra is most often rupt- ured in the perineum, but the accident may occur in any part of its course. A fall astride a bar or some sim- ilar object is a frequent cause of the injury. Slip- ping through ladders, falls upon carriage-wheels when mounting or dismounting, or from the rigging of a ves- sel and alighting across a spar, are instances of these in- juries. A blow from the pommel of a saddle produces the same effect. H®morrhage from the meatus, often quite profuse, shows that the urethra has been injured. Retention often occurs, and catheterization may be very 394 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. U retlira. Urethra. difficult. Urinary infiltration is exceedingly common after such injuries, and symptoms of stricture appear within a few weeks. Injuries which cause fracture of the pelvic bones often produce laceration of the urethra, although the external force has not come in direct contact with the urethra. The forcible usage of instruments within the urethra is also occasionally the cause of injury which results in stricture from cicatrization. During the Civil War, in the "eighty-three reported cases of recovery from shot injuries of the urethra, stricture was an almost uniform, if not inevitable, re- sult." 12 Strictures of Large Calibre.-For several years Dr. F. N. Otis, of New York, has taught that the normal cali- bre of the urethra is an individual peculiarity, and not a fixed matter for all mankind ; that the calibre of the urethra is much larger than has been previously supposed, and that deviation from the normal individual calibre toward a smaller calibre constitutes stricture, although the stricture may allow the passage of an instrument larger than the size previously considered a standard, and although such stricture deviates but slightly from the calibre of the rest of the urethra. Dr. Otis believes that a constant relationship exists between the circum- ference of the penis and the diameter of the urethra. That relationship is as follows : When the circumfer- ence of the flaccid penis is three inches, the circumfer- ence of the urethra is at least thirty of the French scale, and each additional eighth of an inch in the circumfer- ence represents an increase in the urethra of one size of the French scale. Dr. Otis affirms as a most important axiom, that the slightest abnormal encroachment upon the calibre of the urethral canal, at any point in its course, is sufficient to perpetuate a urethral discharge, or even, under favoring circumstances, to establish it de novo without venereal contact.13 Strictures at the Meatus.-Aside from congenital nar- rowing, strictures at the meatus are quite frequent. They are most often the result of ulceration. Chancre and chancroid may leave behind them cicatrices at the meatus which cause a very sensible hindrance to the flow of urine. The induration of a primary syphilitic sore at the meatus may cause nearly complete retention, the effects of which will be marked during its continuance, but which will disappear under the administration of mer- cury. Occasionally stricture at the meatus is due to the re- moval of a slice of the glans, including the meatus, dur- ing the rite of circumcision. These strictures deserve special mention because they are liable to be overlooked, especially if hidden beneath a tight prepuce. No attempt should be made to dilate them. Cutting is the only remedy. Symptoms.-The progressive changes in the urethra which result in the formation of a stricture often go on with symptoms of so slight a character that for a long time they entirely escape the notice of the patient. This is sometimes due to the disregard by patients of matters which would attract the attention of a physician, but often because the symptoms are really ill defined. A slight discharge characterizes the earliest stage of most strictures. Sometimes this is just sufficient to ap- pear at the meatus, or it may be so slight as to show itself only by the presence of shreds in the urine. The retention within the urethra of a small amount of urine, which dribbles out gradually after micturition and soils the clothes, is an early symptom in many cases. It is usually explained on the supposition that the urine is retained in the enlarged urethra behind the strictured portion. This is undoubtedly the true explanation in the late cases, in which the calibre of the stricture is decidedly small, and the enlargement behind it well marked ; but the dribbling is present in some cases in which the calibre is but slightly diminished. The urethra, when it has simply lost its elasticity, fails to contract, and thus retains a certain amount of urine which gradually flows out. Frequency of micturition is often a prominent and early symptom, and is not uncom- monly for a long time the only symptom that attracts atten- tion. While often marked, it may find its only expres- sion in causing the patient to rise at night or very early in the morning. As the calibre of the urethra diminishes, the size of the stream of course decreases, and at length the diminution in size becomes noticeable; but a very marked diminution is necessary to bring it absolutely to the notice of the patient. Some patients seem actually unaware of any change going on in their urethras until actual retention occurs. Increase in the time necessary to empty the bladder seems to make a greater impression upon the strictured individual than does the increased effort required. In patients with well-marked, or even moderately devel- oped stricture, any exposure to cold and wet, or unusual indulgence in stimulants, or even an unusually good din- ner, is liable to be followed by an absolute inability to pass water. If the retention remains complete, the blad- der gradually distends and the patient's sufferings are very severe. If left without surgical assistance the stricture may relax sufficiently to allow the passage of a few drops at a time, or the bladder may fill and give rise to the false incontinence of overflow. When relief is not found in this way, rupture at last takes place. Rupture of the bladder itself is quite rare ; it is more common into the cellular tissues in the perineum behind the stricture, giving rise to extravasation of urine. The time which may pass with complete retention before rupture takes place must vary very greatly. Even when the retention is but temporary, each attack leaves the stricture in a somewhat worse condition than before. At last the urine is habitually discharged in drops, and at length the patient loses power to retain it. Such a patient suffers from excoriation, and his clothes are soaked with urine and exceedingly offensive. When the stricture is small enough to cause a notable hindrance to micturition, feverish attacks and chills oc- cur in some persons. Chills accompanying a stricture are not infrequently referred to some other cause. They occur w'henever the stricture is aggravated in any way. They often denote some complication or effect of the disease, but they also occur when no special reason can be given for them. They are specially prone to occur in patients who have lived in malarious districts, and in such individuals an abscess or other concomitant of the stricture is easily overlooked. Many patients have a rigor every time an instrument is passed, and operations on strictures are exceedingly liable to be followed by rigors. A rise of temperature, with the general pheno- mena of fever following the introduction of an instru- ment into the urethra, is known by the special name of urethral fever. Various reflex phenomena occur in cer- tain patients with stricture, and are relieved by its cure. Such symptoms are particularly pains in the lower ex- tremities, in the testicles and other parts of the body, frequent micturition, and various defects in the genital functions.9 Epileptic attacks and other serious troubles occasionally have a similar origin.10 There are several occasional and remote results of stricture which must not be omitted in an account of the disease. As a result of the straining, hernia is said to occasionally occur. This is a fairly well-established result, in children, of the straining due to a tight phi- mosis, and it is logical to expect the same result from a tight stricture lower down in the urethra. A man may be rendered sexually incompetent. Oc- casionally the increase of connective tissue is so great, or is so situated, as to prevent erection ; in other cases erection takes place, and the reproductive function is properly performed, but the semen is not ejected until the organ has regained its flaccid condition, when the seminal fluid runs slowly out. The enlargement of the stricture is followed by improved ejaculation.1 Diagnosis.-Perhaps nothing is easier than the recog- nition of a well-marked stricture, and still there is often a difference of opinion as to the existence of stricture in a given urethra, arising sometimes from differences in the conception of stricture, sometimes from faulty methods 395 Urethra. Urethra. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. of examination. In many cases the history will deter- mine the diagnosis, but usually an instrumental examina- tion is necessary to confirm it. On the other hand, the patient occasionally misleads the doctor by his story, ab- solutely denying any local ailment, and at the present day placing all the blame for his troubles upon his kid- neys. With the patients whose stories are misleading, much trouble may be saved if the physician follows the rule of making his patient pass his urine before him. The fact that the passage is constricted may be ascer- tained by the passage of any instrument that is larger in calibre than the stricture itself, but the information so gained is comparatively slight. The conical instruments usually employed in the urethra will pass slightly con- stricted portions without giving any sign, or, if arrested while passing through, they do not give very accurate information as to the size or situation of the stricture. More accurate knowledge is obtained by the bullet or acorn-tipped bougie-the bougie d boule of the French -which consists of a spherical or acorn-shaped bulb mounted on a slender stilet. The instruments are con- structed of steel, or material similar to that used for elastic bougies, and of graduated sizes. Such instruments were used by Sir Charles Bell as early as 1807. His in- struments were spherical; the acorn-shaped bulb has the advantage of defining by its more abrupt shoulder the lower boundary of the stricture. In using the bougie d boule, one is chosen which just enters the meatus ; this is passed gently down the urethra until an obstruction is met ; a smaller instrument is then entered in the same way, and if necessary a smaller one still, until one is found that will pass the obstruction, which it usually does with a little catch. It is then gently withdrawn, and on the return the shoulder will catch at the posterior border of the constriction ; it may then be passed below the first stricture, and if another stricture of the same size, or narrower, exists below the first, it will be defined in the same way. If the stricture is definitely and abrupt- edly distinguished from the normal tissue, it is very easy to mark it out in this way ; but where, as is usually the case, the contraction is a gradual one, it may require some delicacy of touch to mark out its limits. It is seldom necessary to pass an acorn bougie into the bladder. If it seems advisable to do so, the proper curve may be given to a metallic instrument, but it is usually best to use a blunt steel sound in entering the bladder. Of course, with these instruments no stricture of larger calibre than the meatus can be defined. When the me- atus is quite small, it is necessary to incise it, or to have recourse to an instrument which expands within the urethra, after passing the meatus, by means of a screw at the handle. Such an instrument is known as a ure- thrameter. It is introduced closed as far as the bulb, and is then slowly expanded until the patient complains of a sense of fulness. As it is withdrawn it will indicate the narrowed portions by the same sort of a catch that the acorn bougie gives. Bougies are also figured by Sir Henry Thompson, with a projection like half a sphere or acorn upon one side only, to locate the strictured portion as to the position it occupies on the urethral circumference. In many cases it is possible to locate the stricture by the finger on the outside, especially when an instrument is in the urethra. The anterior limit of the first stricture may be located by passing through the meatus the largest blunt-pointed steel sound that will enter it, and continuing it down to the point of obstruction, then completing the examina- tion with the bougies d boule. It is no useless play to make out the number, the situ- ation, the extent, and the size of the strictures, since treatment is exact as our knowledge of the difficulty is exact. If the case is to be submitted to urethrotomy, it is absolutely necessary to know where to cut. The greater precision we can give to an operation, the more advantage we may expect. Causation.-Anything which causes a profound dis- turbance of the lining of the urethra may be followed by stricture. By far the most common cause is gonorrhoea. Over eighty per cent, are traced to this cause in the sta- tistics of prominent authors. But it is far from correct to suppose that gonorrhoea is the only cause capable of producing such a result. It is a popular belief that in- jections cause stricture, and in some cases it may be true. Injections of ordinary strength are doubtless harmless so far as any direct injury to the urethra is concerned ; but occasionally we meet a patient who has had recourse to an injection strong enough actually to destroy the mu- cous membrane, and that stricture should result in such cases is not surprising. The nozzle of the syringe may be a cause of extreme irritation and consequent stricture when used roughly, or when allowed to become irregular and jagged. When glass syringes, with long nozzles, were more frequently used in the treatment of gonorrhoea than at present, it was not very rare to see a patient with a broken-tipped syringe, and to hear him acknowledge that he occasionally drew blood by its use. The use of the syringe with extra long nozzle presents increased dangers in this respect. The fact that injury may be done by the improper use of syringes is not, however, an argument against their proper use. Cases are occasionally met with in which, judging from the history, it seems fair to believe that the im- proper use of some urethral instrument has caused a traumatism which has given rise to the very condition of stricture it was intended to prevent. Mr. Distin Mad- dick, in a recent book,29 lays special stress upon this point. Self-abuse is considered an occasional cause of strict- ure by such good authorities as Gross and Bumstead and Taylor. If the following history can be believed, it presents an entirely exceptional causation. A sailor fell into my hands, with a urethral discharge, in 1874. He had never had a gonorrhoea until a very short time previous to my seeing him. Some years before he had had a severe case of scurvy attended by various haemorrhages, among them a decided flow of blood from the urethra. Examination showed a marked stricture a short distance within the meatus, which there was every reason to suppose must have originated long before the urethral discharge then existing. In a history which was apparently perfectly frank, no other cause save the scurvy could be found. In looking over the records of cases of stricture at the Boston City Hospital, the number of cases in which both gonorrhoea and traumatism antedate stricture is quite marked. Situation.-Sir Henry Thompson carefully measured the seat of constriction in various museum preparations, and found sixty-seven per cent, in the region which he de- signates as the sub-pubic, and seventeen per cent, at the meatus or in the two and a half inches behind it. On the other hand, Otis, measuring on the living subject, found 163 within two and a fourth inches from the mea- tus, out of a total of 258, or sixty-three per cent. The different methods of examination, and the differ- ent ideas as to stricture held by these two gentlemen, go far toward explaining the discrepancy in these figures. It must also be remembered that the section of the urethra, to display the specimen, destroys the contraction in cer- tain cases, as pointed out by Voillemier. In the third revised edition of his book on " Stricture," Sir Henry wrote: "If a No. 8 (English) bougie passes easily into the bladder, we may be satisfied that no strict- ure, or at most a very slight contraction, exists." In the fourth edition, 10 is substituted for 8. The opinions of Dr. Otis, in regard to strictures of large calibre, have already been given. Prognosis.-We may consider strictures as to their ef- fect upon life, and as to the curability of the local le- sion. If untreated, strictures gradually become more and more narrow and their consequences increase in severity, until death results either by extravasation or by degen- eration and acute inflammation of the kidneys, septicae- mia, pneumonia, or cardiac disease. A very important point in prognosis is the extent to which the kidneys 396 Urethra. Urethra. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. have suffered, a matter by no means easy to determine in every case. Some evidence of their condition can be gained by careful examination of the urine, noting the quantity secreted and the amount of urea and albumen, even when the amount of pus makes microscopical ex- amination difficult. The condition of the heart ought also to be considered, as it is affected by renal disease of vesi- cal origin. Mr. E. Hurry Fenwick8 has recently drawn attention to the amount of residual urine in cases of strict- ure as of value in estimating the damage to the kid- neys, by showing the amount of pressure the kidneys have been working against. It may be safely assumed that five ounces of residual urine, which is probably near the average of unreleased narrow strictures, would indi- cate sufficient damage to cause anxiety as to the effects of any intercurrent inflammation or disease ; while an amount over ten ounces would make us cautious in op- erating for stricture by internal urethrotomy, and in giv- ing anything but a grave prognosis of the ultimate ef- fects of the constriction. The behavior of the bladder, in its progress in regaining the power to completely empty itself, will teach us much as regards the future course of the case. As to the local lesion, we may safely say that some strictures are curable. There is fairly conclusive evi- dence that some recent strictures are occasionally cured by gradual dilatation, though evidence of the actual cure of old and inveterate strictures by such means is thought to be wanting by most writers. In either internal or ex- ternal urethrotomy, if the lesion is curable, the success of the operation must depend upon the complete division of all the strictured tissue. Both Dr. Otis and Mr. Syme believed stricture curable by their favorite operations, and each dwells upon the necessity for actual division of every constricted fibre. Their followers may not suc- ceed in every case, but in a fair proportion of cases cure is possible if the proper means are used. But the term stricture is applied to lesions of very varying severity, from the single little bridle to a mass of cicatricial tissue which embraces a large extent of the urethra. Of course these varying conditions offer widely different opportunities for curative measures. Occasion- ally cases show themselves in which restoration of the urethra is impossible, and only palliative measures, and possibly only a perineal fistula, can be expected. Treatment.-Before proceeding to consider the local and instrumental treatment of stricture, it is but right to say a few words on the general or constitutional treat- ment. It is a fact too often overlooked, that a stricture may be rendered nearly innocuous, or a source of con- stant trouble and danger, according to the manner of life a patient adopts. Exposure to cold and dampness, alco- holic indulgence, and other irregularities tend to aggra- vate a stricture ; while, on the other hand, regularity of life, unirritating food, freedom from alcohol, an equable temperature, all tend to preserve the stricture at its wid- est calibre. Patients on whom no catheter can be passed, and who are threatened with retention, or in any way are suffer- ing from their stricture, need to follow certain general rules. They should stay in the house, and, if symptoms are severe, in bed ; the bowels should be made to operate every day; a hot bath of ten minutes, in water of 100° to 110° F., should be taken once a day. The diet should be simple but nourishing, and should consist in great meas- ure of milk. For drugs an opiate may be given at night, and tincture of the chloride of iron during the day. The value of the latter drug it is difficult to estimate, as it is never used without at least general hygienic measures in ad- dition ; but it may do some good, and is not likely to do harm. The methods of treating strictures are numerous, and the partisans of different methods, influenced sometimes, it is to be feared, by prejudice, are very zealous in the championship of their chosen means. The treatment must vary with the character of the stricture, its situa- tion in the urethra, and the condition of the patient. It is by no means always an easy task to decide just what is the best course in a given case, and surgeons may honestly differ. One reason for difference is the diffi- culty of deciding upon the value of different operations and methods of treatment. The methods in vogue at the present day may be classed under the following heads : Dilatation by bou- gies ; forcible stretching or rupture by instruments made to enlarge while lying in the urethra ; internal urethrot- omy ; external urethrotomy ; and galvanism. Caustics and forced catheterism are methods now obsolete. These various methods may be variously subdivided, and two or more different methods may be united upon the same subject. Gradual dilatation must, for many reasons, be the com- mon method of treatment. Many cases do well enough with it, and it is, generally speaking, the method least likely to do harm. If not always as brilliant in its im- mediate results as more distinctly operative methods, it has the advantage of offering a minimum of risk, and usually of allowing the patient to pursue his ordinary avocation. It is also of service in cases where other pro- cedures are finally necessary, in so far enlarging the calibre of the urethra as to reduce the traumatism of a subsequent operation to a minimum. Certain cases must also be treated by dilatation, when both physician and patient acknowledge that other methods are, in themselves, preferable. In certain cases, when only a small bougie can be en- tered, and that with difficulty, or when the attempts to pass a bougie have long been fruitless, but have at last succeeded, it is the best course to resort to continuous dilatation, by tying in the instrument. This method is of but limited application, however. While it works most satisfactorily and rapidly up to a certain point, the continued presence of the instrument in the urethra is a source of irritation not infrequently causing chills and general constitutional disturbance ; and, even when not followed by constitutional symptoms, the presence of a foreign body in the urethra causes suppuration in the canal, and its beneficial effects are usually not lasting. It is chiefly of use in tight strictures, as a temporary ex- pedient. But cases occur in which treatment by bougies is ab- solutely ineffectual so far as any permanent benefits are concerned, and others in which the passage of any instru- ment into the urethra is absolutely harmful, so that some other method must be adopted. In stricture at the meatus no other procedure than the use of the knife can be allowed. The tissue to be divided is directly under the surgeon's eye, and nowhere else than at the meatus would one think of anything but an incision under similar circumstances. Some other mode of treatment is advisable : In strict- ures of large calibre which keep up a constant slight discharge, and are attended by a constantly recurring acute urethritis, in spite of systematic and careful dila- tation ; In cases where the gentlest interference by bougies is followed by rigors; In resilient stricture; In impacted calculus behind a stricture ; In some cases where time is an object, and perhaps in the catheter-life of elderly men, where the stricture pre- vents the passage of a fair-sized instrument; And in some cases where the stricture is attended by an obstinate fistula. As to the choice of operations in such cases as have been enumerated, surgeons would honestly differ. The choice will be influenced by the situation of the strict- ure. When situated in the penile urethra, the choice will lie between internal urethrotomy and divulsion. Statistics show little difference between these two opera- tions so far as danger to life is concerned, nor is their relative value fully settled as to the ultimate results, save so far as the opinion of surgeons can settle it. So that in this matter it seems necessary to rely upon general principles. Unless there is some weighty reason to the contrary, a single straight incision is always to be pre- ferred to a chance rupture when the object to be obtained 397 Urethra. Urethra. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. is the formation of a smooth, non-contractile cicatrix. And as this is true within the urethra as w'ell as without, it leads to a choice of internal urethrotomy. But in the deeper urethra, when the stricture is situated in the region of the perineum, the conditions are somewhat al- tered. Internal urethrotomy done in this region pre- sents dangers which do not exist, or are exceedingly small, in the anterior part of the urethra ; and external urethrotomy, which is impossible in the anterior portions, or at least unadvisable, because of the incurable nature of the fistula left behind, presents here great advantages. There is a tendency to leave external urethrotomy to the most desperate cases, and hence to regard it as a desper- ate remedy. The operation, in a healthy adult, done with proper precautions, is not one of great gravity. The result is usually good and the recovery speedy. But patients very naturally object to such an operation if something apparently less severe will give good results. Divulsion certainly has some claims to favor in this part of the urethra. If every case could equal one de- scribed by Dr. A. T. Cabot, it should be the first choice. His patient died twelve or fourteen days after divulsion, from a cause unconnected with the urethral disease, and autopsy showed that the forcible rupture had been confined to the submucous tissues, as no sign whatever of injury to mucous membrane was visible.15 The immediate results of rapid dilatation and divul- sion are certainly brilliant, but there is good ground for believing that the results are less durable than those of external urethrotomy. It must be recognized that strict- ures differ widely from each other in severity and in be- havior under treatment. It is impossible to mark out a single line of treatment which shall be invariably appli- cable. The severest cases will require on the part of the surgeon the utmost skill, knowledge, and fertility of re- source. With these general remarks as to the choice of methods, the different procedures will be treated sepa- rately. Gradual Dilatation.-When an instrument can be passed through a stricture it is generally possible, by care- ful and well-directed efforts, to introduce at successive sittings a succession of larger instruments so as to dilate the contracted portion of the canal to its natural capacity or near it. The process thus accomplished has been called naturally, but unfortunately, dilatation, since this name conveys the idea of a purely mechanical effect. But it should be remembered that while the cause of stricture is cell-proliferation, relief is afforded by the op- posite action of absorption and that the beneficial effect of dilating instruments depends upon their exciting such a counteracting agency on the living tissue.4 The object to be attained by the successive introduc- tion of bougies of gradually increasing size is not so much the mechanical operation of stretching and dilat- ing as the setting in operation of the absorptive powers of nature. There can be no doubt that the mechanical dil- atation is an important factor-indeed, the only factor- in the immediate results that we see when a fine stream passes after the insertion of a bougie through a stricture that a moment before refused to permit any water to pass; but the surgeon who looks upon dilatation as pure- ly mechanical will not reach the best results. Bougies may be used as divulsors-forcibly passing in one that is too large to pass the stricture without split- ting it. Their use for this purpose may be a perfectly legitimate one in exceptional cases, but they are not the best instruments for rapid dilatation. To pass every day, or every second or third day, a bougie which requires ac- tual force for its passage tends not to promote absorp- tion but to set up irritation. It is not very uncommon to see patients who are made worse by what is intended to be gradual dilatation. Too large a bougie is forced through, and while the irritation is at its height the oper- ation is repeated. Sir Henry Thompson expresses himself most clearly on this subject: "If . . . dilatation be employed by steps sufficiently gradual and with special care not to produce irritation . . . the result will generally be satisfactory, not merely in mild cases but in those of no ordinary severity. But if, while opening the contraction by dilatation, we at the same time irritate unnecessarily or inflame the parts acted upon, we shall at best only af- ford temporary relief to the complaint at the expense of its future augmentation. Employed in this way, dilata- tion is assuredly not a satisfactory method of treating stricture." The instructions of Allingham in regard to the care of stricture of the rectum are worth quoting here to show that the same opinion in regard to gentleness of manipu- lation is held by competent authority in regard to similar ailments in other parts of the body. " . . . it must be remembered that to do any good the greatest gentle- ness must be practised by the surgeon ; indeed, pain ought not to be caused, although considerable discom- fort cannot, in most cases, be avoided. A bougie of too large a size should never be employed ; no greater mis- take can be made than to suppose that the larger the bougie you can get in the better ; keep below the size that can be well borne rather than at all above it ; in the one case good may ensue, in the other irritation and re- trogression are sure to take place." When based upon the ideas here expressed, dilatation is a very different process from that too often pursued. If the calibre and location of the stricture have been made out, a bougie should first be chosen that will pass easily through the stricture-if the stricture is large enough to admit of such a procedure-to be followed by a second which wull practically fill the stricture. When the first instrument has been passed it should be withdrawn to be immediately followed by the second, which should also be withdrawn immediately after its passage. The pas- sage of the smaller instrument oils and opens the way so that the passage of the second is much easier. The retention of the instrument for a few moments or even half an hour is sometimes advised. Ordinarily its retention is not advisable in the early sittings ; later in the treatment, however, if the contraction does not yield to the simple passage, the bougie should be retained for a few moments. An interval of three days should be allowed to inter- vene between the sittings ordinarily, though no invio- lable rule can be laid down as to their frequency. It is more usual to find a patient do better with a longer than with a shorter interval. Twice a week is an interval well adapted to a majority of patients ; some will do better with longer intervals. To accomplish the best result needs a patient who will return at such intervals as the surgeon deems best, and the surgeon must not so far de- scend into routine as to stick to his previously determined interval without regard to the effect of his instrumenta- tion. The instrument should never be passed into the bladder if the stricture is so situated that dilatation can be accomplished without it. To enter a bladder with an instrument that has traversed an unhealthy urethra is to run a certain amount of risk of cystitis. The danger is sufficient to deserve a warning, and to be avoided if pos- sible. Solid bougies should always be chosen for purposes of dilatation, because the eye of a catheter is exceedingly liable to be rough, and also because a catheter gathers pus and impurities, and is not, for that reason, a proper instrument to transfer from one urethra to another. For the smaller sizes, the conical French elastic bou- gies are to be preferred. For the larger sizes, the same instruments may be used, but my personal preference is for the conical steel sounds. The surface of a nickel- plated sound is much smoother, and passes through a stricture with less friction than the elastic bougie ; its surface, in addition, has no powers of absorption, and is more likely to be perfectly clean. The patient usually gives the preference to the steel sound, in my experience, after he has felt both. As for the liability to do violence to the urethra, it is possible to use either in such a way as to do harm. Both should be used with the greatest gen- tleness. Experience has made me feel safer with the steel instruments, as I feel with them that I know the direction the point is taking; if it is going wrong it is my fault. 398 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Urethra. Urethra. Bougies have been constructed of material that swells when exposed to heat and moisture, like sponge-tents. Very various materials have been employed for such a purpose, but none has met with very great favor. They certainly dilate temporarily to some extent, but the dil- atation is accomplished at the expense of no little pain and irritation. A fatal objection to their use lies in the fact that the bougie swells most where the opposition is least ; so that if a bougie of this character is passed through a stricture, and allowed to lie in position for a sufficient length of time, it assumes, as it swells, an hour-glass shape, its expansion being least at the strict- ure and greater on each side. Such a bougie is diffi- cult to withdraw without actual violence. Steel sounds are sometimes made so as to expand with- in the urethra. Without personal experience with them, they seem preferable to the bougies just mentioned, but their use would present a constant temptation to forcibly dilate at frequent intervals in a manner that would not be for the permanent good of the patient. When exploration, or the patient's history, gives rise to the belief that a very small stricture exists, nothing will give so great an amount of information as the actual sight of the patient as he passes his water. If he actu- ally passes a stream, we may know that the bougie that can pass will be a little smaller than the apparent size of the stream. The smallest of catheters may sometimes be passed through such a stricture, and secured in situ. When the instrument does not pass readily, a syste- matic search for the opening must be entered upon. The instrument should be advanced until it brings up against solid tissue, when it should be withdrawn and again advanced. This manoeuvre should be several times re- peated, the penis being held upon the stretch. These attempts failing, the instrument should be made to fol- low round the circumference until it has made the -at- tempt to advance at all points of the circle. The instru- ment usually advances farther in some places than in others, entering false or blind passages. The bougie- may be left occupying one of these passages, while another bougie is entered by its side, and attempts are made to find the true passage with the second while the first remains in position. In this way successive bou- gies may be entered until the meatus will admit no more. This is a method often successful. As the various false passages are filled, the last bougie takes the true course. The injection of oil until the urethra is dis- tended, and then introducing the bougie, while the fore- finger and thumb of the operator's left hand compress the meatus so as to retain the oil, often affords great assistance. Not only is the passage thoroughly lubri- cated, but the narrow portion may be a little widened by the distention of the canal. Sometimes a bougie will enter immediately after a patient has micturated when it refused to enter before. For the tightest of strictures the whalebone capillary bougies are especially adapted. They are stiff enough, so that the surgeon can control the direction they take. They can easily be made to penetrate the urethral walls, and the surgeon must remember that force is useless un- less the bougie is travelling the right path. Bougies are made with various ends, with curves, with angles and double angles, like bayonets, all of which are sometimes of use ; but for ordinary purposes the straight bougies are preferable. Any shape or curve desired may be given to the whalebone instruments by soaking them in hot water for a moment until they become flexible, when they may be bent, and the desired shape retained by im- mersing them in cold water. When the whalebone in- strument has been passed, it may be used as a guide for the passage of tunnelled instruments, as will be men- tioned under the head of Retention. Internal Urethrotomy.-The term internal urethrotomy is applied to operations widely different in character- operations that barely nick the strictured portion, and those that cut through to the skin ; those done with sev- eral cuts in different parts of the circumference, and those with a single cut; those where the cut is made at random, and those carefully made through the strictured part alone ; those made carelessly with dirty instruments, and those made with all the care of modern antisepsis ; and the results of the operation are compared, no matter in what part of the urethra the different strictures oper- ated upon were situated. Now, statistics of internal ure- throtomies need classification as much as statistics of lithotomies. There is the greatest difference between a harmless operation at the meatus and one at the bulb ; there is also great difference between the operation in a healthy young man and in a man whose kidneys have suffered for years from backward pressure. When internal urethrotomy is determined upon, the variety of instruments is very great. None offers greater advantages than the dilating urethrotome of Otis. It consists of a pair of steel shafts connected together by short pivotal bars, on the plan of an ordinary parallel ruler, save that the pivotal bars are concealed when the instrument is closed. Its expansion and contraction are effected by means of a screw which traverses the handle. To the screw is attached an indicator, which registers on a dial, in millimetres, the amount of dilatation which is being effected. The upper bar is traversed by a steel wire, at the extremity of which is a thin blade which is concealed in a slot at the end of the upper bar. In use, the distance from the meatus at which the stricture is situated is accurately determined. This distance is measured on the instrument from the heel of the con- cealed blade, and marked by an elastic band. The ure- throtome is then introduced into the urethra with the blade concealed, until the rubber band is partly within the meatus. Then the screw at the handle is turned gradually until the hand on the dial marks two milli- metres beyond the normal breadth of the urethra, the blade is drawn completely through the breadth of the stricture, and pushed back again into its place of con- cealment. "Expand the instrument a millimetre or so farther, and if there is no sense of resistance, the strict- ure is probably divided," is Dr. Otis's direction. Of course, with this instrument no stricture can be divided which is not large enough to allow it to pass. The in- strument is of a size equal to 12 or 14 French calibre. When the stricture is too small to permit the use of the Otis urethrotome, and cannot be brought up to it by gradual dilatation, it is necessary to have recourse to some instrument which cuts from before backward, like that of Maisonneuve. This instrument consists simply of a grooved staff which need not exceed No. 7 of the French scale, provided at its extremity with a screw point, to which may be attached a filiform bougie. In the groove slides a blade, triangular in shape, sharpened before and behind, but surmounted at the point by a knob. This blade is expected to pass healthy mucous membrane without wounding it. Some of these instru- ments are grooved on the convexity, some on the con- cavity. In use, the flexible conductor is first introduced, the staff is then screwed upon it, and both staff and bou- gie are carried along the urethra, the bougie curling up in the bladder. When the staff has passed, the penis is put upon the stretch, and the blade is entered in the groove and thrust down to its extremity, dividing every obstruction before it. This instrument may be construct- ed to travel upon the whalebone bougie by tunnelling the extremity. A tight stricture may also be stretched so as to allow the admission of the Otis urethrotome by the previous use of a dilator, like Thompson's. The principal danger to be apprehended from internal urethrotomy is haemorrhage, which may be controlled by pressure. If the incision is in the pendulous urethra, the spot of the incision may be compressed between a folded towel laid over the pubes, and another over the penis, the whole being confined by a T-bandage. In the perineum, pressure may be made against a crutch cut of proper length, so that the bottom rests against the foot of the bed, and the cross-piece at the top, over which is a folded towel, presses on the perineum. Among the possible complications of internal ure- throtomy, Voillemier describes certain cases in which the borders of the wound remain separated, the interven- 399 Urethra. Urethra. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ing tissue becomes excavated, and a cavity is formed which he designates as a urethral pocket. Rapid Dilatation and Divulsion.-The simplest method of rapid dilatation is by means of large conical sounds, instruments of progressively increasing calibre being successively introduced. This method seems to have gradually lost favor, and very properly. This operation is also performed by introducing an instrument into the stricture which can be rapidly ex- panded in situ. Performed by such instruments it seems to do less damage than when instruments of in- creasing size are made to follow each other rapidly. One of the best known of these instruments is that of Thompson, who used it at first simply as a dilator, tak- ing from seven to ten minutes in reaching the maximum of dilatation ; but the instrument is more efficient as a di- vulsor, employed rapidly to rupture rather than to dilate. This instrument dilates by turning a screw at the handle, which opens its diverging blades. Thompson has him- self ceased for many years to use any form of divulsor. Perhaps the present state of opinion in regard to divul- sion is best given by Keyes, who considers that this in- strument has three important uses. 1. To pass over a whalebone guide in cases of very tight strictures, so as to dilate them moderately in the (a) anterior urethra, in order that the rather large shaft of the dilating urethrotome may be made to pass ; in the (6) deep urethra, in order to make it possible to take up the treatment by gradual dilatation with sounds. 2. To divulse stricture of the deep urethra in the oc- casional cases where that operation seems to be called for, when the patient refuses external section, and a choice lies between divulsion and deep, extensive in- ternal urethrotomy. 3. To pick up and remove small foreign bodies from the urethra.16 External Urethrotomy.-The essential point in an ex- ternal urethrotomy, as in internal urethrotomy, is the complete and accurate division of every fibre of the contracted part of the canal. This is a deliberate opera- tion undertaken to restore the calibre of the urethra, and is an entirely different matter from an attempt to find the urethra without a guide behind an impassable strict- ure, and ought not for a moment to be confounded with it. It is the operation described by Syme, and known by his name. The patient ought to be carefully examined before the operation, that all information possible may be gained as to the situation and extent of the stricture. The patient being etherized, is placed in the lithotomy position. The grooved staff is passed and confided to an assistant, who holds it in the median line. This is an important duty, as to insure success the operation ought to divide the urethra cleanly, so far as possible with a single cut directly in its axis and through every fibre of the constriction. The operator, sitting in front of the patient, makes an incision in the median line down to the staff ; when that is reached the urethra is incised on the staff to the full extent necessary to divide the strict- ure, so that a full-sized instrument will pass without hitch. A catheter may then be introduced into the bladder and tied in through the perineal wound. This is not essential, but is often desirable, so that the wound may be packed to prevent the oozing, which may be suf- ficient to require such treatment. Mr. Syme looked upon this operation as a complete remedy for the most obstinate forms of stricture, and as affording a more speedy, safe, and permanent cure for cases of obstinate character than simple dilatation. After the operation, immediate and complete relief from all distressing symptoms is the usual result. The frequent and painful calls to urinate are followed by complete repose. Cases which previously could not be touched with a bougie without chills or distressing symp- toms of some sort, usually bear the operation well. But it must not be supposed that the operation is always en- tirely free from accident. It is sometimes followed by some bleeding, and, like other urethral operations, by chills and constitutional disturbance. In a large pro- portion of cases the final result is permanent. Syme certainly had many cases in which no symptoms re- turned for a long series of years, and many of these cases were known to admit a large-sized sound. So many of these cases do well permanently that when a case re- lapses we are justified in feeling suspicious at least that there has been some failure in the operation itself. Mr. Harrison, in common with a number of surgeons of the present day, looks upon external urethrotomy as present- ing in many cases a complete cure for the complaint. When the stricture is too tight to permit the passage of anything but the smallest of bougies, the operation is somewhat more difficult; but even the smallest guide is infinitely better than none. It is not easy to cut down upon a capillary bougie through an indurated perineum -in fact, it is surprisingly easy to go astray, and the presence of a larger and metallic instrument, passed as far as it will go, is essential to accuracy and rapidity in the operation. The tunnelled instruments are particu- larly serviceable in such cases. The whalebone-capillary having been introduced, the tunnelled staff should be passed so far on it as it will go-presumably until its ex- tremity rests against the anterior face of the stricture. It should then be committed to an assistant, and the patient put in the lithotomy position. The surgeon, seated in front of his patient, makes his external incision from the base of the scrotum to within half an inch of the anus and proceeds inward, having the extremity of the steel sound for his objective. Having reached the urethra, he exposes the extremity of the sound by an incision along its groove. A loop of silk is then threaded through each side of the incision, and the urethra lies open just at the upper extremity of the stricture, with a whalebone to direct the incision through it. Dr. Gouley uses a narrow- beaked straight bistoury, about the size of a small probe (a modification of Weber's knife for dividing the canali- culus lachrymalis), to enter and divide the stricture alongside the capillary. The stricture being divided, the tunnelled sound is carried forward on its w'halebone guide into the bladder. The operation is thus completed with ease and rapidity. Care must be taken during its performance not to divide the whalebone guide. If the tunnelled sounds are not at hand, any metallic instru- ment passed by the side of the capillary will furnish very great assistance. When no instrument can be passed through the strict- ure, the operation becomes one of the most formidable known to surgery. It has been advised to commence such an operation very early in the morning of a long summer's day. The object of this operation is to con- nect the pervious urethra, in front of and behind the stricture, by an incision which lays open the stricture, or follows the proper channel of the urethra as nearly as possible, with the hope that the urethra may be re-estab- lished in healing. For this purpose the catheter was formerly tied in for the urethra to heal over. Mr. Wheelhouse, of Leeds, has described a method of doing the operation which renders it successful in many cases. The principle of the Wheelhouse operation is to open the urethra in front of the stricture to the surgeon's eye, thus giving an additional opportunity to find the opening. The special instruments required are a special straight staff fully grooved through the greater part, but not the whole, of its length, the last half inch of the groove being stopped, and terminating in a round, but- ton-like end, with a slight projection on the side opposite the groove ; a well-grooved and finely probe-pointed di- rector, and Teale's probe-pointed gorget. The patient is to be in the lithotomy position, and the operation pro- ceeds as follows, as described by Mr. Wheelhouse him- self.6 The staff is to be introduced with the groove looking toward the surface, and brought gently into con- tact with the stricture. It should not be pressed much against the stricture for fear of tearing the tissues of the urethra and causing it to leave the canal, which would mar the whole after-proceedings, which depend upon the urethra being opened a fourth of an inch in front of the stricture. Whilst an assistant holds the staff in this po- sition, an incision is made into the perineum, extending from opposite the point of reflection of the superficial 400 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Urethra. Urethra. perineal fascia to the outer edge of the sphincter ani. The tissues of the perineum are to be steadily divided until the urethra is reached. This is now to be opened in the groove of the staff, not upon its point, so as certainly to secure a fourth of an inch of healthy tube immediately in front of the stricture. As soon as the urethra is opened and the groove in the staff fully exposed, the edges of the healthy urethra are to be seized upon each side by the straight-bladed, nibbed forceps, and held apart. The staff is then to be gently withdrawn until the button point appears in the wound. It is now to be turned round so that the groove may look toward the pubes, and the button may be hooked into the upper angle of the opened urethra, which is then held stretched open at three points, and the operator looks into it immediately in front of the stricture. Whilst thus held open, the probe-pointed di- rector is inserted into the urethra, and the operator, if he cannot see the opening of the stricture, which is often possible, generally succeeds in very quickly finding it, and passes the point onward through the stricture toward the bladder. The stricture is sometimes hidden among a crop of granulations or warty growths, in the midst of which the probe point easily finds the true passage. The director is then passed into the bladder and the strictured tissue divided on it. The point of the probe gorget is then passed along the director into the bladder, and the director being then withdrawn the gorget forms a me- tallic floor, which renders easy the passage of a catheter from the meatus into the bladder. Mr. Wheelhouse rec- ommends the retention of the catheter for three or four days. it is very important in this-more important if possible than in other operations for perineal urethrotomy-that the assistant who holds the staff should realize that he is performing a very essential part of the operation. Of course, the forceps which Mr. Wheelhouse uses to hold the edges of the urethra, may be supplanted by the loop of silk so commonly used for the same purpose. Combined Internal and External Urethrotomy. - In many cases the diseased portion of the urethra is too ex- tensive to be all included in the perineal incision. In these cases the internal and external operations may be advantageously combined. Mr. Harrison also combines the two operations with the idea of putting the anterior urethra at rest and keeping it free from the contact of urine after a more than usually extensive internal ure- throtomy. In such cases a drainage-tube is introduced into the bladder, through the perineal opening, to divert the urine-a second drainage-tube may be inserted from the meatus to the perineal opening to maintain the size of the urethra, prevent haemorrhage, and secure drain- age. Cock's Operation.-Cases occasionally arise in which none of the methods thus far described is perfectly satis- factory, cases in which the urethra is practically imper- meable, at least for the moment; in which the perineum is more or less disorganized by abscesses or extravasa- tion ; in which the urine is discharged by fistulae which cause constantly recurring abscesses, and a general condi- tion which puts the patient's life in danger, and in which it is desirable to establish drainage from the bladder as quickly as possible. Such are cases in which there is extravasation, an inability to pass any catheter into the bladder, and a constant distillation of urine through the disorganized tissues of the perineum. In such cases the operation described by, and known by the name of, Ed- ward Cock, Surgeon to Guy's Hospital, is useful. Mr. Cock called the operation "tapping the urethra at the apex of the prostate unassisted by a guide-staff." As Cock's operation seems to be not always properly under- stood, it will be described here, so far as possible, in his own words. The patient is to be placed in the usual posi- tion for lithotomy ; and it is of the utmost importance that the body and pelvis should be straight, so that the me- dian line may be accurately preserved. The left forefin- ger of the operator is then introduced into the rectum, the bearings of the prostate are carefully examined and ascertained, and the tip of the finger is lodged at the apex of the gland. The knife is then plunged steadily but boldly into the median line of the perineum, and carried on in a direction toward the tip of the left forefinger, which lies in the rectum. At the same time, by an up- ward and downward movement, the vertical incision may be carried in the median line to any extent that is considered desirable. The lower extremity of the wound should come to within about half an inch of the anus. The knife should never be withdrawn in its progress toward the apex of the prostate ; but its onward course must be steadily maintained, until its point can be felt in close proximity to the tip of the left forefinger. When the operator has fully assured himself as to the relative positions of his finger, the apex of the prostate, and the point of his knife, the latter is to be advanced with a mo- tion somewhat obliquely either to right or left (as may be necessary to hit the apex of the prostate), and it can hardly fail to pierce the urethra. It is of the utmost im- portance that the knife be not removed from the wound until the object is accomplished ; then the knife is with- drawn, but the left forefinger is still retained in the rec- tum. A probe-pointed director is carried through the wound, and, guided by the left forefinger, enters the ure- thra and is passed into the bladder. The finger is now withdrawn from the rectum ; the left band grasps the director, and along the groove of this instrument the cannula is slid until it enters the bladder.'1 Electrolysis.-A comparatively new candidate for favor in urethral surgery is the treatment of stricture by elec- trolysis. It is not yet possible to pronounce finally upon this method. Its advocates are few, but they are for the most part enthusiastic ; but converts to their opinion are made slowly. Mallez and Tripier22 advocated the use of electricity with currents so strong as to cauterize the stricture. It was intended to destroy by cautery the constricting tis- sue, so that separation of the tissues cauterized followed later in the shape of a circular slough; and it was claimed that the resulting cicatrix had none of that re- tractile tendency which other scars possess. These claims were set forth with great emphasis. They were inves- tigated in America by Keyes30 and in Germany by Dit- tel.20 Keyes's ten cases turned out badly. The treat- ment was painful, and many of the patients refused to submit to it, and even when it widened the urethra, re- contraction took place. Dittel's cases also did badly. This method is no longer advocated, in America at least. With other forms of caustic it ought to be entirely dis- carded from urethral surgery. But the action of an electro-cautery is said to differ entirely from electrolysis. The electrolytic treatment of stricture is specially advo- cated by Dr. Robert Newman, who alleges wonderful success in its use. He published in August, 1885,24 the first table of one hundred cases of permanent cure. His cases became, and remained, permanently well, the cure being proven by examination at varying periods of from three and a half years to eleven years after all treatment had been discontinued. The duration of the disease before treatment is stated to have varied from one to twenty-five years. The strictures were situated at points varying from close to the meatus up to nine inches away from it. The num- ber of sittings required to effect a cure was jive or six, and two or three months about the average time. Newman's second series of one hundred cases of radical cures was published in September, 1887, in the Journal of the Ameri- can Medical Association. Dr. Newman advocates the avoidance of pain, advises that the patient be in the erect position, condemns the use of two electrodes in succession at one sitting, de- nounces the use of force or the employment of the treat- ment when the urethra is even subacutely inflamed, ob- jects to anaesthetics, and states that: " All strictures are amenable to the treatment by electrolysis." He adds that the patients may keep about, that the method re- lieves at once, that it is devoid of pain, danger, or incon- venience, is not followed by haemorrhage, fever, or other unpleasant consequences, and that no relapse takes place. It is impossible to give the details of treatment as insisted upon by Dr. Newman. The references to his 401 Urethra. Urine. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. articles will be found in the bibliography. Many inter- esting researches have been made by other surgeons upon the method of Newman, and he has received a qualified approval from some ; but the majority of those who have recorded their experience fail to agree with him. Dr. William T. Belfield21 draws the following conclu- sions from a series of nine cases: (1) It (electrolysis) is applicable to stricture in any point of the urethra. (2) Any stricture, or succession of strictures, however rigid and cartilaginous, however long and tortuous, however tight, even if impermeable, can be readily and safely perforated. (3) As a rule, it causes no pain or bleed- ing, is followed by no chill or urethral fever, and is al- ways devoid of danger. (4) When properly performed, it can produce no false passage or other local lesions. (5) The effects are more enduring than those either of cutting or of stretching. These deductions have the unqualified approval of Dr. T. H. Burchard,26 who believes that no harm can come to the urethra by electrolysis. In England Steavenson and Bruce Clarke28 speak in its favor after trial, while Berkeley Hill and Buckstone Brown have expressed their scepticism concerning the feasibility of the method. A very able article upon the other side of the question is that of F. Tilden Brown,28 who reviews the literature of the subject and also contributes six cases of his own. From this study, which he designated as brief, but which was evidently careful and conscientious, he inclines to the conviction that electrolysis, apart from the dilating effect of the instrument by which it is applied, is fol- lowed by no benefit. The last article upon the subject is by Dr. Keyes,23 in which he gives the results of eight cases treated in ac- cordance with the directions of Dr. Newman. Dr. Keyes did not meet with favorable results. He closes the report of his investigation as follows : " My study of the subject and the experience it has brought me, digested with all the impartiality I possess, lead me to state that the allegation that electricity, how- ever employed, is able to remove organic urethral strict- ure radically, lacks the requirement of demonstration. The confidence of its advocates that it will radically cure organic fibrous stricture is, in my opinion, due either to the combined credulity of the patient and imagination of the surgeon, or to some special but fortuitous act of Providence, upon the co-operation of which, in the case of his own patients, the general practitioner cannot with any confidence rely." Electrolysis is being widely studied, and with great care. It can only be settled by clinical evidence, and every surgical community will probably require some special experience. At the present moment we may say that there seems to be great diversity in the views of those who practise and advocate its use ; that the bound- ary line between the beneficial currents of electrolysis and the positively caustic currents is not very wide, and that some of the most careful observers fail to gain the beneficial effects which its most enthusiastic advocates claim. Drainage and cleanliness, the principles of Listerism, are to be applied to all operations on the urethra as else- where. " There is no part of the human body in which disregard of these conditions is more likely to be at- tended with disastrous consequences, whether we have regard to the present or the future." 11 It is true that in its ordinary form the antiseptic treat- ment is difficult, and in some cases even impossible of application ; but instruments, sponges, and fingers can be scrupulously clean ; the speedy removal of urine from the field of operation can be provided for, or, if it must come in contact with the wound it can be impregnated with those substances unfavorable to fermentation which may be administered by the mouth and are largely elim- inated by the urine. Retention.-When a patient presents himself suffering from absolute retention due to stricture, in a large ma- jority of cases he can be relieved by the catheter, which should be immediately employed, and should be used with gentleness. Its use should not be persevered in for any great length of time, nor should the operator forget that other means may be successful when he is unable to enter the bladder through the urethra. If he fails, his course will depend upon the condition of the patient. If the retention is of but a few hours' standing, and the case is not particularly urgent, the patient should have a hot bath and be put to bed. Often the urine will dribble away in the bath. If this does not occur a full dose of opium should be administered. When the opiate has reached its full effect a small amount of urine may pass, or it may dribble away as the patient dozes. An active purge may also be administered, and as the bowels act the urine will also flow, often in a tolerably free stream. After such treatment for a few hours a catheter may enter the bladder. Ice suppositories are recommended, and hot-water rectal injections may possibly be of service. When no catheter can be passed urine will sometimes follow the withdrawal of a small bougie, which has been introduced into, but not through, the stricture, and allowed to remain there for a few moments. When a capillary bougie can be passed through the stricture the tunnelled catheters, usually known by the name of Gouley, may occasionally be passed. These in- struments are tunnelled at the extremity for perhaps a quarter of an inch. This tunnel is of the proper size to pass over a capillary bougie. The capillary being intro- duced into the bladder, the bougie is threaded over it and passed along it as a guide into the bladder. These various methods failing, or if the case is an urgent one when first seen, we must have recourse to puncture of the bladder. The bladder may be punctured by an ordinary trocar over the pubes, or by a curved one through the rectum. The aspirator is a most important addition to our means of treating retention in cases in which the urethra is for the time being impermeable. The needle should be demonstrated to be permeable and the aspirator in working order. The needle is to be introduced directly above the pubes until urine flows, and then carried in further, that the bladder wall may not slip away from its point as the viscus contracts. Aspiration may be re- peated twice or more times in the twenty-four hours if necessary, and its use may be continued for several days ; but ordinarily the rest given by thus emptying the blad- der will so modify the condition of the urethra as to allow the passage of an instrument after some hours. It is a very common occurrence to see the urine flow through its natural channels within a few hours after aspiration. The use of the aspirator was vaunted by Dieulafoy as absolutely harmless ; so far as any danger of wounding the peritoneum is concerned that is prob- ably correct, as we know that when the bladder is dis- tended the fold of peritoneum is carried an ample distance above the pubes. Otherwise its dangers are quite as small as those of any procedure that can be fol- lowed under the circumstances, yet accidents do occa- sionally follow the operation. Mr. William II. Bennett believes that in cases of old standing obstruction, whether from stricture or prostatic enlargement, when the bladder walls are hypertrophied, varying in thickness, and often rotten or easily lacerable, the procedure may be produc- tive of serious harm, and is altogether inferior to the older method of tapping with a large trocar. He gives cases in which aspiration was followed by a slough of the vesi- cal wall at the seat of puncture.14 The surgeon must not consider his work fully done when the retention is relieved. Sudden retention and over-distention of the bladder is usually followed by a loss of power which does not permit the complete empty- ing of the viscus, and requires regular catheterism for a while as well as the administration of iron and strychnia. The bladder may in these cases become inflamed and irritable, and the urine offensive. Mr. Harrison speaks of cases of retention so extreme and prolonged as posi- tively to induce more or less sloughing of the lining membrane of the bladder from pressure and stretching.1* Abscess, Extravasation, and Fistula.-One of the serious complications of old stricture is the so-called urinary ab- 402 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Urethra. Urine. scess. It may be sometimes formed by the escape of a drop from the urethra into the submucous cellular tissue, but a very large proportion of these abscesses, when opened early, are found not to communicate with the urethra. They occur usually in the perineum, and when first felt present little more than an enlargement of the urethra in the perineal and scrotal portions. The abscess being beneath the fascia, presents but little prominence, and fluctuation is represented by a slight feeling of elas- ticity. The constitutional reaction is in many cases not great, and the local discomfort is not marked, and it is sometimes difficult to convince the patient that he is in constant danger of a serious accident. These abscesses take the easiest road to evacuate themselves, and in a large proportion of cases open communication with the urethra. This is fortunate when the opening is of such a character as not to encourage urinary infiltration, but the escape of pus through the urethra is too often fol- lowed by the escape of urine into the cellular tissue. It is not always easy to establish the existence of a deeply seated abscess in the perineum, but when made out it should be opened. Less damage will follow an unneces- sary incision in the perineum than the unchecked bur- rowings of pus beneath the deep perineal fascia. But abscesses about the urethra are not always so poorly marked. They may occur in a very acute form. Sus- picion should be excited when a patient with stricture is attacked with severe pain, with a sense of weight and heat at the neck of the bladder or in the perineum, with chills and general febrile reaction, while the stream of urine is greatly diminished and pain greatly increased during micturition. Even if the local swelling and ten- sion seem relatively small, a perineal incision is the only safe course. When an abscess has been opened and no connection with the urethra is found to exist, the question sometimes arises whether an incision shall be made through the strictured portion of the urethra, or the canal be allowed to remain intact. That is a question to be decided with each individual case. If the stricture is a tight one, I certainly believe it best to complete the urethrotomy. Urinary extravasation, whether due to the bursting of an abscess or to a traumatic rupture of the urethra, requires immediate incision to evacuate the confined urine and pus. The course of extravasation will be determined by its position relatively to the perineal fascia, but whatever its course, thorough drainage must be secured. Urinary fistulae may communicate with the bladder or the urethra -the latter most commonly. They are preceded by ab- scess, extravasation, or rupture of the urethra ; occasion- ally the abscess which precedes may be an exceedingly slight affair. It is not infrequent to find that a perineal abscess, which at first did not communicate with the urethra, after a few days allows the escape of urine with each micturition. Fistulas open most commonly in the perineum or through the scrotum. They may discharge in various places, as in the thigh, or over the pubes. A fistula at the latter place is always the result of extrava- sation and an incision at that particular spot. The first point in the treatment of urethral fistulae is the treatment of the stricture to which they owe their origin. With the improvement of the stricture the fistula will usually improve. It is only in exceptional cases that distinctly operative measures are needed upon fistulae in the peri- neum and scrotum. Urinary fistulae in other places and from other causes are not considered here. Abner Post. 1 Harrison, Reginald : Third edition, p. 33. 2 Browne, G. Buxton: British Medical Journal, April 16, 1887. 3 Thompson, Sir Henry : Stricture of the Urethra, fourth edition. 4 Syme, James: Stricture of the Urethra. Edinburgh, 1849. 6 Wheelhouse, Mr.: British Medical Journal, June 24, 1876. 7 Lane, W. A.: Pathology of Extravasation of Urine. Guy's Hospital Reports, 1855-56. 8 Fenwick, E. Hurry, F.R.C.S. Eng.: Notes upon the Prognosis of Or- ganic Stricture of the Urethra. A paper read before the American Asso- ciation of Genito-urinary Surgeons, September 20, 1888. 9 Otis, Fessenden, N.: Syphilis and the Genito urinary Diseases, p. 487 et seq. lu Otis, Fessenden, N.: Diseases of the Male Urethra, p. 37. George S. Davis, publisher. 11 Harrison, Reginald : Letsomian Lecture. 12 Medical and Surgical History of the War of the Rebellion. Surgical Volume, Part. II. p. 388. 13 Otis, Fessenden N.: Stricture of the Male Urethra, p. 28. 14 Medico-Chirurgical Transactions, vol. lxx„ p. 207. 16 Boston Medical and Surgical Journal, Decemoer 29, 1887, p. 627. 16 Keyes, E. L.: Genito-urinary Diseases, with Syphilis, p. 118. 17 Cock, Edward : A Few Words on the Means to be Adopted for Estab- lishing a Communication between the Bladder and the Exterior of the Body when the Urethra has become Impermeable. The last Resource Available in certain Cases. Guy's Hospital Reports, Third Series, xii., p. 267. 1866. 18 Simon, John : Medical Times and Gazette, 1852, i., 386. 19 Harrison, Reginald: Surgical Disorders of the Urinary Organs. Third edition, p. 109. Curtis, T. B.: Du Traitement des Retrecissements de 1'Urdtre par la di- latation progressive (Prix Civiale pour 1'annee 1872). Paris, 1872. Newman, Robert: The Medical Record, 1886, vol. xxx., p. 341. Phil- adelphia Med. Times, 1886-87, xvii., 365. N. E. Med. Monthly, 1886-87, vi., p. 241. 20 Dittel, Leopold : Deutsche Chirurgie. Xieferuhg 49, 197, 1880. 21 Belfield, William T.: Nine Cases of Impermeable Urethral Stricture treated by Electrolysis, Journal of the American Medical Association, 1886, vol. vi., p. 455. 22 Mallez et Tripier: De la Guerison durable des R6trecissements de 1'Urdtre par la Galvano-caustique chimique. Paris, Mai, 1867. Mallez et Tripier: Traitement des R6tr6cissements Uretraux par la Galvano-caustique Chimique Negative, Compte Rendu de F Academic des Sciences. Bulletin Th^rapeutique, 1868. 23 Keyes, Dr. E. L.: The Curability of Urethral Stricture by Electricity. An Investigation. New York Medical Journal, October 6, 1888. 24 Newman, Robert: Electrolysis in Surgery, and Tabular Statistics of One Hundred Cases of Urethral Stricture treated by Electrolysis, without Relapse, Journal of the Am. Med. Asso., vol. iv., p. 449. 26 Burchard, T. H.: The Treatment of Stricture of the Urethra by Electrolysis, N. Y. Med. Record, 1888, vol. xxxiii., p. 655. 26 Steavenson, W. E., and Bruce Clarke: Treatment of Stricture of the Urethra by Electrolysis. Proceedings of the Royal Medical and Chirurgical Society, May, 1886. 28 Brown, F. Tilden : The Limitations of Electrolysis as a Therapeutic Agent in Organic and Spasmodic Stricture of the Urethra, with Cases, Journal of Cutaneous and Genito-urinary Diseases, July and August, 1888. Rizat, Dr. Armand : Observations de r6tr6cissements etroits du canal de 1'uretre, . . . traitds etgueris par la dilatation temporaire progres- sive. Annales des Maladies des Organes Genito-urinaires, Octobre, 1888. 29 Distin-Maddick, E.: Stricture of the Urethra, 1887. 30 Keyes, E. L.: Practical Electro-therapeutics: Galvano-puncture in Abdominal Aneurism, with a few Cases illustrative of Stricture of the Urethra and of hydrocele, New York Medical Journal, vol. xiv., 569. URINE. General Characteristics.-Introduction. -The worn-out products of tissue metabolism and the useless matter of the food are eliminated from the body- in the expired air, the faeces, and the urine. The car- bon of the tissues, fully oxidized to carbon dioxide, is exhaled from the lungs, the insoluble and unavailable debris of the food is excreted by the intestines, while the urine contains essentially the nitrogenous and other soluble products of tissue change. Hence it is that the qualitative and quantitative ex- amination of its constituents affords the means of ap- proximately estimating the nature and degree of the disintegration going on from time to time in the various organs and tissues of the body. No other product of the body, therefore, possesses such interest to the medi- cal practitioner, as no other can throw the same light on the organic processes of the diseased as well as the healthy body. This secretion has been investigated with great dili- gence, and the changes which it undergoes in many dis- eases, as well as its variations in health, have been studied from the earliest periods in the history of science. Hip- pocrates pointed out the effects of food and drink on this excretion, its variations in color, odor, and trans- parency, and taught the symptomatic and prognostic signification of these changes, attributing most of them to disease of the urinary organs. The later Grecian waiters on medicine closely followed the views of Hip- pocrates and made but few observations. Galen alone added to the then existing knowledge by some useful observations on the variations of urine in health (De differentiis urinarum in hominibus sanis). The Ara- bian, Avicenna (980-1037), pointed out the difference be- tween the urine voided in the morning and that at night, and the influence of age, food, medicines, and overwork on the color, etc., of urine. In a work remarkable alike for the number of the observations collected and the skill and care with which they were arranged, Actuarius, the "Uroscopist" of the Byzantine court, described in the minutest detail the visible changes of urine in health 403 Urine. Urine. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. and in disease. Many of his observations on the urine in fevers and in diseases of the kidneys, circulation, in- testines, and liver are of no inconsiderable value to-day. Upto the middle of the seventeenth century the entire investigation of urine consisted in observations on its physical characteristics. When, however, the study of the appearances of urine had yielded all the informa- tion that could be obtained at that time the alchem- ists began to investigate its composition, and what may be called the age of uroscopy was succeeded by the chemical period. This second stage in the development of urinary physiology and pathology was opened by Van Helmont, but the most valuable investigations were made by Lorenzo Bellini (1643-1704), who, by evaporat- ing urine, discovered the important fact that changes in the color, fluidity, taste, and odor of urine were due to variations in the relative proportions of water and solids present. Brandt, while searching for the philosopher's stone in the ash of urine, discovered phosphorus, and Margraff subsequently showed that this was derived from the phosphates. Catugno, in 1770, found albumen, and in 1798 Cruikshanks pointed out the connection be- tween its presence in the urine and dropsy; still, the re- lation of albuminuria to kidney disease was not appre- ciated until it was proved by Bright, in 1827. Willis discovered sugar, and Rouelle, in 1773, urea. Rouelle also pointed out the difference between human urine and that of herbivora ; he noted the fact that in herbi- vora carbonates replaced the phosphates of human urine, and from the former he separated hippuric acid. To Steele and Wollaston is due the earliest knowledge of the composition of urinary calculi. Steele attributed all calculi to uric acid, hence the name lithic acid, but Wollaston found phosphate and oxalate of lime, triple phosphate, and cystin among the concretions examined by him. Still later the laborious investigations of Prout, Wetzler, Berzelius, Gmelin, Wohler, and Liebig threw a flood of light on the chemistry and pathology of urine. Modern urinary analysis and urinary pathology, how- ever, may be said to date from the appearance of Rayer's "Traite des Maladies des Reins" (1839) and Bequel's " Semiotique des Urines" (1841). Since the publication of these works so many chemists and pathologists have been engaged on the subject that, to-day, no department of pathology or of organic chemistry possesses so full a literature as this. Organic chemistry owes its origin as a science to Wohler's study of urea, the chief constituent of urine ; so, in turn, in its more rapid development, the study of the chemistry of carbon and its compounds has reacted beneficially on the physiology and pathology of urine. The importance now attached to its investi- gation, and its value as an aid to diagnosis, are chiefly due to the more thorough comprehension of the relation between its composition and tissue metabolism, together with the more accurate knowledge of the minute an- atomy of the kidneys. Indeed, no true conception of the physiology and pathology of urine is possible without a knowledge of the functions and histology of the urinary apparatus (see Vol. IV., pp. 267 to 275). In the following pages the physical properties of human urine, and those characteristics possessed by the secretion as a whole, will be first considered, and then, as briefly as possible, its principal normal constituents and their varia- tions in health and disease, and, finally, the more impor- tant abnormal substances and urinary sediments. Quantity.-The quantity of urine passed in twenty- four hours by a healthy adult, eating and drinking moder- ately, may be estimated at from 40 to 60 oz., or 1,200 to 1,800 c.c. Calculated for the weight of the body, an adult passes about 24 c.c. (6 drachms) for each kilogram (2.2 lbs.); children from three to seven years of age ex- crete about 60 c.c. for each kilogram of body-weight. The secretion of urine is therefore about 2.5 times more active in children than in adults. The quantity of urine is usually estimated by measure for twenty-four hours, but during observations on the effects of drugs, etc., it is often necessary to estimate the urine hourly. In all cases where the condition of the urine is to be noted from day to day, it is most con- veniently collected in glass cylinders 4 to inches in diameter, holding about two litres, graduated to 25 c.c., and covered with glass plates, the latter fitted to the ground rim of the jar by a coating of wax or paraffin (Fig. 4250). The jar should be kept in a cool place, to retard fermentation and to prevent evapo- ration in accurate experiments. This mode of collecting the urine pos- sesses many advantages; the physician is able to observe at a glance its quantity, color, transparency, and the nature of the sediment, if any be present; and, what is of great importance, such jars are much less likely to be carelessly cleansed by attendants than vessels made of porcelain or earthenware. The quantity of urine passed in twenty-four hours forms the basis of all quantitative estima- tions of the various constituents of the urine. Jt is obvious that, from a medical point of view, the analysis of a few ounces of urine passed at any time in the day is, generally speaking, a waste of time, No conclusions of clinical value can be drawn without a knowledge of the rela- tion that the quantity analyzed with its constituents bears to the whole quantity passed in a definite time, say twenty-four hours, since the quan- tity and composition of urine vary greatly in healthy persons, not only from day to day, but at different times during the twenty-four hours (see sections on Specific Gravity, Acidity, Urea, etc.). In health the secretion of urine is increased during hours of mental and physical activity, and is diminished during sleep. If these conditions be reversed, it usually means chronic renal trouble or diabetes. In some stages of atrophic degeneration, a nocturnal rise of urine is marked, and whenever it occurs it calls for investigation. The quantity of urine excreted is increased (1) by gen- eral increase of pressure in the blood vascular system, such as from drinking large quantities of water, or from any cause which retards the elimination of water from the body by the skin, lungs, and bowels; (2) through the increased excretion by the urine of substances with high co-efficients of solubility-salts, sugar, etc.; (3) temporary increase through psychical influences-fear or anxiety ; (4) through direct action of the nervous system on the excretions, e.g., injury to the floor of the fourth ventri- cle ; (5) through the influence of certain drugs, etc., as alcohol, digitalis, tea, coffee, and acetate of potassium, on the blood vascular system. Here, also, may be noted the diuretic effects of inhaling compressed air. The amount of urine excreted is decreased (1) by ab- stinence from fluids; (2) by all those causes which in- crease the action of the lungs, skin, and bowels ; (3) by any cause which lessens the force and pressure of the cir- culation-by myocarditis and non-compensating heart action ; (4) by acute affections of the kidneys through the swelling of the lining epithelium of the tubules. So, also, pressure of exudation on the vessels may even bring about anuria. Consistence.-Normal urine is a watery, easily dropping fluid. The consistence may be increased from presence of pus, ■which, with the alkaline ammonium salts, forms a thick, tenacious mass of an alkaline ammoniate adher- ing to the bottom of the glass. In chyluria, and when there is great excess of albumen, the urine is perceptibly less fluid. Upon the Isle of France and in Brazil, a urine is observed which coagulates, soon after passing, in a gelatinous mass that cannot be poured from the vessel. Hofmann describes a similar condition of the urine caused by a villous tumor of the bladder. Healthy urine gives a light foam, which disappears quickly ; but in saccharine urine and in most urines of a specific gravity above 1.024, the foam remains for a con- siderable time. Fig. 4250.-A, Cylinder for containing the urine of twenty-four hours; B, glass for collecting sediments. 404 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Urine. Urine. Transparency.-Healthy urine is always transparent and clear when passed, but on standing frequently shows a mucous cloud suspended near the bottom of the glass. This cloud is found, under the microscope, to be com- posed of epithelium and mucous threads; it is usually more marked in the urine of women than in that of men. Granular, amorphous urates and earthy phosphates remain suspended for many hours in urine, and give it a marked turbidity when in excess. Cloudiness or turbid- ity from these salts is easily recognized. If, on warm- ing the urine, it becomes bright, then the amorphous acid urates of sodium and ammonium caused the turbid- ity, as these are readily soluble in hot urine. If the tur- bidity is due to earthy phosphates, it is increased by heat, owing in part to the expulsion of the carbonic-acid gas which helps to hold the salts in solution. If, however, a few drops of acetic acid are found to clear up the fluid, the turbidity is due to the amorphous phosphates of cal- cium and magnesium precipitated from the neutral or alkaline urine. If neither warming the sample, nor the addition of acid clears it up, the turbidity is due to organic matter-suspended pus, blood, mucus, or bacteria. Bacteria give the urine a peculiar silky, iridescent appearance on looking through it after agitation, and the tur- bidity is equally dense thoroughout. Urine sometimes shows, in cases of urethral or prostatic inflammation, be- sides a few pus-cells, a number of thready fibres floating through it. These are the so-called "gonorrhoeal threads" which, though very common in chronic gonor- rhoea and gleet, are seen in many other inflammatory lesions of the deeper part of the urethra. Under the microscope they are found to be made up of pus- cells and round nucleated epithelium (Fig. 4251). For other causes of turbid urine, see the section on Urinary Sediments. Odor.-Urine has a characteristic aro- matic odor in health which varies in intensity, being usually stronger when the percentage of solids is high. Urine alkaline from fixed alkalies has a pecul- iar odor, like horse's urine, but the so- called " urinous odor" of alkaline urine is from the ammonia. Diabetic patients often exhale a peculiar ethereal odor; this is occasionally obtained from the urine as well, and is due to the presence of certain members of the acetone group. This odor is found in cases of acetonuria as well. Diabetic urine gives a peculiar sweet odor like whey, and when decom- posed is attended with a decided acid smell. Urine that contains cystin, when fresh, has a pleasant odor like sweet- brier, but decomposes rapidly, emitting a most offensive odor, probably due to some of the mercaptan bodies as well as sulphuretted hydrogen. The odor of sulphuret- ted hydrogen is sometimes due to decomposition of albu- men. Its presence is readily shown by its blackening moistened lead-paper held over the warm urine. Tur- pentine administered internally imparts to the urine the perfume of violets. Asparagus, cauliflower, garlic, etc., give to the urine very disagreeable odors. Cubebs, saf- fron and copaiba also impart their odorous principles to urine. De Beauvais and some other French pathologists state that the peculiar odors of turpentine, asparagus, etc., are not transmitted to the urine of patients suffering from organic disease of the kidneys. Recent observations of Vogel and others have thrown some doubt on the diag- nostic value of this, although they admit its utility in some doubtful cases. Heller believes the characteristic odor of normal urine to be due to a pigment body called uropbaein. Certain experiments of Stiideler go to prove that the odor is prob- ably due to a number of aromatic, volatile acids (phenyl- ic, taurylic, damaluric, and damolic acids) which he ob- tained by distilling large quantities of urine. Color.-The color of urine is normally golden- or am- ber-yellow, but may vary in health from very pale yellow or colorless to red or reddish-brown. (Vide Vogel's color scale.) The usual general classification of shades for descrip- tive purposes is as follows: pale, colorless to straw-yel- low ; normal, gold to amber-yellow ; high-colored, red- dish-yellow to red ; dark, deep beer color to black. The depth of color in health varies with the concentra- tion ; abundant, copious urines are pale; diminished discharges of high specific gravity are, as a rule, darker. The color of urine depends on the presence of several coloring matters, all probably derivatives of urobilin or directly derived from haematin. In spite of the fact that Fig. 4251.-Gonorrhoeal Thread as seen under the Microscope. (Peyer.) the nature and origin of the coloring matters of the urine have for many years attracted the attention of the best physiological chemists, our knowledge of even the nor- mal coloring matters is very scanty. There probably exist, as separate bodies, at least two coloring substances in normal urine, viz., Urobilin (Jaffe) and Urine indican (Heller's Uroxanthin). (See Urinary Pigments.) Varia- tions in the color of urine may be due to increase or diminution of the normal coloring substances, or to the presence of abnormal pigments. These unusual urinary pigments may be subdivided into two groups : (1) essen- tial, or those derived from pathological changes in tlje body, e.g., blood and biliary pigments, uroerythrin, etc.; and (2) accidental abnormal pigments, or those derived from food or medicine and eliminated with the urine. Chrysophanic acid found in rhubarb and in senna- leaves gives a reddish-yellow or blood-red color to alkaline urine, which fades when an acid is added and returns when the urine is again made alkaline-distinction from blood. Santonin gives a bright yellow color in acid urine, w'hich resembles bile in the way it stains linen, but it, unlike bile pigment, is turned crimson by alka- 405 Urine. Urine. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. lies. Madder, indigo, gamboge, logwood, carrots, whortleberries, etc., also impart their peculiar color to urine. Many aromatic bodies, e.g., salicylic acid, car- bolic acid, tar, creasote, etc., give a smoky or dark tint to urine, but this is easily distinguished from such essential pigments as blood or melanin. The color of a sample of urine often gives a hint toward diagnosis, or acts as a guide to further investigation. Thus the existence of a pale urine is almost an infallible indication that the patient does not suf- fer from acute febrile diseases. A copious pale urine is character- istic of hysteria and other paroxysmal ner- vous ailments, of anae- mia, chlorosis, and chronic Bright's dis- ease, especially the waxy and granular kid- ney. On the other hand, high-colored urines are suggestive of a very active tissue change, and are also met with in diarrhoea and other affections where there is diminished excretion of waste by the kidneys. This high color is characteristic of febrile affec- tions. In hectic fevers it is often a surer indication than pulse or temperature of the intensity of a febrile increase of metabolism (Vogel). Dark urines usually indicate the presence of some ab- normal pigment, and suggest further examination. The term alcaptonuria has been applied to that rare condition in which the urine becomes dark, or even black, when made alkaline with soda or potash. Bb- deker, and recently Robert Kirk, have investigated this peculiarity and find it due to the presence of organic acid bodies (alcapton) with strong reducing powers. For- merly the acid was regarded as pyro-catechin or proto- catechuic acid. Kirk has shown that these bodies are not present, but two or three new acids, one of which, named by him uroleucic acid, has the compo- sition C6Hio05, crystallizes in scales of stel- late crystals, and melts at 133.5° C. What he formerly described (in 1886) as urodinic acid he now finds to be a mixture of uroleucic and perhaps two other acids, all possessing high reducing powers. Specific Gravity and Urinary Solids.-The specific gravity of the mixed urine of twenty- four hours is normally about 1.020, but is of course influenced in health by all causes that affect either the quantity of water or the quan- tity of solids excreted by the kidneys. A variation from 1.005 to 1.030 may be not in- compatible with perfect health. The quan- tity of urinary solids excreted in a day varies in health much less than that of the fluids. The quantity of pigment substance is also very constant; so one should notice the rela- tion of these three factors to each other, viz., volume, color, and specific gravity, before pronouncing a sample abnormal. The scanty high-colored urine of summer should in health show a higher density than the pale, bulky urine of midwinter. The specific gravity of urine is usually taken by means of a special form of hydrometer, called a urinometer (Fig. 4252). This method, though inaccurate, gives re- sults true enough for clinical purposes if the instrument used be accurately graduated, and proper precautions be taken in using it. Many of the pocket urinometers are, however, very inaccurate and misleading. It is never safe to use one without first testing its accuracy by immersing it in distilled water at 60° F., when it should sink exactly to the line marked 0 or 1.000. If possible, every new urinometer should be compared with another of known accuracy. The long English instrument is usu- ally more accurate than the short, cheaper German one, though not so convenient. The scale in all urinometers should be read from above, not below, the liquid (Fig. 4255, D). Dr. Squibb has greatly lessened one of the er- rors inseparable from the use of urinometers by his little instrument seen in Figs. 4253 and 4254. The sides of the jar that contains the urine are fluted and the bulb of the instrument is a double cone, thus the urinometer does not cling to the sides of the vessel, but floats freely. The fluting also enables one to take the density with a smaller quantity of liquid. The advantages of this in- genious modification are seen in Fig. 4254; the instru- ment can touch the containing vessel at only one or two points, instead of having a large surface in contact as in the older form. The use of glass beads of known specific gravity is a very convenient method (Fig. 4255, A and B), as these are very portable and no special vessel to hold the urine is necessary; any wuneglass or tumbler will answer the purpose. These beads are marked from 1 to 40 and will give the specific gravity of fluids from 1.000 to 1.040. To ascertain the density of a sample of urine by these beads it is only necessary to find the bead that neither floats nor sinks in the fluid, but remains wherever placed. Thus in Fig. 4255, B, the specific gravity of the fluid lies between 1.015 and 1.020, as the bead marked 20 sinks and the one marked 15 floats. Dr. Oliver has greatly improved this method by using but one bead with a specific gravity of exactly 1.008 (Fig. 4256); this is dropped into the gradu- ated test-tube, seen in the illustration, filled to the lowest mark with urine, and if it sinks the density is below 1.008, but in almost all cases it will float; then water is added little by little with some force, so as to mix with the urine, till the bead begins to sink ; then the specific Fig. 4254. - Section Through the Jar at the level A, Fig. 4253 Showing the Position of theUri- nometer. Fig. 4252.- The Com- mon Uri- nometer. Fig. 4253.-Squibb's Uri- nometer. (Tyson.) Fig. 4255.-Apparatus for Taking Specific Gravity. A and B, By the specific gravity beads ; C and D, by improved urinometer ; E, F, are picnometers. (After Tyson.) gravity is read off on tlie right-hand side of the tube at the level of the fluid. If it be of greater specific gravity than 1.024 the mixture is poured out to the original lower line, and water again added ; the specific gravity is now- shown on the left side of the tube. This instrument is very portable, can be quickly used at the bedside, re- quires only a very small quantity of urine, and gives more accurate results than the common urinometer. ■ 406 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Urine* Urine* For purposes of scientific investigation, the only proper way to take the specific gravity is by the picnometer, or specific gravity bottle, and balance (Fig. 4255, E and F), being careful to bring the urine to the temperature at which the picnometer was originally graduated, usually 60° F. or 20° C. The modern forms of picnometer have thermometers attached as in Fig. 4255, F. The bottle is first weighed empty, then filled with distilled water at 60° F. and again weighed, the difference being the weight of the contained water. The wreight of urine required to exactly fill the bottle at the same temperature, divided by the weight of water, gives the specific gravity; ex- ample : Picnometer and water. 80 grams. Picnometer 30 " Contained water 50 " Picnometer and urine. 81.2 " Picnometer 30 " It contains then ...... 51.2 " of urine. „. 51.2+1.000 . Then =.. 1.024 sp. gr. OU A healthy man should excrete in twenty-four hours sufficient solids to give a specific gravity of about 1.020 to 50 oz., or 1,500 c.c. of urine ; this is found to be a little over four per cent. From these data the amount of solids may be readily calculated from the specific gravity by multiplying the last two figures by two (or 2.33, Kaser), the results being parts per thousand. Thus a urine gives specific gravity of 1.017 : 17 x2=34 ; i.e., 34 gr. per thousand, or 3.4 per cent, of solids. Vogel finds that Kaser's co efficient (2.33) gives very accurate results, more so than Trapp's (2), but the advantage of the latter is that the solids may be calculated mentally from the specific gravity, and the error is very slight. A good simple rule is to multiply the last two figures of the specific gravity by the number of ounces passed in twenty-four hours, and the product will approximate- ly give the number of grains of urinary solids passed in twenty-four hours. The normal amount is from 800 to 1,000 grains. Example : 55 oz. of urine, sp. gr.=1.015, then 15 x 55=825, the solids of the day's urine expressed in grains. The total solids in most samples of urine may be esti- mated quite as accurately by taking the specific gravity of the urine with a picnometer and balance, and midtiplying by Kaser's co-efficient (2.33), as by the tedious process of evaporation, unless the latter operation be conducted with great care. It must be remembered that in the process of evaporation and drying the residue to con- stant weight at 100° C., there is a continuous stream of ammonia and ammonium carbonate evolved from the decomposition of urea by the acid sodium phosphates. To avoid error this ammonia must be collected, esti- mated as urea, and this weight added to the total residue. For Neubauer's method of drying and collecting am- monia, see Neubauer and Vogel's " Analysis of Urine," seventh edition. The writer's method of estimating the solids exactly is to evaporate in vacuo over sulphuric acid, at ordinary temperature. Fine asbestos fibre is laid in a porcelain dish, and both are dried at 100° C. and weighed. Then 5 c.c. of urine are poured on, again weighed, and placed in vacuo over the acid for twenty-four hours. The acid is then changed, the chamber again exhausted and the urine residue left for another day, then weighed, and the process repeated until no further loss occurs in twelve hours. The results thus obtained are very constant, but the method is slow. Among the physiological causes of variation in the total solids of urine may be noted the direct influence of the quantity and nature of food. Activity, mental and physical, increases, and rest diminishes, the solids. Body- weight is an important factor, for about 7.8 grains are excreted for each pound of body weight; children under seven excrete proportionately about twice as much as adults. Clinical variations : With a normal or subnormal amount of urine the solids may be deficient, from slow or failing tissue metabolism, from premature senile in- nutrition, or from what Sir Andrew Clark so well calls " renal inadequacy." There is a deficiency in anaemia, in hydraemia, and in the cachexia of syphilis, cancer, and chronic alcoholism. The greatest cause of decreased solids is a crippled state of the kidneys, as seen in acute nephritis, some forms of chronic Bright's disease, and hy- peraemia of the kidney from irritants or disease ; here the total amount of urine is also greatly reduced. There may be a great reduction in the solids with an increase in the quantity of urine, as in diabetes insipidus and cir- rhotic kidney. The urinary solids are increased without correspond- ing increase in the daily flow of urine in fevers, and in some forms of dyspepsia and in lithaemia. As a rule, however, increase of solids is accompanied by an in- creased discharge of urine, as in diabetes mellitus, phos- phaturia (phosphatic diabetes of Tessier), and that form of polyuria called azoturia, characterized by excessive excretion of urea. Chemical Reaction.-The mixed normal urine of twen- ty-four hours gives an acid reaction, i.e., it turns blue litmus red. The daily acidity is equal to from 1.5 to 2.5 grammes (25 to 35 grains) of oxalic acid. This amount represents the total acidity, but during the day the urine is subject to very marked fluctuations. Bence Jones, Roberts, and others, have shown that the acidity is highest during sleep and before meals, while from two to three hours after meals there follows a wave of reduced acidity termed the "alkaline tide." The urine at this time may be neutral or even alkaline in persons of perfect health. This alkalinity, as seen in the Fig. 4256.-Oliver's Apparatus for Taking Specific Gravity. (Oliver.) Fig. 4257.-Diagram Showing the Daily Variations in the Acidity of Urine. (Oliver.) accompanying diagram, follows about one hour after breakfast, holds its maximum strength for an hour, and is succeeded by an acid wave. The alkaline tide that follows the chief meal of the day usually retains its strength for two hours, and is suc- ceeded by a strong acid wave. The acid wave is usually proportionate in intensity to the preceding alkaline tide. The urine passed in the morning before breakfast is usu- ally highly acid, while after a substantial midday meal, about 3 p.m., it becomes neutral, or even alkaline, and turbid from the precipitation of phosphates. Various explanations have been offered of these tidal variations in acidity. Dr. Roberts regards the alkaline depressions as caused by the introduction into the blood of substances from the newly digested food, which is usu- 407 Urine. Urine. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ally alkaline. Bence Jones believes the alkaline tide to be due to the withdrawal of acid from the blood by the gastric juice, and the blood, thus rendered more alkaline than at other times, gives a less acid urine. Although neither of these theories is entirely satisfactory, Dr. Rob- erts' hypothesis seems the more reasonable. The cause of the normal acidity of urine lias not yet been satisfactorily demonstrated. Liebig long ago ad- vanced the hypothesis that the acidity of normal urine was due to the presence of the acid sodium phosphate (NaH2PO4). This view is based on an experiment easily verified, viz., that if the difficultly soluble uric acid be treated with an alkaline solution of disodium phosphate (NaaHPO4), the mixture becomes acid, owing to a sepa- ration of part of the base from the alkaline phosphate. This hypothesis has been generally accepted, but recent careful analyses of urine have revealed many other sub- stances which may aid in producing this reaction. The acidity is probably not due, in health, to any free acid or acids, but in the present state of our knowledge it is scarcely safe to say that the acid urates, hippurates, and lactates do not play an important part in giving urine its characteristic reaction. For a long time no explanation was offered for the chemical paradox of an alkaline blood giving forth an acid fluid like the urine. Maly has offered a very simple solution. Neutral sodium phosphate exists in the blood. Now, when a mixed solution of the neutral and acid so- dium phosphate is placed in a dialyser, the acid salt dif- fuses more rapidly through the animal membrane into the surrounding water than the neutral one ; so in a short time the water outside the membrane becomes acid, and that inside neutral or alkaline, i.e., the acid diffuses more rapidly than the bases. After the urine has been passed, if it was originally acid, and is kept in a clean jar tightly covered, it will in two or three days increase its acidity, undergoing the so- called "acid fermentation." This change, though com- mon, is by no means constant for all urines. The vesical mucus is supposed by Scherer to set up this acid fermen- tation. Urine which has undergone this change gives a sediment composed of peculiar yeast-like cells, amor- phous granular urates, uric-acid crystals, and oxalate of calcium (Fig. 4258). According to Voigt and Hofmann, ules (Fig. 4259). The ammoniacal odor is due to the presence of ammonium carbonate, which is formed by the decomposition of urea. This alkaline fermentation always depends on the presence of the micrococcus urea?, except when the urine becomes ammoniacal before leav- ing the bladder. Musculus has shown that it is possible to separate a urea-decomposing ferment from the bacteria which produce or accompany it. It is an unorganized ferment, like diastase or pepsine, and may be prepared by precipitating the ammoniacal urine with alcohol, thor- oughly washing the precipitate on a filter with more alco- hol, and drying it. The powdered substance is now ex- Fig. 4259.-Sediment Formed during the "Alkaline Fermentation " of Urine. Showing large triple phosphate crystals, the thorn apple, and spiculated crystals of ammonium urate, and amorphous earthy phos- phates. tracted with water, and this filtered aqueous extract is found to possess the power of changing urea into ammo- nium carbonate. As it does not similarly decompose any other nitrogenous animal substance, it may be used as a delicate test for the presence of urea. A piece of bibulous paper, dipped into the extract and dried, is moistened with a dilute turmeric solution, and if this be introduced into even a dilute solution of urea it is quickly turned brown from the formation of ammonia. It must not be forgotten that urine may be alkaline without its alkalinity being due to the decomposition of urea. From causes mentioned below, urine may be neu- tral or alkaline from presence of the fixed alkalies (soda and potash) in excess. Alkalinity from either cause will of course change red litmus paper blue, but if the alkali present be ammonia, as it is very volatile, on drying the paper the original red color of the litmus will return ; on the other hand, the blue color remains after drying if the alkali be soda or potash. It occasionally happens that a sample of urine will change blue litmus-paper red and red-litmus paper blue-the amphoteric reaction of Bamberger. It is thus both acid and alkaline at the same time. The probable explanation of this is to be found in the fact that this peculiarity is seen at the outset of the alkaline fermentation, when the atmosphere above the fluid and its upper strata contain the lighter ammo- nia from the urea fermentation, while the urine below still reddens the litmus by reason of the presence of the acid sodium phosphate. If such a sample of urine be thoroughly stirred it becomes uniformly acid or alkaline. This view is supported by the fact that urine giving an acid reaction sometimes shows an iridescent film of triple phosphate, which from its chemical nature cannot exist in an acid medium. * Quantitative Estimation of the Acidity of Urine.-It is often a question of considerable moment to the physician to know whether or not a given sample of urine is abnormally acid. This must be ascertained volumetri- cally by determining how much of a standard alkaline solution is required to neutralize the acid in a definite quantity of urine. As the acidity of urine is not depend- ent on the presence of acid sodium phosphate alone, but may be due to other acid salts, and in disease occasion- Fig. 4258.-Precipitate from Urine during " Acid Fermentation," show- ing oxalate of lime and uric-acid crystals, amorphous urates, and torulce. there is no acid fermentation of normal urine. They ex- plain the separation of uric acid from the urates on chem- ical grounds. There is no doubt that the entrance of yeast-spores causes a rapid increase in the acidity; ac- cording to Briicke, this is owing to the formation of acetic and lactic acids from traces of sugar normally pres- ent. Sooner or later the urine undergoes the so-called " alkaline fermentation." It now evolves a strong am- moniacal odor, and a sediment appears, composed of crystals of ammonio-magnesium phosphate (triple phos- phate), bacteria, and ammonium urate in spiculated glob- 408 trine, trine. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ally to free acids, so it is usual to express the total acid- ity as equivalent to so much oxalic acid per twenty-four hours. Normal urine, according to Vogel, = 2 to 3 grammes; according to Salkowski, Kerner, and other au- thorities, about 1.8 to 2 grammes of oxalic acid per diem. Vogel's estimate is probably rather high. The solu- tions required in estimating the acidity are : (1) A standard oxalic-acid solution for fixing the strength of the soda solution. It is prepared by dissolving ten grams of pure oxalic acid in one litre of distilled water. Each c.c. then contains 0.01 gramme of oxalic acid. (2) Sodium hydrate solution ; pure caustic soda, made from metallic sodium, can now be easily obtained in commerce, and one has simply to dissolve about 6.5 grammes in a litre of distilled water and determine its exact strength with the standard oxalic acid. One c.c. of the alkali must be exactly neutralized by one c.c. of the standard acid ; if the alkali be too strong, it should be diluted to the required strength, and when prepared should be kept in a well-stoppered bottle. (3) A solution of litmus, to be used in ascertaining the strength of the standard alkali. This indicator is prepared by dissolving 3 grammes of litmus in 20 c.c. of ■water and filtering the deep-blue solution. To estimate the acidity of a sample of urine, 100 c.c. of the urine are measured into a beaker or flask, and from a small burette the standard alkali is slowly dropped in with constant stirring, until a feather or thin rod dipped in the mixture and drawn across a piece of well-pre- pared violet litmus paper, ceases to produce a red color. Owing to the yellow color of urine, if the indicator be added directly to it, the change from red to blue would not be sharply marked. Then, as each c.c. of alkali used is equal to 0.01 gramme of oxalic acid, the acidity of 100 c.c. expressed as oxalic acid may be obtained by simply multiplying the.number of c.c. used by 0.01. From this the acidity of the day's urine may be readily calculated. Example: Urine for twenty-four hours=l, 500 c.c. ; 100 c.c. of urine required 12 c.c. of the alkali to neutralize them. Therefore 12 x by 0.01=0.12 grammes of oxalic acid, is the acidity equivalent to 100 c.c. ; or 0.12 x 15 = 1.8 gramme of oxalic acid, is the acidity of 1,500 c.c. or the total acidity of the day's urine. Clinical significance of variations in the chemical reac- tion of urine.-In disease urine may be (a) highly acid, or (b) alkaline from fixed or volatile alkali. (a) Highly acid urine. This is usually marked by a de- posit of urates or of uric-acid crystals when the urine cools. Acidity may be caused by a high degree of con- centration of the urine from profuse perspiration or from diarrhoea, and yet the total daily acidity may not be abnormal, i.e., not exceed three grammes of oxalic acid. A high degree of acidity is found in most cases of dia- betes mellitus, and this increases rapidly after the urine is exposed to the air, from the development of free acetic and lactic acids by fermentation. In acid dyspepsia a very highly acid urine may alternate with urine that is neutral or even alkaline. This variation is more marked in children. A very acid condition of the urine favors the formation of sediments and concretions which irri- tate the kidneys and urinary passages (Vogel). (5) Alkaline urine. This condition of the urine, if per- sistent, always demands the careful attention of the phy- sician. Its clinical significance, particularly in reference to prognosis and treatment, depends on whether it is temporary or permanent, and whether, if permanent, the reaction is due to carbonate of ammonium or to fixed alkali. Temporary alkalinity is generally physiological, and of no practical signification. Among the causes are a vegetable diet, hot baths, medicinal use of alkaline car- bonates, and alterations in tissue metamorphosis of a tran- sient nature. When, however, the urine is permanently or frequently alkaline, important semiotic conclusions may be derived from it. If the alkalinity is found to depend on ammonium carbonate, it is due to the decom- position of urea within the urinary passages. This has been found to be invariably associated with an unhealthy condition of the mucous membrane of the urinary tract, such as one finds in cystitis or pyelitis from foreign sub- stances, calculi, enlarged prostate, stricture, etc. Experi- ments have shown that the introduction of the micrococ- cus urese into the bladder will not set up the ammonical fermentation if the mucous membrane be entire and healthy. Ammoniacal urine has a strong odor, and always gives a sediment of triple phosphates and mu- cus. Urine, alkaline from fixed alkalies, such as the car- bonates and phosphates of sodium and potassium, has quite another significance. Here the cause is alterations in the general tissue metabolism. It is found associated with the symptoms of chlorosis, anaemia, defective nu- trition, and general debility. Rademacher states that, generally speaking, a constantly alkaline urine is an iron affection, i.e., requires tonic treatment. This is especial- ly true if the urine is deficient in pigment (Vogel). In alkaline urine from fixed alkalies there is often a de- posit of the earthy phosphates, though they may not be in excess. Vogel calls attention to the erroneous practice of treat- ing all cases of alkaline urine by administration of acids, and points out that this condition is frequently due to inflammatory lesions of the urinary passages depend- ent on the irritant action of urine already highly acid, or to uric-acid gravel deposited from an acid urine. Here, on the contrary, demulcents and alkaline carbon- ates are indicated. For cases where acids are indicated, phosphoric and benzoic acids have been found most ef- ficient. Vegetable acids and their salts become oxidized to carbon dioxide and alkaline carbonates in the blood, thus increasing the alkalinity of the blood, and this tends to diminish the acidity of the urine instead of in- creasing it. II. Normal Constituents.-Chemical Composition of Normal Urine.-The following table gives at a glance the daily quantities of the different constituents of nor- mal urine that readily admit of quantitative estimation, together with some constituents already discussed. Ker- ner's estimations were made on the urine of a healthy man, aged twenty-three, of one hundred and fifty pounds, and are the average of eight days. Vogel's results are the average of a great number of observations on differ- ent people, extending over several years : Fig. 4260. - Burettes and Beakers for Volumetric Analysis. (Tyson.) Kerner Urine of Twenty- :our Hours. J. Vogel. Components. Mini- mum. Maxi- mum. Average. Urine of Twenty-four Hours. Quantity l,099c.c. 2,150c. c. 1,491 c.c. 1,500 c.c. Specific gravity 1.015 1.027 1.021 1.020 Water 1.440 c.c . Solids 60.00 grms. grms. grms. grammes. grammes. Acidity 1.74 2.20 1.95 3.00 Urea 32.00 43.40 38.10 35.00 Uric acid 0.69 1.37 0.94 0.75 Sodium chloride 15.00 19.20 16.80 16.50 Phosphoric acid 3.00 4.07 3.42 3.50 Sulphuric acid 2.26 2.84 2.48 2.00 Calcium phosphate 0.25 0.51 0.38 Magnesium phosphate 0.67 1.29 0.97 Total earthy phosphates.... 0.92 1.80 1.35 1.20 Ammonia 0.74 1.01 0.83 0.65 From a chemical standpoint, as the above table shows, urine is essentially a solution of urea and sodium chlo- ride, containing numerous other organic bodies and min- eral salts in relatively small quantities. Any decided 409 Urine. Urine. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. variations in the amount of these two constituents must evidently affect greatly both the total solids and the specific gravity, as they alone make up about three- fourths of the solid urine. For descriptive purposes it is convenient to consider the various constituents of normal urine in the order of their physiological and pathological importance, first the organic, then the inorganic. The gases dissolved in urine are of slight importance, and demand but short notice. Normal Organic Constituents.-The following organic bodies have been identified in normal urine : Urea.-Baumstark's substance (diamide of lactic acid). Bodies of the Xanthin Group.-Uric acid, xanthin, hypoxanthin (sarcin), paraxanthin, heteroxanthin, and allantoin. Creatinin.-Creatin ? Aromatic Sulphuric Ethers.-Phenol, cresol, pyro- catechin (?), indoxyl, and skatol sulphates. Hippuric Acid. Aromatic Oxyacids.-Para-oxy-phenyl acetate, and para-hy dro-cu marate. Acids of the Fatty Series and their Derivatives.-Volatile acids-lactic, oxalic, oxaluric, sulphocyanic, and suc- cinic. Ethereal Salts of the Fatty Series.-Glycerine phosphate. Urinary Pigments. Soluble Ferments.-Pepsine, trypsine, and a diastatic ferment. Mucin. Besides these there are traces of certain other bodies, such as toxic alkaloidal bodies (Bouchard), animal gum (Landwehr), a levorotatory body (Haas), and krypto- phanic acid (Thudichum). Many of these substances are present in small quanti- ties, and as the methods employed for their isolation are very complicated, the reader must refer to such treatises as Neubauer and Vogel's " Analysis of Urine," or Salkow- ski's " Lehre vom Harn," for further details regarding those not mentioned in this text. , Urea.-CONa H4. O = C j Urea is the amide of carbonic acid, and is therefore called carbamide. Its chemical relations are well established by numerous syntheses and reactions. Its relation to carbonic acid, for instance, is seen through its preparation from phosgene gas. o _ c j OH o _ c f Cl o _ c f NH, u ~ 1 ( OH °-c}Cl u"l|NH3 Carbonic Acid. Phosgene Gas. Carbamide. COCla + 4 NH3 = O =C j + 2 NH4 Cl Phosgene gas and ammonia yield urea and ammonia chloride. Few substances are of such historical interest to science as urea. It was first prepared by Rouelle in 1771, and called by him extractum saponcecum urina. Foucroy and Vauquelin obtained it in a state of purity in 1799, and gave it the name urea. In 1828 Wohler made the observation that cyanate of ammonium, then regarded as an inorganic body, could be readily converted by heat into urea. Thus a substance hitherto produced only in the animal body, was for the first time obtained by arti- ficial means. Urea is a solid, crystallizing in long white quadratic prisms with oblique ends. Melting point, 132° C ; very soluble in hot water ; soluble in one part of cold water and five of alcohol; insoluble in ether. The aqueous solution is neutral in reaction, but urea acts as a base, readily uniting with acids to form chemical compounds. These are generally less soluble than urea, and serve as a means of detecting it in solution. The nitrate, CO (NIIa)a HNOS, and the oxalate of urea, 2CO (NHa)a.Ca II2O4, are the easiest to recognize. To detect the presence of urea in any solution, concen- trate the liquid to a syrupy consistence on a water-bath, place a drop on a slide or watch-glass, add a drop of nitric acid, and examine with a low power under the microscope. The rhombic and hexagonal plates of the nitrate of urea are characteristic. A watery solution of furfurol added to urea in concentrated hydrochloric acid gives a violet color that rapidly becomes deep purple (Schiff). These reactions may be confirmed by the brisk effervescence of a solution containing urea on adding nitrous acid, hypobromite, or hypochlorite of sodium. In testing for the presence of urine it is not sufficient to find urea alone, as the latter is not only present in traces in most of the fluids of the body, but its solution readily transudes through animal membranes. If uric acid be found together with urea, the presence of urine may be considered established. Urea may be prepared from urine by first concentrat- ing it into a small bulk and precipitating the urea with strong nitric acid as nitrate of urea. These crystals are dissolved in hot water and decolorized with permanganate of potash. The decolorized crystals are reprecipitated on cooling the solution. The nitrate of urea is then de- composed by barium carbonate, the mixture evaporated to dryness, and the urea extracted with strong alcohol. If the alcoholic solution is not colorless, it may be decol- orized by filtration through animal charcoal, and evapo- rated over a water-bath to precipitate the urea. Urea not only unites directly with acids, as stated above, but also forms definite chemical compounds by direct union with many neutral salts, oxides, etc. Of these, the compounds formed by the action of a solution of urea on a nitric-acid solution of mercuric oxide are of special interest, as they form the bases of Liebig's volu- metric method of estimating urea in urine. Liebig found that after evaporating a mixture of solu- tions of urea and mercuric nitrate, three different com- pounds were left, in which one molecule of urea was combined with two, three, or even four, atoms of mer- cury. He further found that in dilute solutions (about two per cent.) of each, instead of the three possible substances, only one was found, viz., the last, the com- pound of one molecule of urea with four equivalents of mercury. This has the formula (CONSH4)2 Hg (NOS)2 + 3 HgO ; that is, a definite compound is formed which contains urea and mercury in the proportion of 60 to 432 or 10 to 72 ; so a solution of urea containing 10 grammes would require to precipitate it just 72 grammes of mer- cury dissolved in nitric acid, and any further mercury added would remain uncombined. The precipitate so formed is white, gelatinous, and not decomposed by car- bonate of soda ; but if the nitrate of mercury is in excess, a yellow precipitate is formed when carbonate of sodium is added. Thus the exact point at which all the urea is precipitated by the mercury can be determined, as then, and not before, will carbonate of sodium give the yellow precipitate of mercuric oxide when brought in contact with the mixture. It has been found that a slight excess of the mercury solution is necessary to produce an ap- preciable reaction, viz., 5.2 grammes of the oxide per litre of standard solutions ; therefore, the relation of the urea to the mercury in actual operation of titration is calcu- lated as 10 to 77.2 instead of 10 to 72. Before an estimation of the urea in a sample of urine can be made by Liebig's method, the sulphates, phos- phates, and chlorides must be removed by precipitation, as well as any albumen or blood. The urine so prepared is titrated with a mercuric nitrate solution standardized by a solution of urea of known strength. To obtain accurate results by this method it is essen- tial that a number of details be carefully observed, and a number of fallacies avoided. Indeed, without regard to the minutest detail the results are very unsatisfactory. Space precludes the possibility of giving full instructions here ; these, however, may be found in Tyson's "Prac- tical Examination of Urine," Sutton's "Volumetric Analysis," or any larger text-book on urine. While Liebig's method is, in skilful hands, the most accurate one for the determination of urea, it is not entirely free from inaccuracies. Pfliiger and Bohland have shown that creatinin, xanthin, and probably some active constitu- ents of urine, also unite with mercury. The error from this source is small. To determine the total proteid metamorphoses going on in the body, it is not sufficient 410 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Urine. Urine. to determine the urea alone, as it has been shown that about sixteen per cent, of the total nitrogen excreted by the urine passes out in other forms. Total Nitrogen in Urine.-For the accurate estimation of the proteid changes going on in the body, it is often necessary to ascertain the total nitro- gen excreted in urine. This is most conveniently done by Piliiger and Bohland's modification of Kjaldahl's classical method. This is briefly as follows : 5 c.c. of urine are measured into a conical flask holding about 300 c.c., and to this are added 10 c.c. of strong sulphuric acid, and 10 c.c. of Nord- hausen fuming sulphuric acid, and the mixture is heated on a wire gauze over a Bunsen flame, till the water and any gases formed are driven off and the color of the mixture is changed from black to brown ; then the flame is made small and the heating continued gently till the fluid is a light yellow and there is but little " bump- ing." Half an hour suffices for the decomposition of the urine. The mixture, after cooling, is now dilut- ed to 200 c.c. with distilled water, and when cold 80 c.c. of caustic soda solution (specific gravity 1.3) is add- ed and the mixture slowly distilled over a small flame. The liquid and gas passing over are led through a measured quantity of a standard solution of sul- phuric acid which absorbs all the ammonia. The end of the operation is ascer- tained when a piece of litmus paper held in the stream from the retort is no longer turned blue. The uncom- bined sulphuric acid is now determined by titration with standard alkali, and the amount of ammonia combined with the acid thus calculated. From this the amount of nitrogen in 5 c.c. of urine is at once obtained. For the purposes of the practising physician, one of the now numerous devices for determining the urea by measuring the quantity of nitrogen evolved, when it is decomposed by hypobromites, or hypochlorites, is suf- ficiently accurate, and requires little expenditure of trouble or time. All these methods depend on the reaction represented by the following equation : CON2H4 + 3 Na Bro = 3 Na Br + Urea. Sodium Hypobromite. Sodium Bromide. Na + 211,0 4- CO2 Nitrogen. Water. Carbonic Acid. According to this reaction, 1 gramme of urea should evolve 372.7 c.c. of nitrogen gas at normal temperature and pressure. Careful experiments of Hofner, confirmed by others, show that 1 gramme of urea really evolves but 354.33 c.c. of nitrogen, and therefore each cubic centimetre of nitrogen gas collected at 0° C. and 760 mm. of pressure corresponds to 0.00282 gramme of urea, instead of to 0.00268, the theoretical quantity. Of the many forms of apparatus suggested for the purpose of rapidly and conveniently collecting and measuring the evolved nitro- gen, only a few of the more recent and convenient forms will be noticed. Dupr&s Method.-(Fig. 4261). Here 5 c.c. of urine are introduced in the small tube attached to the cork. Into the small bottle are poured 25 c.c. of strongly alkaline hypobromite solution, made by dissolving iOO grams of caustic soda in 250 c.c. of water and adding 25 c.c. of bromine. To this are added from 35 to 40 c.c. of water. The tube is suspended in the hypobromite so- lution by carefully fitting the cork into the bottle. The glass tube in the perforated cork is now tightly con- nected with the receiver by a piece of rubber tubing ; and the receiver is filled to the zero mark with water, by low- ering it in the cylinder. After opening the tap, d, at the top, the bottle is tightly closed, and the receiver elevated half out of the water in the cylinder. If the apparatus be tight, the water remains at a constant level, and the estimation is made by tilting the bottle so as to pour out the urine from the tube into the hypobromite ; the carbonic-acid gas evolved is absorbed by the caustic soda, and the nitrogen only goes over and replaces the water in the graduated receiver. When no more gas is evolved the receiver is lowered in the water, allowed to stand to cool the gas, and then raised till the water inside is on a level with that in the cylinder ; the volume of gas is then read off, and the number of c.c. multiplied by 0.00282, gives the urea present in 5 c.c. of urine. From this the amount excreted in twenty-four hours is to be calculated. If extreme accuracy be required, the correction for temperature and volumetric pressure must be made. The percentage of urea is then calculated by the follow- ing formula : Percentage of urea ) 760 x 354.3 xa. (1 + .003662.), where a = volume of urine used. h = barometric pressure in millimetres. h' = tension of aqueous vapor at temperature. t = temperature of room (centigrade). v = observed volume of nitrogen. This correction is quite unnecessary for ordinary clini- cal work. This apparatus is especially to be recommended for laboratory use and purposes of demonstration. Green's Method.-Dr. W. H. Green's apparatus (Fig. 4262) is much simpler than Du- pre's and admits of rapid work. It consists of a simple graduated measuring-tube, a graduated pi- pette, and a funnel-tube. The essential part is the grad- uated tube, whose under por- tion, holding about 50 to 60 c.c., has a side tube. The upper part of the tube is graduated for 20 to 25 c.c. To make the determination, a measured quantity (about 2 c.c) is introduced by the bent graduated pipette into the glass vessel, which has been previous- ly filled with hypobromite solu- tion, and placed in a saucer to catch the alkali that escapes. The nitrogen evolved collects in the graduated part of the tube. When decomposition is complete, the bent funnel-tube is inserted into the tubulus, and this filled to the same level as that in the graduated tube with hypobromite solution. The volume of gas is read off, and the urea calculated as explained above. The above apparatus has been modi- fied and improved by Dr. Marshal. Dr. C. A. Doremus has prepared a very simple form of urea apparatus (Fig. 4263). This is a modification of the apparatus used by Kuehne, of Heidelberg, to detect fermentable sugars, and consists of a simple tube bent at an angle of 45 degrees, the long arm closed and graduated, the short arm open and bulb-shaped. A nip- ple pipette, graduated to hold 1 c.c., is used to deliver the urine. Fig. 4261.-Dupre's Apparatus. Fig. 4262.-Green's Apparatus for the Estimation of Urea. (Tyson.) 411 Urine. Urine. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. To use the apparatus the long arm is filled with hypo- bromite solution, made as above, or filled with caustic soda (100 grms. dissolved in 250 c.c. of water), up to the mark =, and 1 c.c. of bromine, delivered from the pipette, is added, thus making the hypobromite in the tube. Enough water is added to fill the long arm and the bend of the tube ; 1 c.c. of urine is now slowly injected, the point of the pipette be- ing introduced well under the long arm, and with care this may be done without any loss of gas ; after standing a minute or two to allow the bubbles to disappear, the quantity of urea in parts of a gramme may be read off at once. The tubes are also graduated to in- dicate grains per fluid ounce of urine. The tube is graduated by experiment at 65° F., and has no pretensions to great scientific ac- curacy, but the estimations are quite close enough for practical use, and it has many obvious advantages for rapid approximate estimations. Dr. Squibb has proposed a very ingenious and simple method of estimating urea. This simple apparatus can easily be constructed by a student or practitioner for himself. It consists, as seen in Fig. 4264, of two bottles connected by rubber tubing, and stoppered with rubber stoppers ; one has a doubly per- forated stopper and is partly filled with water, the other is to contain the decomposing fluid, and a ho- moepathic vial or short test-tube, holding the urine. Squibb recom- mends the use of fresh chlorinated soda, made according to the Unit- ed States Pharmacopoeia, instead of the hypobromite. The former is but a strongly alkaline solution of hypochlorite of soda, and reacts similarly to the hypobromite. The screw clip on the pendent rubber tube is closed, and the 5 c.c. of urine in a tube are introduced into the smaller bottle with 25 to 30 c.c. of chlorinated soda, the stopper is tightly replaced, and the screw clip opened ; a fewr drops of water escape, and if the corks, etc., be tight, no more water drops. Then, the apparatus being in equilibrium, the open tube is placed in a graduated glass, and the urine emptied into the decomposing fluid by tilting the bottle. The gas liberated displaces exactly its own volume of water from the larger bottle, and this is col- body. A healthy man from twenty to forty years of age excretes thirty to thirty-five grammes, or about five hun- dred grains, per day, women somewhat less, and children, in proportion to weight, more than adults, relatively about 1.7 to 1. Between the ages of forty and fifty years a reduction of about five per cent, should be made, and a reduction of ten per cent, between fifty and sixty. Late in life the decrease is still greater. Although numerous researches go to show that urea is derived from the oxi- dation of proteids, it has never been prepared outside of the animal body by direct oxidation of albumen. Duchsel's interesting experiments point to the con- clusion that salts of carbaminic acid and oxaminic acid are the immediate antecedents of urea. The decomposi- tion of proteids into glycocol, leucin, and tyrosin by the action of alkalies and acids is well known. Duchsel, by oxidation of these with permanganate of potash in an al- kaline medium, obtained, besides carbonic anhydride and ammonia, carbaminic and oxaminic acids. Oxaminic acid by oxidation gives rise to carbaminic acid. More- over, carbaminic acid is formed when ammonia and car- bonic anhydride act on each other under certain con- ditions, and according to Duchsel it can be recognized in the blood. From salts of carbaminic acid urea may be formed thus :- 2 CO ONa - pQ i NHg pp ( ONa 2 CU } NIL ~ ( NH, + CU 1 ONa Sodium carbaminate. Urea. Sodium carbonate. By electrolysis Duchsel obtained urea from ammoni- um carbaminate thus: CO j OH4N pp ( NHj 1 tt 0 ] NIL ~ ( NH2 + Voit, Bischoff, and Ranke have shown that in twenty- four hours the quantity of urea, or more exactly, the total nitrogen excreted in urine, varies directly as the quantity of nitrogen in the food digested, where the nu- triment taken is sufficient to cover the daily loss of body substance. This nitrogenous balance is accompanied by a constant nitrogenous deficit from the nitrogen thrown off in epidermal structures (hair, nails, and epidermis), and from the nitrogen excreted as ammonia by the lungs and skin. Voit has shown that each 100 grms. of muscle-tissue corresponds to 3.4 Grms. of nitrogen or 7.286 Grms. of urea. Therefore each gramme of urea excreted cor- responds to 13.72 Grms. of muscle-tissue, and a starving patient loses daily as many times 13.72 Grms. of muscle- tissue from his body as he excretes grammes of urea. The chief physiological causes of variation in the quantity of urea in the urine are as follows : It is increased by all that increases tissue change, e.g., exercise, physical and mental, high temperature, and warm baths, also by copious drinking, and large eating, especially of animal food. It is diminished by all that depresses the nervous system and lessens tissue change, such as indolence of body or mind, fasting or vegeta- ble diet, abstinence from water; the use of alcoholic drinks, or of tea and coffee, also causes its excretion in subnormal quantity. In disease a retention of urea in the system occurs in all cases where there is decreased diuresis (see Quantity of Urine), e.g., disease of the kidneys or diminished arterial pressure. Excessive perspiration, diarrhoea, and transudation of water into the serous cavities of the body or into the connective tissue, by lessening the fluids excreted by the kidneys, also diminish the quantity of urea excreted. Urea is increased in acute febrile diseases until the acme of the fever is reached. It then later becomes subnormal, and during convalescence gradually approaches the normal. In croupous pneumonia, during the crisis, from 50 to 70 Grms., or over two ounces of urea are excreted daily. In the early stages of typhus, typhoid, and acute rheuma- tism the daily quantity of urea may reach 50 Grms., though the total quantity of urine is greatly reduced and the quantity of nitrogenous food taken is almost nil. In intermittent fever, Jachmann and Traube have ob- Fig. 4263.-Apparatus of C. A. Doremus for Estima- tion of Urea. lected and measured ; thus the volume of nitrogen is in- directly but quite accurately ascertained. The number of cubic centimetres of water liberated, multiplied by .00282, gives the urea in 5 c.c. of urine. Urea is the most constant constituent of the urine, and forms about half of the total solids. It is the end prod- uct of the decomposition of proteids in the human body, and approximately, in health at least, its amount is a measure of the activity of the tissue changes in the Fig. 4264.-Squibb's Apparatus for Estimating Urea. 412 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Urine. Urine. served an increase of urea during the paroxysm; this in- crease is seen just before the cold stage. In diabetes the urea may reach 100 Grins, per diem. In most chronic diseases accompanied by diminished tissue metabolism and impaired nutrition, the urea sinks below normal. During the stadium algidum of cholera there is dim- inution of urea. In most liver affections the urea falls far below normal; in some cases, as in acute yellow atrophy, it is almost absent, yet the total nitrogen ex- creted may not be very low, as it passes into the urine in the form of leucin and tyrosin. Prolonged retention of urea in the body suggests always the danger of uraemic poisoning. Prognosis should be guarded in these cases, unless the total nitrogen excreted be greatly reduced. Rosenstein reports a case in which the total nitrogen in the urine was above normal while the urea was almost absent. Xanthin Group of Organic, Bodies. Uric acid (Lithic acid), C5ILN4O3.-The salts of this acid are, next to urea, the most important and constant of the nitro- genous constituents of the urine of mammals. It is exclusively in the form of uric acid and urates that the worn-out nitrogenous material of the tissues of fish, birds, and reptiles is excreted. The chemical constitution of uric acid has been in late years carefully worked out, especially by E. Fischer. Its decompositions and relations to other compounds may be indicated by the formula c°-^-co-g-gg-co (Fischer)- As uric acid gives rise to urea and alloxan on oxidation, it was long supposed that the proteids of the body were first oxidized to uric acid and subsequently to urea, and that the former was but imperfectly oxi- dized urea. This view was supported on physio- logical and pathological grounds as well as chem- ical, as it was observed that the uric acid in urine was increased by all causes that rendered oxi- dation imperfect, i.e., it is increased by excess of nitrogenous food, a sed- entary life, and in such diseases as emphysema, etc. This view, however, is no longer held. Birds have a higher tempera- ture than mammals, and their blood is highly oxi- dized, yet they excrete little or no urea. The wide researches of Krie- reim proved that those substances, glycocol, leu- cin, and asparagin, which in man give rise to urea, and which are obtained by the decomposition of proteids, are in birds converted into uric acid. It is highly probable that the source of uric acid, in man and mammals generally, is nuclein, which by its decomposition gives rise to the so-called xanthin bodies. The connection between these substan- ces and uric acid is well known ; the reduction of uric acid by nascent hydrogen gives rise to xanthin and hy- poxanthin, and these when oxidized yield uric acid. The relation of these bodies is seen at a glance : Hypoxanthin (sarcin), C6H4N4O Xanthin, C»H4N4Oa Uric acid, C6H4N4O3 Uric acid, -when pure, crystallizes in colorless, shining groups of rhombic tablets, but in urine the crystals are always colored a yellow-red, and vary greatly in their size and form, lozenge-shaped, elliptical tablets, "whet- stone form " being the commonest (Fig. 4265) ; but it is frequently seen as rounded disks, spear-heads, dumb-bells, stars, rosettes, rarely as prisms or hexagonal plates (for other forms see Figs. 2317 and 2318, Vol. IV.) It is very slightly soluble in water, 1 part of uric acid dis- solving in 14,000 to 15,000 parts of water at 20° C., and in 1,800 to 1,900 parts of boiling water. It is insoluble in alcohol and ether. It is much more soluble in water containing neutral phosphates of the alkalies, as it de- composes them, uniting with the base, thus forming an alkaline urate and an acid phosphate. It is strikingly soluble in lithium carbonate ; 1 part of lithium carbonate dissolved in 90 of water will take up 4 parts of uric acid (Lipowitz). Owing to its insolubility, very little uric acid is excreted as such in the urine, but is found combined with the metals of the alkalies or alkaline earths as urates, which are much more soluble. Uric acid acts as a dibasic acid, forming acid and nor- mal salts. The former are much the more insoluble ; the acid urate of soda is soluble in 124 parts of hot water and in 1,100 to 1,200 parts of cold, while the neutral salt is soluble in 65 parts. Hence all urates precipitated in urine are acid salts. Dissolved neutral urates are often precipitated as acid salts by the action of nitric and other acids. In the process of testing for albumen, the first effect of the strong mineral acid is to take away part of the alkali combined with the uric acid, thus forming an acid urate. These acid urates form one of the commonest sediments of the urine. They are al- ways colored, from a flesh-color to brick-red or brown (sedimentum late- ritium), and disappear on the application of slight heat. Uric acid is best recog- nized by the appearance of its crystals under the microscope (Figs. 2317 and 2318). A fluid sup- posed to contain uric acid is concentrated on the water-bath to small bulk, a few drops of hydrochlo- ric acid added, and set aside. If a linen thread be placed in the liquid, the crystals will form about it, and these may be recognized under the microscope. Chemically, several tests are used to identifythis acid,whether free or combined. The muroxide test of Wohler and Liebig consists in evaporating to dryness over a water-bath the sus- pected substance moist- ened with nitric acid. The reddish residue on the porcelain is turned purple-red by ammonia, and this changed to a violet color on the addition of caustic alkalies. Schiff identi- fies uric acid by dissolving it in a drop of soda solution, moistening with this solution a piece of white filter-paper to which has been added a drop of silver nitrate solution. Uric acid causes a dark brown spot of reduced silver. With of a milligramme a stain is produced. Boiling uric acid with Fehling's solution produces a yellow pre- cipitate of cuprous oxide ; one molecule of uric acid re- duces two of cuprous oxide (W. Muller). In the presence of excess of caustic potash, dissolved uric acid precipi- tates from a deep blue solution of copper hydrate the white cuprous urate. Quantitative Estimation.-Salkowski's modification of Fokker's method : 250 c.c. of urine is mixed with 50 Fig. 4265.-Whetstone and other Common Forms of Uric Acid Crystals. (Hof- mann.) 413 Urine. Urine. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. c.c. of an ammoniacal magnesia mixture, and immedi- ately filtered to avoid the formation of the insoluble urate of magnesium ; 250 c.c. of the filtrate, equal to 200 c.c. of urine, are now precipitated with a three per cent, solution of silver nitrate. This precipitate settles rapid- ly. A few c.c. of the clear supernatant fluid are tested for excess of silver by acidification with nitric acid ; if silver be not present in excess, it is again made alkaline with ammonia, and more silver nitrate added until the supernatant fluid contains a slight excess of silver. This precipitate is thrown on a folded filter and washed with water till the filtrate gives no trace of either silver or chlorine. The filter and contents are now placed in a flask, 200 c.c. of water is added and well shaken, and a stream of sulphuretted hydrogen is then passed through with occasional shaking. The contents are then heated to near the boiling point and acidified with hydrochloric acid, and then filtered free from the sulphide of silver (and paper) ; the clear filtrate is now evaporated to a few cubic centimetres in a porcelain dish. To this is added a few drops of strong hydrochloric acid, and after standing for twenty-four hours in a cool place the pre- cipitated uric acid is collected on a weighed filter, washed with water, then with alcohol, and finally with absolute alcohol and ether. The wash-water is measured, and for every 10 c.c. of it, 0.48 milligramme of uric acid is added. E. Ludwig has recommended a modification of the above, which is a decided improvement. He precipitates the urine with a mixture of magnesium and ammoniacal silver nitrate ; washes the precipitate with dilute ammo- nia, and then decomposes it with a hot dilute solution of sulphide of potassium ; filters off the silver sulphide and phosphates, and acidifies the filtrate with hydrochloric acid ; evaporates to 10 or 15 c.c. and again adds a few drops of hydrochloric acid ; allows it to stand and washes the precipitated uric acid on a weighed filter with water ; dries, and again washes with carbon disulphide and ether to remove traces of sulphur. Any albumen in the urine must be first removed by precipitation with acetic acid and a saturated solution of sodium chloride. The quantity of uric acid excreted daily in health va- ries from 0.2 to 1.10 gramme, or from 3 to 16| grains. Normally, the excretion of uric acid runs parallel to that of urea ; a relation of about 1 part of uric acid to 45 of urea is maintained in health ; so all causes that produce variations in the urea excreted in health proportionately affect the quantity of uric acid. This relation is dis- turbed in disease. Bartels observed that in the initial stage of fevers the relation was 1 to 37, and during defer- vescence it was only 1 to 64. He finds, however, during the course of the disease, that the uric acid rises and falls with the urea; an absolute increase was observed only when the fever was complicated with marked disturb- ance of respiration, e.g., in pneumonia, pleurisy, or acute bronchitis. Ranke found that starvation reduced the uric acid to 0.24 gramme, with a diet free from nitrogen 0.3 gramme was excreted, while a meat diet increased the quantity to 2.11 grammes. In the new-born the quantity is proportionately greater than in adults. It increases up to the third or fourth day, and then rapidly falls. It is increased by muscular fatigue. Certain medicinal agents decrease the amount of uric acid passed, e.g., quinine, potassium iodide, caffeine, and the alkaline car- bonates ; in febrile affections generally-acute exanthe- mata, articular rheumatism, and typhoid fever especially -uric acid is increased ; and the other constituents of the urine are present in subnormal quantity in such diseases of the liver as cirrhosis, acute yellow atrophy, and can- cer ; also in scurvy and splenic affections. In functional derangements of the liver, and as a condition antecedent to the development of syphilis, phthisis, and cancer, uric acid is in excess, as are also most of the other constitu- ents of the urine. Of special interest is the marked in- crease of uric acid in leukaemia, on account of the rela- tion it bears to the other xanthin bodies and to the nuclein of the white blood-corpuscles. As much as 4.2 grammes of uric acid have been obtained from a day's urine (Ranke). Chronic gout, chlorosis, anaemia, and diabetes mellitus are characterized by a subnormal excretion. A deposit of uric acid from the urine on standing does not necessarily imply an excessive elimination from the body. This is due to an excess of acidity, either absolute or rela- tive. When the healthy action of the skin is checked, as in cold weather or from psoriasis and eczema, there is an absolute hyperacidity accompanied by a sediment of acid urates or uric acid. A relative increase of acidity with the urine loaded with urates is seen in pyrexia, diarrhoea, and especially in acute rheumatism, when from the ex- cessive elimination of water by other channels, urine be- comes too concentrated and acid to hold up the uric acid. Uric acid passed with the urine is always pathological, and frequently indicates the presence of calculi. Xanthin (CsHiNiOa) occurs in urine normally, about 1 gramme in 300 litres. It is an amorphous yellow-white powder, slightly soluble in boiling water. It is the first stage in the oxidation of hypoxanthin to uric acid. Gau- thier has prepared it artificially, as he has also the allied substance, guanin. It closely resembles in reactions and formula the plant alkaloids theobromine and thein. It is found in largest quantity in the urine of leukaemic patients and in the nephritis of children. It occasionally forms calculi. Hypoxanthin(or sarcin), C5H4N4O, can scarcely be called a normal constituent of urine, as it has hitherto only been recognized in the blood and urine of leukaemic patients. Besides the above, traces of paroxanthin and heteroxan- thin have been found by Soloman in normal urine. Hippuric acid. This occurs abundantly in the urine of herbivora. The quantity found in human urine varies greatly, being influenced more especially by the nature of the food ; 0.3 to 1.0 grain daily is about the limit of variation. It is an odorless, bitter-tasting, monobasic acid of the aromatic series, having the for- mula C9H9NO3. From its reactions and relations its formula has been established as benzoyl-amido-acetic acid, CII2 co2H I1 crystallizes in four-sided prisms with bevelled ends and edges (Fig. 4266), and is easily soluble in alcohol, but only in 600 parts of water. It is formed in the body either from benzoic acid itself, or indirectly from some allied substance that easily gives rise to benzoic acid when oxidized or reduced. This acid, uniting with glycocol, gives rise to hippuric acid. C7H6O2 (benzoic acid)+C2H5NO2 (glycocol) = C9H9NO3 (hippuric acid) + H2O. If 10 to 15 grains of benzoic acid be taken at night, the morning urine will give a precipitate of hippuric acid. It is obtained from urine containing an excess, by evap- orating the urine acidified with hydrochloric acid, as in the separation of uric acid ; warm alcohol dissolves the hippuric acid from the mixed precipitate of uric and hip- puric acids. Kiihne has observed that benzoic acid ad- ministered to patients suffering from diseases of the liver is excreted as such, and not as hippuric acid. From this he concludes that the seat of the formation of hippuric Fig. 4266.-Hippuric Acid Crystals. (Vogel.) 414 (Trine. Urine. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. acid is in the liver. The excretion of hippuric acid is in- creased by excess of vegetable aromatic substances in the food. The aromatic constituents of blueberries, plums, blackberries, pears, and some other fruits, pass out of the body as hippuric acid. The physiological synthesis of hippuric acid from its two constituents was the first known case of the forma- tion in the body of these ether-like bodies, containing a member of an aromatic united to one of a fatty group. Since then, not only the formation of hippuric acid from benzoic acid, but nitro-hippuric acid from nitro-benzoic, salicyluric from salicylic, and other similar syntheses, have led to the important generalization that aromatic bodies, i.e., substances allied to phenol, benzol, etc., are not, like the fatty compounds, oxidized to carbon dioxide and water in the body, but are excreted, after partial oxi- dation, in the form of an ethereal substance that is soluble in water. Of the excretion of hippuric acid in disease very little is known. That it can be, and is, formed from proteids during pancreatic digestion, has been fully established (Salkowski), but the relation of its increase or diminu- tion in the urine to disease is not well understood. It is found to be increased in jaundice, and in all febrile dis- eases, as well as in diabetes, but it is absent in acute and chronic nephritis. Creatinin, C4H7N3O, and creatin, C4H8N3O2, are closely related bases that are found in urine. The latter (crea- tin) is never found in normal acid urine, but replaces creatinin when the urine becomes alkaline. These sub- stances are easily transformed one into the other; thus creatinin by action of alkalies takes up water and be- comes creatin, while the latter in an acid medium loses water and becomes converted into creatinin. Hence it is that the creatin of the body is excreted in the acid urine as creatinin. The excretion of creatinin is dependent on the creatin derived from the digestion of proteids, and from the met- amorphosis of muscle flesh. It is found, not only in the urine of man, but also in that of dogs, cows, and horses. When pure, creatinin crystallizes in rhombic prisms, very easily soluble in water and alcohol. It is a basic sub- stance uniting with acids, and also with a few salts, to form well-crystallized compounds. Among these the best characterized is the creatinin zinc chloride (C4H,N3 O)2 Zn Cl2, which crystallizes in spherical groups of radi- ating needles, or in moss-like masses of similar crystals. These crystals are easy of recognition under the micro- scope, so are used to detect the presence of the base in alcoholic solutions. A very beautiful and delicate test for creatinin is the following one, devised by Th. Weyl: To a cold dilute solution of creatinin, or directly to urine, is added a few drops of a very dilute aqueous solution of nitroprussiate of sodium, and, drop by drop, a dilute so- dium hydrate solution is added, when a ruby-red color, which rapidly changes to yellow, indicates the presence of creatinin ; 0.003 per cent, gives the color in water, and 0.006 per cent, that in urine. Acetone gives a simi- lar color, but it is only for an instant. To be safe, if the presence of acetone be suspected, the urine should be first boiled to expel the acetone, and after it has cooled the test is to be applied. The daily excretion by healthy persons is from 0.6 to 1.3 grin., i.e., about the same quantity as that of uric acid. Its relation to urea is 1 to 35. Infants and those fed on an exclusively milk diet excrete very little or no crea- tinin. From a clinical point of view this base is of especial interest in connection with progressive muscular atrophy and diabetes mellitus. In the former disease Weiss and Ludwig found only 0.08 grm. daily, and in diabetes Galthgens only 0.17 to0.4 grm., its relation to urea being 1 to 103. In pneumonia and typhoid Hofmann observed an increase, and a decrease in anaemia, chlorosis, malaria, and tuberculosis. In two cases of tetanus Senator ob- served a slight decrease. Grocco, in some recent investigations, finds that in- creased muscular effort increases the creatinin in urine. He finds no relation between the intensity of fever and the quantity of creatinin, but in fevers with rapid mus- cular wasting creatinuria is never marked. In nervous diseases with muscular agitation it is increased. In others with immobility it is decreased. He confirms previous observations that in muscular atrophy there is marked de- crease, but he finds in very rapid atrophy there may even be an increase of creatinin. Aromatic Ethereal Sulphates.-This group in eludes a number of interesting compounds of analogous composition. They are all alcohols of the aromatic series (phenols) combined with sulphuric acid and potassium, and have received considerable attention of late. The principal members of this group are phenol (carbolic acid), cresol, pyrocatechin, indol, and skatol. They are not found free, but occur as the potassium-sulphuric bodies. Their relation to sulphuric acid may be shown by the general formula : R where R represents the radicle of KO 2 the combined phenol. Phenol (carbolic acid) CfiH6OH, may be detected in hu- man urine by strongly acidulating it with tartaric acid, distilling off about half, and shaking the distillate with an excess of ether two or three times. The ether washes out the phenol, and the residue, after distilling the ether extract, dissolved in a little water, gives the usual reac- tions of carbolic acid, i.e., a crystalline precipitate with bromine water, and a red color with Millon's reagent. It occurs in urine combined with potassium sulphate. It is derived, as indeed are nearly all of this group, from the aromatic products of tryptic digestion, of which tyrosin and indol are the best known. It is greatly increased in urine by the internal or external use of carbolic acid. Cresol, CeHiCHsOH, occurs in its different isomers (ortho-, meta- and para-cresol) in traces in human urine, combined in a similar way to phenol. Pyrocatechin, C6H4(OH)2, occurs very sparingly in the urine of adults, but more commonly in the urine of chil- dren. Urine containing it becomes very dark on decom- position. Scatol occurs as potassium skataxyl sulphate in urine (Brieger), a compound very closely related to indican. Skatol is probably methylindol, and is produced as a crystalline compound during intestinal decomposition. Indol occurs only as urine indican, potassium induxyl sulphate, described under urinary pigments. Acids of the Fatty Series and their Deriva- tives.-Lactic acid, C3H6O3, is a constant constituent of urine. It is derived from the lactic acid of the stomach, and as paralactic acid from muscle-tissue and bile. It is abundant in urine after phosphorus poisoning, and occurs also in increased quantity in trichinosis and in acute atrophy of the liver. Succinic acid, C4H6O4, has been found in normal urine. It is somewhat increased by a meat diet, and very greatly by the use of wines and spirits. Aspara- gus, from the decomposition of the contained asparagin into succinic acid and ammonia, very decidedly increases its quantity. Succinic acid is also formed in the econ- omy by the reduction of the salts of malic acid. Hofmann thus generalizes regarding the effect of dis- eases on the excretion of this substance. Local affections are without influence ; fevers increase it ; diseases at- tended with malnutrition produce a decrease. Advanced kidney disease diminishes it. Oxaluric acid, C3H4N2O4, appears in traces in urine as the ammonium salt. It is a w'hite powder but slightly soluble in water. It can be prepared from urea, and in turn decomposes into urea and oxalic acid with the elim- ination of water. Oxalic acid, C2H2O4, appears, but not constantly, in urine in the form of oxalate of calcium. The crystals of this substance are easily recognized under the micro- scope ; they occur in small envelope-shaped masses (reg- ular octahedra) (Fig. 4258), usually requiring a high power to recognize them. Sometimes, especially when mixed with mucus, the crystals are hour-glass shaped. It is excreted in health to the amount of about 20 mil- ligrammes daily. This quantity is increased by eating 415 Urine. Urine. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. substances such as rhubarb, sorrel, etc., which contain the acid. The increased excretion of oxalic acid has been called oxaluria. It is indicative of retarded tissue change, and is usually accompanied with an excess of uric acid. The oxalate of lime is held in solution in urine by sodium phosphate, and its separation is in- creased as the urine approaches a neutral reaction. Neubauer's method of demonstrating the presence of oxalate of calcium in urine is very accurate. About 500 c.c. of urine is treated with chloride of calcium and ammonia. The precipitate is dissolved in acetic acid, avoiding an excess of acid. After twenty-four hours the precipitate formed is collected on a filter and washed with water, and then treated with hydrochloric acid, which dissolves the oxalate but leaves the uric acid on the filter. The solution in hydrochloric acid is diluted with water to 15 or 20 c.c. and carefully overlaid in a test-tube with excess of dilute ammonia. After twenty- four hours the fluids will have mixed and any oxalate of lime present will be precipitated in beautiful octahedra. Normal Urinary Pigment.-The characteristic color of normal urine is probably not due to the presence of any one pigmentary body, but to the combined effect produced by several compounds, of which two at least have been well identified, viz., urobilin and urine indi- can. Besides these there are a number of pigments, for the most part derivatives of these two, which have separate names, but none of these has been shown to possess any chemical individuality. Of those not directly traceable to urobilin or to urine indican, Thudichum's urochrome and Heller's uroerythrin are the most important. Urobilin and urine indican have both been prepared artificially from haematin. Urobilin was obtained by Maly through reduction of bilirubin, and by Hoppe-Sey- ler by reduction of haematin and slow oxidation of the product by exposure to air. E. Ludwig obtained urine indican by reduction of hae- matin and bilirubin with zinc dust and potash. Urine is generally observed to become darker on standing exposed to air, but if oxygen be excluded this darkening does not occur ; it would seem, therefore, that the urinary pigments become changed by oxidation, or that there are not pigments alone, but some material as well that is capable of producing a pigment by oxidation -a " chromogen." The normal yellow-red urine be- comes pale yellow by action of alkalies and is decolorized by nascent hydrogen, but again becomes colored on standing exposed to air. Jaffe extracted a brown resinous substance from urine that is difficultly soluble in water, but readily in alcohol, giving a solution that varies from rose-color to yellow or brown according to the amount of pigment present. This substance he called urobilin. Maly afterward studied it and described it under the name of hydrobilirubin, as he regards it as reduced bilirubin partially absorbed from the intestines and ex- creted by the kidneys. Urobilin, C32H44N4O7, in dilute solution gives a green fluorescence and an absorption band between Frauen- hofer's lines b and f (Fig. 4270, 5). If an alkali (potash or soda) be added, another band appears nearer to b than the former, much darker, and more sharply defined. Jaffe obtained the pigment from the high-colored urines of fever patients by making them alkaline with ammonia, filtering, and precipitating the filtrate with chloride of zinc. This deeply-colored, bulky precipitate is washed free of chlorides with water, then extracted with hot alcohol and slowly dried. The powdered residue is dis- solved in ammonia and precipitated with basic lead acetate. This intensely colored precipitate is decom- posed by sulphuric acid and alcohol, allowed to stand in the cold for twenty-four hours, and filtered. The alco- holic filtrate contains urobilin and will show the above- mentioned characters. This is further purified by pro- cesses to be found in large works on urinalysis. Urobilin may be detected in the urine of fever patients by adding ammonia, filtering, and adding a few drops of zinc chloride to the filtrate. The green fluorescence and the characteristic absorption band show that the pigment is in excess. Normal urine will not, as a rule, yield the fluorescence or spectrum of urobilin by this treatment, but it may be detected by extracting the urine with alco- hol and acid-free ether, evaporating the ether, and dis- solving the residue in a few c.c. of absolute alcohol. Many fresh urines yield no urobilin ; but when they are exposed to the air for some hours, its presence can be demonstrated. Jaffe thinks that this is due to a chromo- gen that precedes the urobilin and is derivable from it by reduction. If we accept Jaffe's opinion that urobilin is a constant constituent of urine, and is not, as Esoff suggests, pro- duced by the oxidizing action of acids on chromogen during the process of extraction, then this substance, normally present in small quantity, is greatly increased in many affections, in febrile urine and in the urine of jaundice especially. To recognize it in icteric urine, it is necessary to first precipitate the bile-pigments by ad- ding milk of lime and leading through it a stream of car- bon dioxide (Salkowski). In some cases of jaundice the urine, though deeply colored, gives negative results with Gmelin's test for the bile-pigments. The pigment is here found to be ex- clusively urobilin. Gerhardt observed this peculiarity in cirrhosis of the liver, in pneumonia complicated with jaundice, and in the mild jaundice that sometimes ac- companies lead colic (urobilin icterus of Gerhardt). Hayem has recently stated that the origin of urobilin is from hepatic insufficiency, and that permanent in- crease of this pigment indicates infiltration or fatty de- generation of the liver-cells. According to Cazeneuve, it is increased in all diseases attended with abnormal de- struction of the red blood-corpuscles. Harley's urohaematin and Heller's urophain are prob- ably identical and are modifications of urobilin, present in large amounts where there is excessive disintegration of the red blood-corpuscles. Urochrome is, according to Thudichum, the one pig- ment of urine to which is due its characteristic yellow color. It is a yellow solid, soluble in water, acids, and alkalies. Its oxidation gives rise to a red pigment called uroerythrin, which is rarely, if ever, present as such in normal urine. Like Harley's urohaematin, uroerythrin contains iron, and its excretion is a measure of the de- struction of blood-corpuscles going on in the body ; to it is ascribed the brick-red color of urates deposited in fevers. Urine indican (Heller's uroxanthin and the indogen of Thudichum) is not a pigment, but like the indican of plants, with which it was originally confused, it gives rise when oxidized to indigo-blue. It is a derivative of indol (C»H7N), one of the products of the proteolytic action of trypsin, and is occasionally found during putrefaction. Indigogen, or urine indican, is a compound formed by the union of indol with the sulphuric-acid radicle, IISO3, in which potassium has replaced the hydrogen of the acid ; CBH6NSO4K (potas- sium indoxyl sulphate). The formation of indigo-blue by oxidation is thus shown by equation : 2 C8H6NSO4K q- O3 - Ci6Hi0N2O2 (indigo-blue) + 2 KHSO4 (acid potassium sulphate). Indican rarely, if ever, affects the color of urine, so its presence must be shown by transforming it into indigo blue. Normal urine contains only 0.0045 to 0.0195 gramme of this substance. Jaffe's method of testing for this substance is very convenient and gives an approximate idea of the quantity present. To 10 or 15 c.c. of urine in a test-tube or small beaker is added to an equal volume of fuming hydrochloric acid, and, with constant shaking, a clear, fresh, saturated solu- tion of bleaching powder is added, drop by drop, till the blue color reaches its greatest intensity. The indigo blue so formed is shaken out with chloroform, and the in- tensity of the tint imparted to the chloroform gives an approximate idea of the quantity of indican in the urine. Albumen, if present, must be removed before testing and dark urine should be decolorized by precipitation with 416 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Urine. Urine. a minimum quantity of basic lead acetate. If iodine be present this extract will be of a brownish-red color. Many of the causes that tend to increase the quantity of indol formed in the intestine, or prevent its excretion in the faeces, also produce an excess of indican in the urine, such as cancer of the liver or stomach, dyspepsia, and various forms of obstruction of the small intestine, e.g., stricture or incarceration of the bowel, and strangu- lated hernia. In some cases the quantity rises to ten or fifteen times the normal. It is also increased in purulent peritonitis, cholera and cholera morbus, Addison's dis- ease, and in every acute and chronic disease of the kidney. Pyrexia does not appear to affect the quantity of indican excreted. Observations made by Lawson in Jamaica show that the urine of the inhabitants of the tropics is nor- mally very rich in this substance. Two coloring substances called uroglaucin (blue) and urrhodin (red) are closely related to indigo blue and indi- go red. These are occasionally found in urine that has undergone decomposition in the bladder and in the de- posits from cystitis. The mixture of one or both of these colored substances with the normal yellow of the urine may give rise to these urines tinted of a violet, blue, or grass-green color. The Inorganic Constituents of Normal Urine. -These form the ash of the urine and include the chlo- rides, phosphates, sulphates, and carbonates of the metals sodium, potassium, calcium, magnesium, and iron. Be- sides these the base, ammonium, is always present in small amount combined with different acids, and there are occasionally found traces of nitrates and silicates. How these acids and metals are united in urine we know but little beyond the fact that the hydrochloric acid is chiefly combined with sodium, since all the other metals together would not satisfy more than one-third of the quantity of that acid present. The bulk of the inorganic constituents of urine cer- tainly comes from the salts in food, yet a portion of the sulphuric acid must come from the oxidation of the sul- phur in proteids, and some of the phosphoric acid is un- doubtedly derived from the decomposition of glycerine phosphate, which is the chemical nucleus of the widely distributed lecithin. Ammonia seems to play the role of a supplementary base to the alkaline salts of sodium found in the blood and to neutralize part of the free sulphuric and phos- phoric acids when these are in excess, as whenever the acidity of the urine is abnormally high, as in diabetes, we find an excess of ammonium salts excreted. The inorganic salts of the body are essential to the healthy action of the various tissues, and each form of tissue seems to require them in a different proportion ; thus the proportion! of phosphoric acid found in the brain is four times as great as that in the muscles, and twelve times that in the blood, wflien compared with the quantity of nitrogen found in these several tissues. There is very little doubt, however, that the tissues can carry on their functions unimpaired when the supply of inorganic salts is deficient, and, on the other hand, they are very tolerant of excess. Besides this the fact that only a variable proportion of these salts is excreted through the kidney must always be considered in interpreting the significance of their excess or deficiency in urine. Sodium Chloride, NaCl.-This salt occurs more abundantly in normal urine than any other constituent except urea; the daily excretion ranging from ten to fifteen grammes. Its presence in urine is easily demon- strated by acidifying it with nitric acid to hold in solu- tion the phosphates, and adding a few drops of silver nitrate solution. The white precipitate of silver chloride will be thick and curdy if the normal quantity of the salt be present, but in some cases it only produces an opalescence. This precipitate is soluble in ammonia and turns rapidly darker on exposure to light. Sodium chlo- ride crystallizes out from the urine when evaporated to a syrupy consistence in the form of cubes, regular octa- hedra and hopper-shaped masses (Fig. 4267). The quantitative method for the estimation of chlo- rides that has given the writer the most constant and ac- curate results is Mohr's method as modified by Sutton. The estimation is made by standard silver nitrate solu- tion with the potassium chromate indicator : 10 c.c. of urine are measured into a thin porcelain capsule and one gramme of pure ammonium nitrate added in powder; the whole is then evaporated to dry- ness and heated over a small flame to dull redness till all the fumes have disappeared and the residue is quite white ; it is then dissolved in a small quantity of water and the carbonates pro- duced by the ignition neutral- ized with dilute acetic acid ; a few grains of pure calcium car- bonate are now added to neutralize the free acids and the liquid colored with a few drops of a solution of potassium chromate. The mixture is then titrated with a standard solution of silver nitrate, which is made by dissolving 29.075 grammes of pure dry silver nitrate in one litre of distilled water. Each cubic centimeter of this solution is thus equivalent to 0.01 gramme of sodium chloride. The titration is thus made : the silver nitrate solution is delivered from a burette drop by drop into the mixture contained in a beaker, placed on a sheet of white paper, till a faint blood-red tinge becomes permanent. This in- dicates that the silver nitrate has combined with all the chlorine and a slight excess has formed the red chromate of silver by decomposing the potassium chromate. This change of color is seen even better by gaslight than by daylight. The number of cubic centimeters of silver nitrate used, multiplied by 0.01 gives the amount of so- dium chloride in 10 c.c., from which the total amount in the day's urine is calculated. Liebig's method is simpler than this, but the end-point is not definite enough to give accurate results. Under normal conditions the quantity of sodium chlo- ride in the urine rises and falls with the quantity taken in the food. It is, therefore, increased after meals and di- minished by starvation. The small quantity excreted during starvation is derived from the fluids of the tissues. The quantity of salt in the blood remains very constant, and if an excess be taken into the system it is immedi- ately followed by an increased excretion in the urine. Potassium chloride taken into the system causes an increased excretion of sodium chloride (Bunge). Exer- cise increases and rest diminishes its excretion. In disease there is often a very marked variation in the sodium chloride. This variation is especially character- istic of acute febrile diseases ; at the onset of the disease the quantity is increased, but at the acme of the fever it may sink to even one-tenth the normal amount. In croupous pneumonia and typhus, at the crisis of the dis- ease the sodium chloride is sometimes entirely absent from the urine. It disappears almost entirely from the urine during acute exudative processes and reappears as the exudation ceases, sometimes greatly increased in quantity ; hence in these affections the quantity of chloride in the urine is often of considerable prognostic value. Vogel found in intermittent fever an increase of chloride during the febrile stage. In dropsy, when the urine is decreased, the salt excreted falls to a minimum as it transudes with the fluid and is retained in the body, but with the appearance of diuresis it increases enor- mously with the increased urine, as much as fifty grammes daily being sometimes eliminated. Vogel cites a case in which the administration of a decoction of digitalis caused an increase from four grammes to twenty-seven in a day without any increased ingestion of chlorides in the food. It may be generally stated that in acute dis- eases the severity of the disease is inversely as the quan- tity of chlorides eliminated, and in most chronic diseases the amount eliminated is a very accurate measure of the patient's power to assimilate food. As digestion improves the chlorides increase; anything below five grammes daily show's an impaired digestion. Greatly increased elimination that cannot be accounted for by Fig. 4267.-Crystals of Com- mon Salt. (Charles.) 417 Urine. Urine. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. food or drugs is usually indicative of diabetes insipidus. In dropsy or hydraemia, however, it is a sign of decided improvement. Phosphates,-The phosphates that occur in human urine are all salts of one phosphoric acid, viz.: the tri- basic or ortho-phosphoric acid, H3PO4. This acid is combined with the metals sodium, potassium, calcium, and magnesium in normal urine. In morbid urine, or in urine that has undergone the alkaline fermentation, we find it also united in part with ammonium to form the so-called triple phosphate. Of the two to four grammes of the acid that are daily excreted about two-thirds are united with the metals of the alkalies, sodium and potassium, and about one-third with the metals of the alkaline earths, calcium and mag- nesium ; the latter constitute what are known as the " earthy phosphates." In very small quantity phospho- ric acid is eliminated in normal urine combined wfith glycerine as glycerine phosphate. The alkaline phosphates are represented chiefly by the acid phosphates of sodium and potassium, the latter in traces only. Of the three possible sodium phosphates, the acid phosphate (NaH2PO4), the disodium or neutral phosphate (Na2HPO4), and the normal or basic phos- phate (Na3PO4), the first only, in which one hydrogen atom of the acid is replaced by sodium, has an acid reaction ; the other two are alkaline to litmus. It is chiefly to this acid phosphate that urine owes its acid reaction, and it is in this combination that most of the phosphoric acid is eliminated. It is doubted by some authorities whether either of the other two alka- line phosphates is present at all in normal urine. The presence of the phosphates of the alkaline metals may be demonstrated by precipitating the earthy phosphates with ammonia, filtering and adding magnesia mixture * to the filtrate, when a crystalline precipitate of ammoni- um magnesium phosphate is formed, which, under the microscope, shows, when fresh, the fern-leaf or snow- flake crystals (Fig. 2324, Vol. IV.), but on standing some time, the common "coffin-lid" crystals appear (Fig. 4259). The earthy phosphates occur normally only in small amount, about 0.9 to 1.3 gramme daily. They consist of calcium and magnesium phosphates in the proportion of thirty-three to sixty-seven, i.e., there is about twice as much magnesium phosphate as calcium phosphate in urine. These earthy phosphates are precipitated from urine when the latter is neutral or alkaline, being held in solution only so long as the urine is acid. Thus it hap- pens that a precipitate of earthy phosphates in urine is no indication whatever that these salts are in excess. This precipitation of phosphates by alkalies may be thus represented by equation : the various forms as just described is derived from a va- riety of sources ; although the greater portion, undoubt- edly, comes from the food, the decomposition of such phosphorus-containing substances as lecithin and nuclein must yield no inconsiderable part of that excess of phos- phates which characterizes some nervous disturbances. The quantitative estimation of the total phosphoric acid in urine may be made in several ways. The most accurate and convenient method is the volumetric an- alysis by standard uranium acetate (Sutton's method). For this purpose the following solutions are required : (a) A standard solution of uranium, 1 c.c.=0.005 gramme P2O6. (b) A standard solution of tribasic phosphoric acid. (c) A freshly made solution of potassium ferrocyanide (yellow prussiate of potash). Standard solution of uranium acetate.-This is made by dissolving about 35 grammes of the salt in a litre of water containing 25 c.c. of glacial acetic acid. The solu- tion should be perfectly clear and free from the basic salt. To standardize this solution a solution of micro- cosmic salt (ammonio-sodium phosphate) is employed. This is made by dissolving 5.886 grammes of the crystallized salt, previously dried by powdering and pressing between sheets of filter- paper, in 1 litre of water ; 50 c.c. of this solution contains exactly 0.1 gramme of P2O6. The titration of the uranium solution is then made by measuring 50 c.c. of this phosphate solution into a beaker, heating it to 90° or 100° C., and delivering the uranium solution from a burette (Fig. 4268), till a drop of the moisture in the beaker placed on a white slab of porcelain when touched with a drop of the ferrocyanide solution gives a red color ; thus showing an excess of uranium nitrate. The number of cubic centimetres of uranium so- lution required to combine w'ith 0.1 gramme of phosphoric acid is thus ascertained : twenty c.c. is the required number, and if exactly this amount is not required the uranium solution is to be diluted or more uranium acetate added until exactly 20 c.c. gives with 50 c.c. of the phosphate solution the red color on addition of the ferro- cyanide. Suppose 18.7 c.c. w'ere used in the titration to give the color, then each 18.7 c.c. of the original solution will have to be diluted to 20 c.c. or 937 c.c. to 1 litre. In laboratories it will be found very convenient to have burettes attached to reservoirs holding the standard solutions ; such a bu- rette is shown in Fig. 4268. To estimate the phosphoric acid in a sample of urine after the uranium solution has been made of the proper strength, all that is necessary is to take 50 c.c. of the clear urine (filtered if necessary) and titrate it as above, after heating to about 100° C. The uranium solution is delivered in from a burette till no further precipitate is seen in the urine, then after each addition a drop is tried with ferrocyanide till the red color appears. Then the number of cubic centimetres used divided by ten will give the percentage of phosphoric acid (P2O6). Example.-The urine for twenty-four hours=1500 c.c. 18.5 c.c. of uranium acetate were required for 50 c.c. of urine. Therefore every 50 c.c. of urine contains 0.0925 gramme of phosphoric acid, i.e. 100 c.c. contains 0.185 gramme ; or the urine for twenty-four hours contains 2.775 grammes of phosphoric acid. To determine the quantity of phosphoric acid that is combined with calcium and magnesium (earthy phos- phates) 100 or 200 c.c. of the clear urine is made alkaline 3Ca(H2PO4)2 + Acid Calcium Phosphate. 12 KOH Caustic Potash. = Ca3 (PO4)2 + Neutral Calcium Phosphate. 4K3PO4 + Potassium Phosphate. 12 H2O Water. Fig. 4268.-New form of burette with reservoir, for laboratories and hos- pitals. Magnesium phosphate is precipitated by ammonia in beautiful crystals as ammonium magnesium phosphate or triple phosphate, thus : MgHPO« Magnesium Phosphate. + nh3 Ammonia. + h2o Water. = (NH<) MgPO, Ammonium Magnesium Phosphate. + h2o To test urine for these salts, it is only necessary to make it alkaline with potash, and a granular precipitate is formed, more rapidly on boiling. If no abnormal col- oring matters be present the precipitate will be quite white, but blood or the vegetable pigments from rhu- barb, etc., if present, impart their characteristic colors to the precipitate. Blood, rheum, and senna, give a red color ; bile pigments, brown to yellow ; uroerythrin gray. Glycerine phosphate (C3H9PO8) is eliminated by the kidneys to the amount of 0.015 gramme per litre of urine. This quantity is increased by many neuroses and during chloroform narcosis. The phosphoric acid occurring in urine combined in * Magnesium mixture consists of magnesium sulphate, ammonium chloride, and liquor ammonias fortis, one part of each dissolved in eight parts of distilled water. 418 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Urine. Urine. with ammonia and allowed to stand for from ten to twelve hours. The clear fluid is decanted through a fil- ter, and the precipitated triple and amorphous phosphates washed from the beaker on the filter with dilute ammo- nia ; this washing is repeated. This precipitate, contain- ing all the earthy phosphates, is now washed with dilute acetic acid, through a perforation made in the filter, into a beaker, dissolved in acetic acid, made up to about 50 c.c. and titrated as above described. Physiological causes of variation in excretion of phos- phates.-The quantity of phosphoric acid excreted is increased by animal diet. This is shown by the fact that phosphates are present in largest quantities after the chief meal of the day, i.e., with most people in the afternoon. Phosphorus or any of its compounds intro- duced into the system causes an increased elimination of phosphates. According to Zuelzer, the extent to which individual organs and tissues are participating at any particular time in the tissue metabolism of the body can be ap- proximately ascertained by comparing the relative quan- tity of the different inorganic constituents eliminated in the urine with the total nitrogen. He found from ex- periments that the relative quantity of phosphoric acid and nitrogen in urine depended on whether a tissue rich in lecithin or one rich in proteids formed the material from which the phosphates of the urine were derived, and that the phosphoric acid did not, as was supposed, always rise and fall with the nitrogen. Zuelzer found in blood 100 parts of nitrogen to 3 parts of phosphoric acid, in muscle the proportion was 100 to 12 of the acid, while in brain-tissue it was 100 to 44. Now if the chemical constituents of the tissues appear in the urine in similar relative quantities to that in which they occur in the tissues, then it is evident that the relative bulk of these constituents in the urine should indicate the nature of the tissue that was undergoing active change, for in- stance, whether it was nerve, muscle, or blood. Cer- tain experiments made by feeding with different tissues went to prove that the proportion of nitrogen to phos- phoric acid found in foods was maintained in the urine. In disease the variations in the elimination of phos- phates are more marked. In acute fevers there is an in- crease of the phosphates generally, but especially of the phosphate of potassium, which is usually excreted in very small amount. These are often increased seven- fold in acute febrile affections from the increased meta- bolism of muscle and of blood-cells. The total daily elimination of the acid is diminished in functional dis- eases of the kidneys, in diseases of the digestive organs which lessen the absorption of the food injected, and in acute yellow atrophy and cirrhosis of the liver. A marked increase of the earthy phosphates is characteris- tic of acute meningitis ; this fact has been used for the differential diagnosis of typhus fever and meningitis in obscure cases. This increase of earthy phosphates, ac- companied by their precipitation, has also been noticed in chronic articular rheumatism, osteomalacia, leukae- mia, and rickets. Zuelzer's researches on the relative elimination of phosphoric acid and nitrogen in diseases are interesting, as his results show that in disease the variations in the relative proportion of phosphoric acid are more constant and of greater diagnostic value than are the fluctuations in the total amount of phosphates excreted. He finds the relative quantity of phosphoric acid is subnormal in fevers generally, in diabetes mellitus, Addison's disease, nephritis, acute liver atrophy, in the excitement preced- ing an epileptic attack, and that its excretion is dimin- ished by the action of such stimulants as alcohol, strych- nine, valerian, and ammonia. The proportionate quantity of phosphoric acid is, on the other hand, increased during convalescence from fevers, in the first urine of cholera, and in patients under the influence of narcotics and seda- tives such as morphine, chloroform, chloral, bromides, and excessive doses of alcohol. Dr. Tessier, of Lyons, has recorded a series of cases that are closely related to diabetes mellitus, in which, however, there is no trace of glucose in the urine ; the characteristic feature of the disease being a very large and constant excess of phosphates in the urine, amount- ing to from 15 to 20 grammes daily. The symptoms in these cases were, increased amount of urine, intense thirst, rheumatic and neuralgic pains, wasting, and secondary lung complications. These cases so closely resembling diabetes mellitus, excepting in the absence of sugar in the urine, often merged into this latter disease, the sugar gradually replacing the ex- cess of phosphates. To this group of symptoms Dr. Tes- sier, and later Dr. Ralfe, of Cambridge, have given the name " phosphatic diabetes." Dr. Tessier distinguishes four groups of cases : 1. Those in which nervous symp- toms predominate. 2. Those which accompany pul- monary consumption. 3. Those which precede, alter- nate with, or coexist with diabetes mellitus. 4. Those which run a distinct course resembling that of saccha- rine diabetes, but without sugar. Even if the cases are not so marked as those described, as Dr. Ralfe has pointed out, whenever we have to deal with persistent elimination of phosphoric acid in exces- sive quantities, very distressing constitutional symptoms are found associated with the discharge. The symp- toms vary, but we generally find great nervous irritabil- ity, dyspepsia, emaciation, pelvic and lumbar pains, the urine copious, acid and clear, or alkaline and milky from a deposit of earthy phosphates. Sulphuric Acid, H2SO4.-This acid, like the other inorganic acids, does not occur in urine free, but always in combination. There are two classes of sulphuric-acid compounds in urine. (1) The Sulphates of the Alkaline Metals.-Here the acid is so combined that, without further treatment, urine containing it gives a precipitate with barium chloride. Sulphuric acid so combined is the " preformed sulphuric acid " of the German physiologists. (2) The Aromatic Ethereal Sulphates, which are nor- mally in very small quantities, do not give a precipitate with barium chloride, unless they are first decomposed by long boiling with hydrochloric acid. The aromatic radicle (phenol, cresol, indol, etc.) is then separated from the sulphuric acid and the latter can be recognized in the usual way. The sulphuric acid united to these or- ganic radicles has been distinguished by the name of " combined sulphuric acid." Besides, in the form of sulphuric acid, a certain amount of sulphur finds its way into the urine in an imperfectly oxidized condition as sulphocyanic acid (HCNS) (Munk) and in the form of taurin (C2H,NSO3) from the taurocholic acid of the bile (Lepine). Com- paratively little of the sulphuric acid found in the urine is derived directly from the food. Nearly all results from the oxidization of the sulphur in albumen. A con- siderable portion of the sulphur introduced into the body is eliminated by the bowels, skin, hair, and epithe- lium, so that in proportion to the quantity of sulphur in the tissues of the body, comparatively little finds its way out through the urine. The normal amount of sul- phuric acid eliminated daily is about 2 grms., or from 1.5 to 2.5 grms.; of this about nine-tenths is combined with the alkaline metals sodium and potassium in the form of neutral sulphates, and the remaining one-tenth united to the aromatic phenol radicles and eliminated as the potassium salts of the aromatic ethereal sulphates. These phenols are in themselves highly poisonous, but when united with sulphuric acid they entirely lose their toxic properties. The administration of sulphuric acid increases the alkaline sulphates of the urine, but has no influence whatever on the quantity of these aromatic sulphates. The variations of the latter depend on the quantity of phenols available in the system at any given time, for they are able to displace the alkaline metals occurring in combination with sulphuric acid in the blood. This is well shown in cases of intoxication from absorption of carbolic acid ; the dark phenol-containing urine gives a very faint precipitate with barium chloride -sometimes none at all-and yet the total sulphuric acid in such urine is, perhaps, more than normal, but it is all combined to form potassium phenol sulphate, and, 419 Urine. Urine. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. as stated above, the sulphuric acid so combined can only be recognized by first decomposing the aromatic ether with hydrochloric acid. The method of detecting the presence of sulphuric acid in the urine has already been referred to ; barium chloride forms with the alkaline sulphates a white precipitate of barium sulphate which is insoluble in nitric or hydrochlo- ric acids. In making the test for the alkaline sulphates, the urine must always be first acidified with acetic acid to prevent the precipitation of barium phosphate. The quantitative estimation of sulphuric acid may be roughly, but quickly, done by Vogel's method for rapid clinical work. His method is based on the fact that the average normal urine for twenty-four hours contains 2 grms. of sulphuric acid, and it only indicates whether the sulphuric acid is considerably increased or diminished ; one-twentieth of the day's urine is taken and acidified with hydrochloric acid, and this should contain 0.1 grm. of sulphuric acid if the urine be normal. To this is added 5 c.c. of standard barium chloride made by dis- solving 30.5 grms. of barium chloride in 1 litre of water ; now, as each c.c. of this barium chloride solution is equal to 0.01 grm. of sulphuric acid (SO3), the 5 c.c. added is equivalent to 0.05 grm. of acid. The precipitate formed is filtered off, and if the addition of more barium sulphate does not give a further precipitate, there is less than .05 grm. of acid in the quantity taken and less than 1 grm. in the day's urine. If, however, a precipitate is ob- tained, another 5 c.c. of the barium chloride is now added to the filtrate, and this once more filtered. If the further addition of barium chloride now gives a precipi- tate, the quantity in the day's urine is more than 2 grms. This rapid method is often quite sufficient for clinical purposes, but, for the accurate estimation, a more elabo- rate process must be employed. For very accurate estimations, the gravimetric process should be used. The precipitated barium sulphate from 100 c.c. of urine is filtered (after boiling) through a filter, the weight of whose ash is known, and the precipitate washed with hot water and alcohol, and dried at 100° C. ; the dry barium sulphate is then carefully detached and emptied into a tarred platinum or thin porcelain capside; the filter is burned and the ash added. The crucible and contents are now heated to bright redness for some time, and after cooling weighed. The weight of the sulphuric acid is then calculated ; one part of barium sulphate being equal to 0.3433 of sulphuric acid. Volumetrically the sulphuric acid may be estimated by titrating with a standard barium chloride solution of such strength that 1 c.c. = .01 grm. of sulphuric acid. The titration is finished when the urine is no longer made turbid by the addition of a drop of barium chlo- ride. For details of these methods, reference should be made to Sutton's " Volumetric Analysis," or to Neu- bauer and Vogel's " Analysis of Urine." The methods of estimation given above only show the quantity of sulphuric acid in the urine combined as salts of the alkaline metals. To ascertain separately the acid united to the alkalies, and that united to the phenols, the alkaline sulphates are first precipitated from 100 c.c. of urine by an excess of barium chloride; the insoluble barium sulphate filtered off, washed, dried, ignited, and weighed as above ; the result gives the acid combined with the alkaline metals. The clear filtrate and washings from this are now heated for two hours with one-eighth their volume of hydrochloric acid. There is now pre- cipitated, as barium sulphate, all the rest of the sulphuric acid ; this is filtered off, washed with alcohol and hot water, dried, ignited, and weighed as before. From the barium sulphate now obtained, the quantity of sulphuric acid that existed combined with the phenol bodies is cal- culated. The sum of the two estimations gives the total sulphuric acid in the urine. The aromatic sulphuric ethers of the urine are in- creased by all the causes previously mentioned, which increase the formation and elimination of phenol and in- dican, such as intestinal obstructions, constipation, etc., and after taking such therapeutic agents as thymol, phenol, salicylic acid, pyrogallic acid, resorcin, etc. In disease, where the excess of sulphuric acid in urine cannot be directly traced to food, it must be due to in- creased oxidization of proteids, and, on the other hand, a diminution must be due to lessened tissue metamorpho- sis. So we find the sulphuric acid increased in acute fevers until convalescence begins, when it becomes sub- normal. This is especially marked in pneumonia and acute meningitis. In chronic affections, as leucaemia, diabetes mellitus, and in many skin diseases, especially eczema, an increased elimination has been usually found ; on the other hand, it appears in diminished quantity in chronic kidney af- fections. Other Inorganic Acids.-From drinking water and some vegetable foods the urine derives a trace of nitric acid, excreted probably as sodium nitrate. During the fermentation of urine by the action of bacteria nitrites can be recognized but not nitrates. Silicon oxide (silica) can be found in the ash resulting from many litres of urine. It is present to the amount of about 0.03 grm. to the litre. Metals Found in Urine.-As stated in a preceding paragraph the metals present in urine are sodium, potas- sium, calcium, magnesium, with ammonium and iron in much smaller amount; the last is probably present only as a constituent of the pigments. A healthy adult ex- cretes in twenty-four hours these metals in the following quantities: Sodium, 4.5 to 6.0 grms.; potassium, 2.5 to 5.0 ; magnesium, 0.15 to 0.4 ; calcium, 0.1 to 0.3 grm. Sodium is recognized in urine by the bright yellow color imparted to a colorless Bunsen flame by a particle of the ash attached to a platinum wire. Normally sodium salts exceed all the others in quantity, indeed there is usually more sodium present than all the other metals together. This is largely due to the excre- tion of sodium chloride. The sodium salts are lessened by abstinence from food and in high fevers. The daily elimination of sodium, estimated as sodium oxide, NasO, is from 5 to 7.5 grms. Salkowski observed in some cases of high fevers only about 0.12 grm. daily. Potassium may be shown to be present in urine by spectroscopic examination of the ash, or more simply by examining the flame produced by the ash through a co- balt glass. The deep blue of the smalt glass cuts off the yellow rays produced by the sodium, which otherwise completely masks the pale violet color of the potassium flame. The excretion of potassium depends far less upon the nature of the food than does that of sodium. Nor- mally the potassium forms about thirty-five per cent, of the total sodium and potassium excreted daily, but in fevers it replaces the sodium, forming as much as ninety- five per cent, of the united alkalies. Calcium may be recognized by acidifying about 100 c.c. of urine with acetic acid and adding to it ammonium oxalate, when a white precipitate of calcium oxalate is seen. This is further identified by filtering it off and strongly heating it in a platinum or porcelain crucible ; by this means calcium carbonate or calcium oxide is formed according to the amount of heat applied. The residue now imparts to the Bunsen flame a brick-red color which gives the spectrum of the metal. Calcium, estimated as calcium oxide, forms about 0.52 to 0.88 per cent, of the total solids of urine. It is greatly influenced in health by the nature of the food taken, but in those diseases characterized by deficient lime salts, as rickets and osteomalacia the calcium is not absorbed by the tis- sues and the quantity in the urine is reduced to a mini- mum. The abnormal deposition of calcium carbonate in the tissues reduces the amount in the urine to from 0.018 to 0.25 grm. per day. (Hirschberg.) Magnesium.-If after the calcium oxalate has been precipitated the filtrate be made strongly alkaline with ammonia a precipitate of ammonio-magnesium phosphate falls. Ammonia may be recognized as a constituent of nor- mal urine by precipitating 100 c.c. of urine with alcohol and platinum tetrachloride. The precipitate consists of the double salts of potassium and ammonium with plat- inum chloride. If this precipitate, after standing twenty- 420 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Urine. Urine. four hours, be filtered off, washed with alcohol, dried and heated in a long dry test-tube, the ammonium chlo- ride will be deposited on the sides of the cool part of the test-tube. The lower part of the test-tube is now cut off and the portion containing the sublimated ammonia- chloride is washed with a few drops of w'aterinto another smaller test-tube, and a few drops of caustic alkali added to this ; then the application of heat causes the evolution of ammonia, which can be recognized by its odor and its action on red litmus paper. The quantity of ammonia in the urine is increased greatly after the administration of ammonium salts and also after taking mineral acids. Iron differs from all the other metals in urine in that it is so combined that it cannot be recognized except in the ash. It occurs not as salts of iron but as an essential part of some of its organic constituents-probably the pigments. To demonstrate its presence the ash from 50 c.c. of urine is dissolved in hydrochloric acid, when a drop of ferrocyanide of potassium gives a deep blue pre- cipitate (Prussian blue) and potassium sulphocyanate a blood-red color. The quantity found in urine varies from 3 to 11 milligr. daily. In acute fevers during the febrile stage the iron in the urine is greatly increased from the rapid destruction of the red blood corpuscles. III. Pathological or Abnormal Constituents.- Urine may be abnormal from one of two causes; either from the elimination of its normal constituents in quan- tities that are too great or too small to be accounted for on physiological grounds, or from the elimination of sub- stances not found in the healthy secretion. The clinical significance of extreme variations in the normal con- stituents of urine having already been discussed it re- mains now to notice chiefly those substances whose presence in the urine, even in traces, is usually sympto- matic of morbid processes going on in the body. The chief abnormal substances that are held in solution in urine are : (1) Albumen and allied proteids. (2) Blood. (3) Sugar. (4) Acetone and allied substances. (5) Biliary constituents. (6) Fat. (7) Cystin. (8) Leucin and Tyrosin. (9) Abnormal pigments. Under Vrine sediments will be noticed chiefly those substances that are carried from the body suspended in the urine, such as epithelium, mucus, shreds of tissue, casts, spermatozoa, parasites, fungi, etc. Albumen.-That urine may under certain circum- stances contain in solution a substance which is coagu- lated by heat was first announced by Cotugno in 1770. This observation is interesting, as it is the earliest attempt made to recognize by chemical means an abnormal con- stituent in urine. No other abnormal substance found in urine possesses such clinical interest and is so easily detected, when present in more than traces, as albumen. Formerly, but one albumen was recognized in urine, and its presence was regarded as positive proof of the exist- ence of some form of kidney trouble, if not of Bright's disease itself. More modern researches and observations now teach us that, so far from being a symptom of the dreaded Bright's disease, albumen is frequently present in the urine of perfectly healthy people, and we must distinguish a definite physiological albuminuria. Sena- tor, Posner, and some other authorities go a step further, and contend that albumen is a constant constituent of normal urine, but occurring in very minute quantity ; and it certainly is difficult to understand how it could be otherwise, when we consider that urine always con- tains fragments of organized tissue containing albumen, which are continually undergoing decomposition and partial solution in the urine ; thus a trace of albumen is liberated, but so small that only very careful examina- tion will lead to its detection. The proteids found in urine are very numerous ; besides serum albumen and serum globulin at least eight other albuminoid substances have been recognized. The more important of these are : Peptone, propeptone, acid albu- men, alkali albumen and mucin. Besides these we occa- sionally find haemoglobin, fibrin, and lardacein, the last two being of but little clinical importance. Serum-albumen is practically the most important al- buminous substance that appears in the urine. It con- stitutes 4.516 per cent, of blood serum, and is present iu most urines that contain any form of proteids. It closely resembles egg albumen, but, unlike the latter, it is not precipitated by dilute mineral acids. The means to be used for the detection of this form of albumen will be stated below. Serum-globulin, or paraglobulin, constitutes about 3.103 per cent, of blood serum, and very frequently ac- companies serum albumen in the urine. As it, unlike all the other proteids, is insoluble in pure water, or water containing a small quantity of salts, its presence may be shown by the slight opacity imparted to clear, filtered urine when it is diluted with an excess of water. It is also precipitated, like acid and alkali albumen, by a sat- urated solution of magnesium sulphate. Still, having proved its presence by dilution, the latter method (Ham- mersten's) is the best for quantitative purposes. When serum-globulin is dissolved in a slight excess of acid or alkali, it is converted into acid or alkali albumen ; indeed, by some authors (Briicke and Heynsius) paraglobulin is regarded as identical with the alkali albumen. Peptone and propeptone (parapeptone and hemipeptone) are the products of the proteolytic action of pepsin and trypsin. They are very soluble and readily pass through animal membranes. Propeptone is a variety of proteid intermediate between true peptone and albumen. It was found by Bence Jones in a case of osteomalacia. Pep- tone is also found during the transformation of tissues and of inflammatory effusions. It may occur either alone (peptonuria) or with serum-albumen. Acid albumen or syntonin and alkali albumen are prod- ucts of the action of dilute acids and alkalies, respec- tively, on albumen. They may be formed artificially during the process of testing, or may occur naturally in urine. Syntonin is not coagulated by heat, but is pre- cipitated by alkalies. Alkali albumen, on the other hand, is coagulated by acids, but is not precipitated by heat or alkalies. Mucin is a derivative of albumen that forms the chief constituent of mucus. It is very diffusible in water, though not soluble. It is precipitated by dilute acids, and by heating with dilute sulphuric acid it is converted into acid albumen. It is not secreted with the urine, but may be taken up with it in its passage through the ure- ters, bladder, or urethra. It is of especial importance as a possible source of acid albumen in normal urine and on account of the difficulty of detecting, by some tests, traces of true albumen in the presence of an excess of mucus. Haemoglobin is found whenever blood is eliminated with the urine, as well as in haemoglobinuria. It gives similar reactions to uncombined serum-globulin, and, in addition, has a peculiar absorption-spectrum by which it is recog- nized. Fibrin occurs rarely in urine in the form of casts or coagula in chyluria and haematuria. Lardacein gives to myeloid organs their peculiar waxy appearance. It is found occasionally in a rare variety of waxy cast. Of all these, the serum-albumen and serum-globulin are of the highest clinical interest, and they are the proteid constituents for whose detection so many devices and tests are now to be found in text-books. Tests for Albumen-(1) Heat and Nitric Acid.-The oldest test for albumen depends on its coagulability by heat. Both serum-albumen and serum-globulin are pre- cipitated by heat. The former becomes opalescent at 60° C., and coagulates at from 70° to 75° C. ; in the latter, opalescence begins at 68° C. and coagulation at 75° C. If, when a sample of clear urine is heated, an opacity appears just before the urine boils, that opacity is due either to albumen or to the precipitated mixture of cal- cium carbonate and earthy phosphates (Heller's "bone- dust"). If itis caused by the latter, the opacity instantly disappears on the addition of a few drops of nitric or acetic acid ; if, on the other hand, the precipitate is due to the presence of albumen, it is permanent. If serum- albumen or serum-globulin be present in decided quanti- ties and the urine be acid, this test presents no difficulty, but, if there be but a trace of albumen, one of two errors may be made and the albumen overlooked ; either too little acid may be added, thus forming the soluble acid 421 Urine. Urine. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. albumen, which is not precipitated by heat, or too much acid may be added and a trace of albumen dissolved. Sir Will- iam Roberts says he has known this latter fallacy to cause the concealment of a trace of albumen in urine for months. If, in an ordinary test-tube, 1| to 2 inches of urine be taken, and this boiled, about fifteen to twenty drops (one-tenth of the volume of urine) of colorless nitric acid or glacial acetic acid should be added. In all cases of doubt, after the test is made as above, the hot urine and acid should be allowed to stand in the test-tube for from eight to ten hours ; as frequently, when there is but a trace of albumen present, the urine remains clear, and only after some time, as it cools, a faint opalescence appears, followed by a gradual precipitation. If, after standing, a precipitate is found, it may be either (1) uric acid, (2) acid urates, (3) nitrate of urea, or (4) albumen. If it be either 1, 2, or 3, it is colored and disappears on again warming the tube ; if albumen, it is white and re- mains unchanged ; again, the precipitates of uric acid or nitrate of urea are easily distinguished under the micro- scope by their crystalline form. (2) Cold Nitric Acid.-Heller's test consists in applying nitric acid so that the acid and urine are in contact, but not mixed ; the albumen is coagulated at the line of con- tact of the two liquids. This test is the one now gen- erally used in the German hospitals, and is made as fol- lows : In a German liqueur-glass-i.e., a small shallow wineglass with large rim and sloping sides-a few cubic centimetres of clear urine is poured, and down the sloping rim of the glass is poured an equal volume of colorless nitric acid. This, owing to its greater density, and the slope of the glass, goes at once to the bottom and floats up the urine. Now, if the urine contain albumen, between the two clear fluids will appear, within a few moments, a well-defined white band or zone of coagulated albumen. This band is white and opaque ; it varies in width with the quantity of albumen present, and is distinguished by the sharply defined line between it and the urine, and its appearance just at the line of junction of the two fluids. Under all circumstances a colored zone appears between the urine and the acid, varying from brown to reddish- brown or purple. This is caused by the oxidation of the pigments and indican present in all urine. It is more marked in the high-colored urine of fever, where the band of coagulated albumen is itself often colored. Unfort- unately there are other substances which will produce a turbidity under similar conditions, but these can be easily distinguished. Normal urates are by the action of the acid changed into the insoluble acid salts and form a cloud, not at the line of junction, as marked by the zone of color, but higher up, and diffused throughout the urine, not in a well-defined band, but more as a cloud which disappears at once on warming the urine. In very concentrated urines nitric acid may precipitate the urea as nitrate of urea. This, however, appears usually only after standing some time. It is not wdiite, and is easily seen to be crystalline, even without the aid of a lens. Both of the difficulties before mentioned may be ob- viated by diluting the urine before testing with two or three volumes of water. If mucus be present in excess, a faint opalescence is produced some distance above the acid in the urine, as mucin is precipitated only when treated with very dilute acids. Hence near the line of junction, where the acidity is sufficient to precipitate albumen, the mucin is dissolved, and appears as a faint haze higher up where but a trace of acid is present. Heller's test may be conveniently performed in a test- tube with or without a foot, the acid being introduced by a pipette. A long pipette is filled to a height corre- sponding to the length of the test-tube with nitric acid, and the top closed with the finger. It is then introduced to the bottom of an inch or two of urine in the test-tube, and on withdrawing the finger from the end the acid flows out and floats up the urine ; the pipette is again closed by the finger and withdrawn. If the acid and urine be previously warmed to about 40° to 50° C., no urates or nitrate of urea will be precipitated. By Hel- ler's method any serum-albumen that may have been converted into acid or alkali albumen is precipitated as readily as the serum-globulin or serum-albumen. On the whole, this method will be found a very delicate test for albumen ; most of the difficulties in the way of its use are largely imaginary. With a little practice-and it is only after some experience that its delicacy is ap- preciated-it will be found to be the most convenient one for use in the physician's office or for the hospital and laboratory. Other Tests for Albumen.-Nitric acid is extremely in- convenient to carry about, so a number of substitutes for this agent, more portable and equally reliable for the detection of albumen, have been found and many of them strongly advocated. The more important and use- ful of these will be briefly noticed in the order of their general utility. Picric acid, either in crystals or in saturated solution, has been very strongly advocated by Dr. George John- son and Galippe. A saturated solution (3-5 grains to the ounce), having a specific gravity of 1.005, is poured on four inches of clear urine in a test-tube to the depth of an inch or two in such a way as to cause a mixture of the upper part of the column of urine with the picric- acid solution. If albumen be present an opacity results, limited to the area in which the urine and acid are mixed. By contrast with the clear urine below even a very faint opacity is perceptible. The application of heat to the upper part of the opaque area increases the turbid- ity. On allowing this to stand, the precipitated albumen sinks and forms a film at the junction of the clear urine with the mixed urine and acid. Dr. Oliver has shown that the addition of a small quantity of citric to the picric acid makes it a more del- icate reagent. This, Johnson says, is due to the precipi- tation of mucin by the citric acid, which he claims does not occur when picric acid is used alone. Dr. Johnson claims that albumen is the only substance found in urine that gives with picric acid an opalescence or pre- cipitate undissolved by heat. Urates, peptones, quinine, morphine, and other vegetable alkaloids are precipitated by picric acid, but the turbidity disappears on application of heat. The great advantage of this test is that the test- substance, being a solid and easily portable, is available at any time for a bedside test in a doubtful case. Ferrocyanide of potassium, added to acid urine, precipi- tates albumen but not peptones, alkaloids, or mucin. The acid urates are thrown down when in excess, but the pre- cipitate disappears on heating. It is not so delicate a test as the preceding, but is a very convenient one. Potassium mercuric iodide, advocated by Charles Touret, of Paris, and Dr. Oliver, is prepared by dissolving in 100 c.c. of distilled water 1.35 Gm. of corrosive sub- limate, 3.32 Gm. of potassium iodide, and 20 c.c. of glacial acetic acid. This is a heavy solution-specific gravity, 1.040-and the test is to be made by the contact method. A cloud is formed by urates and the alkaloids, which disappears on heating. Mucin, when in excess, is also precipitated and does not dissolve by heat (Oliver). Sodium I'ungstate and Citric Acid (Dr. Oliver).-This is made by mixing, in equal parts, saturated solutions of citric acid and sodium tungstate. It does not precipitate the vegetable alkaloids, but precipitates, like the others, urates, peptones, and mucin. These are dissolved by heat. Acidulated Brine Solution.-Dr. Roberts claims that the employment of this solution by the contact method is equally as delicate as Heller's nitric-acid test, and, as it does not stain the skin and clothes, is much more con- venient than the latter. It is made by adding an ounce of hydrochloric acid to a pint of a saturated solution of sodium chloride. The reagent is applied by the contact method. Metaphosphoric acid, HPO3 (vitreous phosphoric acid), was known to Berzelius as a precipitant of albumen, but was introduced by Hindenlang as a practical test. Al- though it is an excellent reagent when pure, its great disadvantage is that it does not keep well but rapidly passes into the other forms of phosphoric acid. Fehling's solution (see under Sugar in Urine), gives, with albuminous urine, a brownish-red or mauve color. 422 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Urine. Urine. Trichloracetic acid (Raabe), a crystal in albuminous urine, produces a turbid zone of precipitated albumen. Besides these, carbolic acid, with or without acetic acid, tannin, and many other substances, have been advo- cated. Test-papers.-Dr. Oliver in England, and Geissler in Germany, have prepared papers saturated with different reagents for the detection of albumen. Dr. Oliver's papers are very convenient. He has two of especial value ; viz., his mercuric and ferrocyanide papers, which are used with citric acid. He adds one of these papers to about 60 minims of water in a small test- tube, with a citric-acid paper to render the water acid; then, after a few minutes, he withdraws the papers, and to the clear solution of the reagent he adds the urine, drop by drop, from a pipette. An opacity appears after a few drops, if much albumen be present; if none ap- pears, twenty to thirty drops more are added. The mer- curic paper enables a distinction to be made between serum-albumen and the diffusible proteids, peptone, etc. -as the presence of a precipitate which disappears on boiling indicates the latter. These papers, as well as many of the most useful reagents in the form of tablets, may be procured from Parke, Davis & Co., Detroit, Mich. It has already been stated that there is but little una- nimity among those who have made urinary analysis a study, as to the relative value of the different devices for detecting albumen. Sir William Roberts and some other authorities would entirely discard these newer re- agents for the detection of albumen, and rely entirely on the heat and nitric-acid test, urging against their use that they precipitate other albuminoid compounds be- sides serum-albumen and serum-globulin. This may be misleading to one unfamiliar with their use, but it can- not be disputed that with the best of them, e.g., picric acid or potassio-mercuric iodide, a greater knowledge of the nature of an albuminous urine is afforded than it is possible to obtain by the use of nitric acid and heat alone. The physician will find it very useful, however, to be familiar with more than one of these tests, always re- taining the nitric-acid (Heller's) and heat with nitric acid as confirmatory tests to be applied at leisure. Of the others, the mercuric and the ferrocyanide tests-most conveniently used in the form of Oliver's test-papers-or picric acid in crystals, might, with advantage, be made as constant a companion as the thermometer or stetho- scope. The following table, taken from a recently published lecture by Dr. T. Grainger Stewart, will show at a glance the action of the more usual reagents on the dif- ferent forms of albumen occurring in urine, and the ad- vantages of becoming familiar with more than one re- agent will be at once apparent: Tests. Serum- albumen. Serum- globulin. Peptones. Propeptones. Acid Albumen. Alkali Albumen. Heat Opacity... Opacity Heat with acetic acid Cold HN.Og Opacity Opacity Opacity. Opacity. Opacity. Opacity. Opacity. Opacity. Opacity. Opacity... Opacity Opacity dissolved by heat... Opacity diminished or dis- solved by heat. Opacity diminished or dis- solved by heat. Opacity dissolved by heat... Opacity dissolved by heat... Opacity dissolved by heat... Opacity.... Metaphosphoric acid Acidulated brine Opacity Opacity Opacity diminished or dis- solved by heat. Opacity diminished or dis- solved by heat. Opacity dissolved by heat... Opacity dissolved by heat... Opacity Opacity Opacity.... Opacity.... Opacity.... Opacity.... Picric acid Opacity Opacity Opacity Opacity Slight opacity . Opacity Potassio-mercuric iodide .. Potassium ferrocyanide.... Dilution with water Opacity Opacity Magnesium sulphate Opacity.... Opacity. Fehling's solution Brownish red, or mauve. Rose, pink, or purple Rose, pink, or purple Randolph's test Yellow opacity Yellow opacity Drs. Stewart and Stevens have recently made some observations on the relative delicacy of several of the common reagents which accord very closely with results obtained by Johnson, Oliver, Tyson, and other English and American authorities, but differ somewhat from those obtained by some German chemists. As Dr. Stewart's experiments were made by diluting with normal urine a sample that contained 0.15 per cent, of albumen, his results are of practical value as in- dications of the amount of albumen each reagent is ca- pable of detecting in urine. The results with cold nitric acid, however, are much too low. method of observing any decided increase or diminution of albumen that may take place from day to day. This is especially true in cases of Bright's disease, where any decided variation of the albumen has a marked influence on the prognosis. A very objectionable practice prevails among some physicians of estimating the quantity of albumen by precipitating in a test-tube with heat and acid, and ob- serving the bulk of the precipitate after the liquid cools. It must not be forgotten that the volume of the precipi- tated albumen is influenced by many conditions ; not only by the quantity of urine and acid used, and the amount of heat applied, but also by the density of the urine, the shape of the test-tube, and the time allowed to elapse before volume is estimated. Now. when these corrections are disregarded or ignored, the inferences drawn from such a quantitative estimation cannot be other than very misleading, even for comparative purposes. We frequently find, besides, among physicians, a very careless and inaccurate way of expressing the quantita- tive relations of albumen. Cases are reported in which forty per cent, or twenty-five per cent, of albumen was found. By this, of course, is meant per cent, by volume, but under conditions which are not explained ; hence the observation is of no value whatever as an indication of the actual quantity of albumen passed by the patient. The total albumen found in the blood does not much exceed five per cent., and the writer has never found in urine 2.5 per cent., and in only one case more than two per cent. The usual quantity is from .5 to 1.5 per cent., and the daily excretion from 5 to 10 Grm. The gravimetric method of estimating albumen is the most accurate one, but far too troublesome for the gen- eral practitioner; 100 c.c. of the albuminous urine are acidulated with acetic acid and heated in a porcelain ves- Tests. Number of Dilu- tions of the Al- buminous Urine. Percent- age. Grains per Ounce. Boiling 300 0.0005 0.00218 Acidulation with acetic acid and boiling 500 0.0003 0.001311 Cold nitric acid 50 0.003 0.01311 Metaphosphoric acid 500 0.0003 0.001311 Picric acid 1000 0.00015 0.000655 Potassio-mercuric iodide test- papers 500 0 0003 0 001311 Ferrocyanide of potassium... 500 0.0003 0.001311 Very few who have used Heller's test will agree with Dr. Stewart that cold nitric acid, used in this way, is not at least as delicate a test as simply boiling the urine. The opaque band in this test sometimes requires an hour to develop, when only a trace of albumen is present, but it certainly will indicate more than 0.003 per cent, of albumen. Quantitative Estimation of Albumen.-It is often of the greatest importance to the physician to have a ready 423 trine. Urine. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. sei on a water-bath, with constant stirring, until the pre- cipitated albumen has become condensed into fine granular or shreddy masses. It is now filtered, through a filter previously dried and weighed, and the precipitated albu- men is washed with hot water and alcohol; then the filter and contents are dried at 120° to 130° C. in an air-oven un- til a constant weight is attained. The total weight, less the weight of the filter, previously ascertained, gives the albumen in 100 c.c. of urine. Estimation by Esbach's Albuminometer. This is the most convenient and accurate method for the clinical estimation of albumen that has yet been proposed. It depends on the observation that picric acid in urine acid- ulated with citric acid gives a very uniformly granular precipitate, which for the same quantity of albumen oc- cupies the same depth in the tube at the end if twenty-four hours. The albuminometer consists of a partially graduated tube (Fig. 4269) with two lines narked U and R. The tube, which is about he size of an ordinary test-tube, is filled to the ine U with urine, and to R with a solution nade by dissolving ten grammes of dry picric icid and twenty grammes of pure, dry citric icid in a litre of distilled water. After adding he reagent, the rubber stopper is introduced, he two fluids mixed, but not violently shaken, md the apparatus left to stand for twenty-four tours in an upright position. The height of he precipitate is then read off, each of the onger lines corresponding to one gramme of ilbumen per litre, or 0.1 per cent. The appa- ratus is not suitable for estimations under 0.1 ler cent., but will be found very useful for the laily observations required in cases of kidney ;rouble. The writer has found the results ob- :ained in this way to correspond very closely svith those obtained by the gravimetric method. (Esbach's tube is made by Eimer & Amend, af New York.) Sir William Roberts's method consists in diluting the urine with equal parts of water until, by the nitric-acid contact method, an opacity appears at the end of from thirty to forty-five seconds ; each dilution corresponds to " a degree of albumen," or 0.0034 per cent. Dr. Oliver coagulates the albumen with the mercuric test-paper and then dilutes the known volume of urine with water till the opacity is similar to that of a certain standard, which is the opacity corresponding to 0.1 per cent of albumen. The percentage is determined by mul- tiplying the number of times the urine (fifty minims) has been increased by dilution by 0.1. This is read off at once on a graduated test-tube, but, though rapid, the results have not been found by the writer to correspond ■with the gravimetric estimations. In urine with a small amount of albumen, under one per cent., the results ob- tained by both Dr. Oliver's and Sir W. Roberts's methods are always too high-often double the amount obtained by the gravimetric method. The Significance of Albuminuria in Health and in Disease.-The soluble albumen found in urine may be derived from two distinct sources-either from the blood that passes through the kidneys or from some al- buminous fluid that becomes mixed with the urine dur- ing its passage through the pelvis of the kidney, the ureters, bladder, or urethra. To the first variety of albu- minuria, viz., that due to the excretion of a portion of the albuminous constituents of the blood with the water and salts of the urine, the term true or intrinsic albuminuria (A. vera) has been applied to distinguish it from the second variety, which is called pseudo- or adventitious albuminuria. The distinction between these two forms is easily made. Pseudo-albuminuria depends upon the presence of such fluids as blood, pus, lymph, spermatic fluid, or the con tents of an abscess-cavity, all of which may easily be recognized by examining the sediment which is deposited when the urine stands for a few hours. The microscope will reveal the presence of pus-cells, blood-corpuscles, or spermatozoa in the sediment, while the clear supernatant urine will be now either non-albuminous or contain but the merest trace of coagulable matter. When, however, urine is strongly albuminous, and at the same time shows the macroscopic or microscopic pe- culiarities of a pseudo-albuminuria-such as the red color of the blood, the purulent deposit, or spermatozoa-to determine whether it is a case of true or false albumi- nuria from the urine alone is extremely difficult, if not impossible. Other symptoms must be looked for. The presence of casts and epithelium in the sediment, or the existence of a hypertrophied heart, would, for instance, point to albuminuria vera. By the term albuminuria, when unqualified, is by most modern writers meant the true or intrinsic albumi- nuria, i.e., urine containing substances coagulable by heat and acids which have been excreted with it, and does not include peptonuria or hsemoglobinuria. Although au- thorities are almost unanimous in the opinion that the coagulable bodies found in urine are derived from the blood of the renal glomeruli, yet, as Senator points out, there are many other possible sources within the sub- stance of the kidneys, e.g., the blood of the interstitial vessels, the lymph and various epithelial cells of the kid- ney-all of which might yield albumen to the urine and are more or less affected in the processes which lead to albuminuria, such as congestion, inflammation, and renal degenerations. While these possible sources of albumen should be kept in mind, the balance of evidence is greatly in favor of its direct origin from the blood. In blood-plasma we find at least two forms of coagulable matter-serum-al- bumen and serum-globulin. And in the great majority of cases of albuminuria we find not one, but both of these substances present in the urine. They are, how- ever, not present in the same proportion as in blood, nor are they found to exist in urine in proportion to their relative diffusibility. No constant relation exists. We sometimes find an albuminous urine where the coagula- ble matter is ninety-five per cent, globulin ; and, again, very many cases of albuminuria in which, by the most careful testing, no globulin can be found. So the gen- eral term albuminuria may be said to include, as special cases, both "serinuria" and " globulinuria." This dis- tinction is as yet of no practical value, as the methods of quantitative estimation of globulin are not exact, and ils clinical significance is not well understood ; nevertheless, investigations of F. A. Hofmann, Senator, and Werner go to show that the intensity of the local disease in kid- ney trouble is to some extent indicated by the relative proportion of these two albuminous bodies found in the urine. (Hofmann's " Eiweissquotient.") Physiological Albuminuria.-That normal urine does contain albumen may now be regarded as an established fact ; not that it can be shown to exist in every sample of urine, as we can demonstrate the presence of urea or phosphoric acid, but it has been found so frequently, by so many accurate observers, in the urine of perfectly healthy persons that we can no longer regard its presence in normal urine either as a rare exception or as a curi- osity of no significance. The doctrine that the presence of albumen is invariably a sign of disease is still strongly upheld by many writers, but the continual accumulation of evidence from all sides has now forced many of the supporters of this view to admit that there are at least exceptions to a dogma which was formerly held to be absolute. More exact methods of research and the application of more delicate tests have doubtless added largely to our knowledge of the conditions under which albuminuria occurs, yet it is not so much to new methods and re- agents, as to the recent changes in the theories of urinary secretion and to direct experiment, that this change in public opinion is due. Space precludes the possibility of discussing the differ- ent views regarding the causes of the secretion of traces of albumen by healthy men (see Kidney, Circulation of, Vol. IV.). Senator holds that the normal urine which Fig. 4269.- Erbach ' s A 1 b u mi- nometer. 424 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Urine. Urine. exudes from the Malpighian tufts is a faintly albuminous fluid-the poorest in albumen of any transudation found in the body, which loses by absorption a portion of its albumen, and becomes at the same time still more di- luted in its passage through the tubules, thus still further reducing the percentage-quantity of albumen, and becom- ing so deficient in albumen that, as a rule, it cannot be detected by means now at our disposal. Any slight tem- porary change, however, in the nutrition of the kidney or in the blood-pressure in the vessels going to that organ might cause such an increase in the percentage of albu- men that its presence in the urine could be demonstrated. It is not possible, in a state of health, to recognize albu- men in the mixed urine for twenty-four hours, as the trace that may be contained in one portion is still fur- ther diluted by mixing it with the remainder. It is only by examining the normal urine excreted from hour to hour during the day that it can usually be found in quantity sufficient to give a decided reaction. Among those who have especially investigated this sub- ject, the following may be cited : Leube found albumen in the urine of 19 out of 119 healthy soldiers (sixteen per cent.); Munn, in 24 out of 200 apparently healthy can- didates for life assurance (twelve per cent.); Furbring- er, in 7 out of 61 healthy children (11.5 per cent.); Klen- den, in 14 out of 32 healthy nurses (forty-four per cent.). In all these experiments the greatest care was taken to ex- clude the possibility of adventitious albuminuria. Now, if one healthy person in nine or ten is found to secrete albumen in his urine, even this small proportion renders untenable the doctrine that albuminuria is always and necessarily a morbid symptom. Hence it must be ad- mitted, either that albumen is a constant constituent of normal urine, but usually in such small quantities as to defy detection by our known means of recognition, though frequently, from physiological causes, there is a temporary increase to such a degree that it will give a more or less marked reaction with our tests, or, on the other hand, that it is altogether absent as a rule, and is only contained in urine when certain conditions are present. The balance of probability seems strongly in favor of the former hypothesis, when we consider that there is a limit to even our most delicate tests for albu- men and that quantitative variations in a function are more in accord with, our experiences of secretions than sudden and complete qualitative changes. Since, then, it is no longer possible to regard all forms of albuminuria vera as symptomatic of severe organic changes in the kidney itself, or of morbid systemic dis- turbance, we must distinguish the physiological or harm- less from the morbid albuminuria. There is, of course, no hard and fast line of demarcation between these two forms of albuminuria any more than there is between health and disease, but one form passes into the other. Dr. Maguire, in a recent paper, recognizes three causes of what he denominates functional albuminuria : First, a group in which the appearance of albumen is accompanied with a feeling of languor, low-tension pulse, but no excess of uric acid ; the second group consists of those in robust health, with pulse of high tension, fre- quently dyspeptic, with heavy deposits of lithates in the urine ; and, thirdly, those rarer cases with albumen in the urine unaccompanied with any marked symptoms. Dr. Grainger Stewart's recent classification of cases of physiological albuminuria into four categories is the most convenient for descriptive purposes, but, as he ac- knowledges, these groups are not sharply defined, but overlap and run into each other. Paroxysmal or cyclic albuminuria, which closely re- sembles paroxysmal haemoglobinuria, occurs at all ages, and is characterized by the sudden appearance of a large amount of albumen in the urine, accompanied by a few casts recurring at intervals, without apparent exciting cause and unaccompanied by any symptoms of other renal trouble. The patients may be anaemic and suffer from neuralgia ; are often badly nourished and dyspep- tic. The albumen is absent at night and appears at cer- tain hours during the day, the hour varying in different cases. Dr. Morley Rooks has shown that this form of albuminuria is kept in abeyance by rest in a recumbent position. Dr. Pavy many years ago compared this cyclic albuminuria to the regular physiological varia- tion observed in other constituents of urine during the day, citing especially cases of phosphaturia, where the urine, normal in the early morning, becomes loaded with phosphates before noon, and clears again after the mid-day meal, remaining so until next day. Dietetic albuminuria has been observed for some time. Here the albumen appears in the urine after the inges- tion of certain forms of food, especially eggs, cheese, and pastry. In some cases it follows a meat-diet, or, in- deed, a substantial meal of any ordinary food. This may or may not be accompanied by indigestion or the appearance of oxalic acid in the urine. Albuminuria following Muscular Exertion.-Albumi- nuria has been observed frequently to follow' severe exercise, such as running, boxing, long walks, or hard riding. The last group in Dr. Stewart's classification is very indefinite. He denominates it simple persistent albumi- nuria. This persistent form is not easy of explanation. No lesion of the kidney seems to accompany it, and the symptoms of the few cases recorded do not seem to point to any one cause. The quantity of albumen is small, but the affection persists often for months. Senator regards the albuminuria of new-born infants during the first week or twro of life as simply a physio- logical manifestation due to changes in the circulation of the blood through the kidneys. Dr. George Johnson has found it to be produced very frequently by sea-bathing. Dr. Clement Dukes found it very common among the boys at Rugby, induced by various and often obscure causes. Among them he men- tions sudden changes in temperature, errors in diet, and muscular or mental exertion. Drs. G. Johnson, Greenfield, Bull, and others believe that all forms of albuminuria are due to a morbid condi- tion of the renal organs, more or less severe, and that what is called physiological albuminuria is only too fre- quently the precursor of some form of Bright's disease. According to this view, albumen in the urine is always a morbid symptom. Morbid Albuminuria.-The causes which give rise to albuminuria in disease are so varied, and the diseases with which this condition of the urine is associated are so numerous, that space does not allow of their discus- sion, nor, indeed, of more than a brief synopsis of the groups of diseases characterized by albuminuria. Albuminuria is characteristic of all diffuse inflamma- tions and degenerations of the kidneys, such as the acute, subacute, and chronic forms of nephritis and amyloid degeneration. The albumen is abundant in the early stages and frequently accompanied by blood ; later, how- ever, when the nephritis becomes chronic, and in amyloid degeneration, the albumen often becomes very difficult to detect. It has been said to be absent for months in cirrhotic kidney, but, as Johnson points out, this is prob- ably due to inaccurate testing. Circumscribed affections of the kidney, e.g., abscess, infarcts, etc., cause an irregular appearance of albumen. If the abscess-cavity communicates with the urinary pas- sages we may have both true and false albuminuria to- gether, from the presence of blood, pus, etc., accom- panied by dissolved albumen. During pregnancy the urine contains albumen, caused by pressure on the renal veins. This nephritis is fre- quently characterized by the presence of hyaline and epithelial casts in a scanty, dark, heavy urine. It usu- ally disappears within forty-eight hours after delivery, but may be the exciting cause of Bright's disease. Il is very questionable if puerperal convulsions are of uraemic origin, but this view has many able supporters, such as Litzmann, Frerichs, Brown, and Wieger. Impediments to the circulation of the blood, such as em- physema, heart disease, abdominal tumors, cirrhosis, etc., by bringing about a congestion of the kidneys, are at- tended with albuminous urine, blood (if severe), and casts of the tubules. 425 Urine. Urine. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Acute infectious diseases and those attended with hyper- pyrexia (such as typhus, pneumonia, erysipelas, rheu- matic arthritis, small-pox, etc.) cause what has been called febrile albuminuria. This must be regarded simply as an incident of the fever, yet it is not to be forgotten that the specific poison of many of these diseases may light up a nephritis, which is so frequently a grave sequela of these diseases. Peptone and propeptone sometimes ac- company the albumen. The high temperature, the in- creased blood-pressure, together with the concentration and acidity of the urine, are all conditions which con- tribute, in varying proportion, to the production of this form of albuminuria. Finally, albumen is found associated with certain ner- vous affections not characterized by any marked febrile con- dition, such as delirium tremens, cerebral apoplexy, migraine, nervous debility, etc., and in some other non- febrile constitutional affections, such as anaemia, leucae- mia, pseudo-leucaemia, as well as in some cases of jaun- dice and diabetes. Whether any of these forms of albuminuria are quite free from anatomical lesion is difficult to determine, but it is not improbable that there is fatty degeneration of the renal epithelium as well as marked general disturbance of nutrition, extending to the kidneys. With regard to prognosis, in cases of albuminuria it may be generally stated that intermittent albuminuria, with a small amount of coagulable albumen, is favorable, while a continuous excretion of a large quantity is very unfavorable. Although in physiological albuminuria the best prognosis can be given, as a rule, yet, if the al- bumen persists after rest and treatment, the prognosis should be more guarded. The possibility of the kidney becoming damaged should not be overlooked. The quantity of urea excreted is also a most important guide to prognosis in all chronic kidney troubles. It is occasionally possible to distinguish physiological albuminuria from that depending on disease of the kid- ney, by the fact that odorous principles, santonine, asparagus, turpentine, etc., pass through into the urine in the former case, but not when there is serious dis- ease of the kidney. This observation has, however, not proved of much practical value. Peptones.-As early as 1852 Miathe found peptone in urine, but it is only of late years that it has been brought prominently before the medical public as an important possible constituent of urine. At least two peptones or soluble albumens have been recognized in urine, viz., propeptone and peptone proper. The latter represents the ultimate product of proteolytic action, and propep- tone, some form or forms intermediate between albumen and peptone. Peptone is not precipitated by heat or acids nor by ferrocyanide of potassium. Potassio-mer- curic iodide and acidulated urine precipitate it as well as metaphosphoric acid, picric acid, and sodium tungstate ; the precipitate in each case being soluble in excess. The best test, which is recommended by Neubauer, is to precipitate the urine with lead acetate, the filtrate being treated with its own volume of strong hydrochloric acid, and phosphor-tungstic acid added till no further precipi- tate occurs ; it is then quickly filtered, and the precipitate, when washed with five percent, sulphuric acid, is mixed with dry baryta in a capsule, a little water added, and filtered after warming. This filtrate contains the pep- tone dissolved in water, and may be recognized by the " biuret " reaction. This is produced by adding liquor sod® to the solution until it is strongly alkaline, and dropping in a solution of copper sulphate ; if peptone be present, a violet-red color appears ; if not, the solution assumes a green color. Ralfe's test reacts when considerable peptone is pres- ent, but it is not decided enough to detect traces. It is made by floating the suspected urine on a few c.c. of Fehling's solution in a test-tube. Above the line of phosphates, if there is much peptone, a delicate rose-col- ored halo appears. If albumen be also present, it as- sumes a purple tint. Clinical Significance of Peptonuria.-Hofmann, Sena- tor, and others, contend that peptone is present in every albuminous urine. It is not, however, always found as- sociated with morbid conditions of the urine, but may occur in urine otherwise quite normal. Its clinical sig- nificance is only now being fully elaborated. It may be generally stated that its presence in urine is frequently associated with hyperpyrexia, with purulent exudation, or with the disintegration of leucocytes somewhere in the body. In one set of cases it seems to be associated with a disorganization en masse of the leucocytes, as in typhus fever, diphtheria, tertiary syphilis, small-pox, phosphorus poisoning, etc. In another set of diseases it is associated with local in- flammatory affections of a purulent tendency, as pleurisy and empyema, croupous pneumonia, abscess, parotitis, etc. In twelve cases of acute rheumatic effusion J. v. Jaksch found peptonuria in all. This observer also diag- nosed a rupture of the sac and suppuration, in a case of ovarian tumor, from the existence of peptonuria ; and generally he regards it of great diagnostic value, in doubtful cases, between simple and purulent exudation. Dr. Oliver places peptonuria by the side of minimal glycosuria and the bile salts, as affording the most relia- ble evidence of imperfect or perverted liver-work ; and Pacancowski has noticed the almost invariable associa- tion of peptonuria with hepatic cancer. Propeptone, or hemi-albuminose, is distinguished from peptone by being precipitated by strong nitric acid, dis- solved by heat, and reprecipitated on cooling ; also by being precipitated by acetic acid and ferrocyanide of potassium. It has been found by Bence Jones and Kuhne in osteomalacia. Like peptone, it gives the biuret reaction. Blood tn Urine.-Blood in the urine manifests itself in two forms, viz. : (a) Ucematuria proper, when the urine contains red blood-corpuscles and assumes a red color more or less distinct. (b) Hoemoglobinuria (hsematinuria, methaemoglobin- uria) when only the blood-coloring matter appears in the urine, imparting to it a smoky-brown or red hue accord- ing to the quantity of the blood-pigment present, and the particular form it has assumed. It is scarcely nec- essary to state that urine carrying either blood or blood- pigments always contains albumen. The color of urine containing blood may vary from a blood-red or brown- red to the color of flesh-water. It may contain blood in such quantity that it forms clots ; indeed the whole urine has been known to coagulate in rare cases. Here, of course, there is no difficulty in pronouncing the case to be one of haematuria ; when, however, the urine is only tinted or has a brownish-red color, a simple inspection is not always sufficient for diagnosis. One or more of the following methods of detecting the presence of blood should be used. 1. Blood-cells in the Urine. If the amount of blood be small, it is difficult to detect the red corpuscles except in the sediment. In light urine, these corpuscles are often colorless and show only the ring-like outline of the cell ; when the urine is concentrated, on the other hand, the blood-cells become crenated in a very characteristic way (Fig. 2309, Vol. IV.). As long as the urine remains acid these cells may be readily detected, but when fermenta- tion occurs the corpuscles become decomposed and a yellow-brown granular mass is found at the bottom of the containing vessel; this volume dissolved will give the spectrum of luematin (Fig. 4270). 2. The spectroscope furnishes the readiest and most sat- isfactory means of detecting the blood-pigments. It, of course, affords little or no information as to whether the case is one of hsemoglobinuria or of luematuria. The larger and more expensive instruments are not at all necessary for the recognition of blood ; a small pocket- instrument, which is now made about the size of a cigar and is quite inexpensive, will afford all the information required for clinical purposes. The detection of any of the following forms of blood-pigment is quite easy : (a) Oxyhaemoglobin is the form in which the blood- pigment is normally present in luematuria. This shows a double-banded absorption spectrum, one line in the 426 (Trine. Urine. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. yellow, and one in the green, i.e., between the Frauen- hofer lines D and E (Fig. 4270, 1). The suspected fluid, after dilution, is placed in a test-tube, or better in a glass cell with flat parallel sides, and interposed between the spectroscope and a gas or lamp flame. The character- istic bands of oxyhaemoglobin are visible in a solution 1 c.c. thick containing only 0.01 per cent. (6) Reduced haemoglobin. A few drops of a reducing agent, i.e., ammonium sulphide, cause the lines to dis- appear, and in their stead a single broad absorption band appears, apparently Alling the space between the two bands of the other spectrum, i.e., between the lines D and E, but nearer to the former (Fig. 4270, 2). This is the characteristic spectrum of reduced haemoglobin. It is not seen in luematuria, unless the urine has been treat- ed by a reducing agent. (c) Methaemoglobin, when present in dilute solutions, gives a spectrum composed of three bands : one in the red, one in the yellow, and one in the green. It resem- bles the oxyhaemoglobin spectrum, with an additional line toward the red end of the spectrum ; when the solu- tion is more concentrated a single band appears in the red, and the whole of the spectrum from the yellow to the violet is absorbed (Fig. 4270, 3). The band in the red, the centre of which corre- sponds to wave length 632 (Gam- gee), is the characteristic line of methaemoglobin ; the others vary with the strength of the solution. Methaemoglobin is present in hsemoglobinuria, and in haematuria when the haemorrhage is very slow. The blood entering the urine slow- ly, or retained for some time, is partially decomposed by the carbon dioxide and converted into methae- moglobin. 3. Heller's test for blood-pig- ments consists in precipitating the phosphates by the addition of strong caustic potash and heat; the bulky precipitate carries down the pigments present, and is col- ored of a red or rose color by blood- pigments. Normal urine gives a white precipitate of the neutral phosphates under similar condi- tions. The precipitated pigments often appear dichromic (green and red) when a small amount of blood is present. Chrysophanic acid and santonin give a red color to the precipitated phosphates, but this is never dichromic and becomes much paler after the addition of mineral acids (see Urinary Pigments). When the urine is alkaline a similar bulky precipitate is formed artificially by adding magnesia mixture (see Phosphates). A few drops only are necessary, and gently heating the mixture will carry down the blood-pigments equally as well as the neutral phosphates. 4. Hcetnin Crystals (Trichmann). A portion of the pre- cipitated phosphates obtained by Heller's method is dried on a glass slide ; the dried mixture of phosphates and haematin is now carefully mixed with a few grains of common salt by means of a small spatula or knife blade, the excess of salt removed, and the mixture covered by a cover-glass with a hair beneath it. A drop or two of acetic acid is passed under the cover-glass and the slide warmed until the acetic acid just boils. After cooling, the slide is examined with a lens magnifying about three hundred diameters, when if blood be present, the small haemin (haemin hydrochlorate) crystals are easily made out. 5. The Guiacum Test. The urine is shaken with a mixt- ure of equal volumes of guiacum tincture and ozonized turpentine (turpentine, after being kept for some time loosely corked, becomes thick and is found to contain ozone). The mixture assumes a deep-blue color, if blood be present. Instead of turpentine, Mahomed used ozonized ether. Stevenson's modification of Mahomed's test is a very pretty method of detecting traces of blood. To about 1 c.c. of urine in a test-tube, one drop of tincture of guia- cum is added with a few drops of ozonized ether, and the mixture well shaken. On standing the ether rises to the top, tinted of a blue color if haemoglobin be present. Dr. Mahomed claims that by this test a quantity of haemo- globin may be detected that is too small to be recognized by the spectroscope or to give the albumen reaction with nitric acid. Thus blood may be detected in the pre- albuminuric stage of scarlatina, and when in chronic ne- phritis but little albumen is present. Albumen interferes with the reaction if much is present. Saliva, nasal mu- cus, and iodides also give a blue color under the same conditions. Hamaturia.-Having determined that the urine con- tains blood, and not the blood-pigments only, from the detection not only of the coloring matter but also of the cellular elements, the question presents itself: Whence comes the haemorrhage ? It may be from the kidney it- self or from the urinary passages; either the pelvis of the kidney, the ureter, the bladder, or the urethra. To locate the haemorrhage is often very difficult, and from the examination of the urine alone frequently im- Fig. 4270.-Spectra of Blood-pigments. 1, Oxyhaemoglobin ; 2, reduced haemoglobin; 3, methaemoglo- bin (concentrated solution); 4, haematin ; 5, urobilin. (Salkowski.) possible ; other symptoms, pointing to one or another part of the uropoetic system as the affected region, must be sought for in making a diagnosis. The old idea that brown blood (methaemoglobin) comes from the kidney, and red blood (oxyhaemoglobin) from the bladder, is oc- casionally true, but the nature of the pigment, as shown above, depends not on the locality, but on the rapidity of the haemorrhage. Generally speaking, however, a large quantity of more or less pure blood that coagulates, indicates haemorrhage from the urinary passages. In such cases the blood on standing deposits completely, leaving above it an almost pure urine. If the bleeding occur in the urethra it is continuous, and the first portions of the urine passed will alone be bloody, while that passed later will be quite free from blood. Urethral haemorrhage may be caused by catheter- ization, traumatism (i.e., rupture of the urethra, passage of a calculus, etc.), acute gonorrhoea (blood mixed with pus), vascular polypus, frequent forced coitus, etc. If the haemorrhage occur in the bladder, the last por- tion of the urine passed will show the deepest color ; sometimes, indeed, only the last portion shows blood. If the bladder be washed out, the water comes back con- tinuously bloody ; whereas, if the haemorrhage is beyond the bladder, the water soon becomes clear. Other symp- toms are usually present which would indicate the seat of the lesion. The causes of bladder haemorrhage are venous hyperaemia and varicosity of the bladder veins, chronic and acute cystitis, concretions, tuberculosis and 427 Urine. Urine. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. diphtheritic ulceration, cancer, and the action of parasites, such as the distoma haematobium and filiaria sanguinis. Haemorrhage from the ureters and kidney pelvis re- sembles the last, and frequently occurs at the same time from the same causes. Quite characteristic of haemorrhage above the bladder is the shape of the clots found in the urine. The blood frequently coagulates where it is poured out, and the coagulum remains there long enough to take a characteristic shape before the pressure of the accumulated urine drives it down to the bladder. Thus, if we find the worm- or pencil-shaped clots from the ureters, or moulds of different parts of tlie tubuli of the kidney in the sediment, the diagnosis is clear ; but, unfortunately, these are not always present to indicate the locality of the lesion, and other symptoms must be sought for. The most frequent cause of haemor- rhage from these regions is the presence of concretions and the effects of their passage to the bladder (renal colic). Besides this local inflammatory and degenerative process, some acute infectious diseases, such as small-pox, etc., the action of some poisons, especially phosphorus, and the action of parasites, may be cited as occasional causes. In most cases of haemorrhage from tlie kidney itself (renal haematuria), the blood and urine are thoroughly mixed, and there is an absence of clots. Occasionally, however, the haemorrhage is sudden and large (as from rupture of a renal aneurism), and large clots are seen. The blood-cells are usually found 'decolorized and not numerous, and the urine is not a bright red, but has more of a brown tint (methaemoglobin), or the color of flesh-water and dichromic. The presence of "blood casts" (see urinary sediment) is quite characteristic of haemorrhage from the parenchyma of the kidney. Omit- ting such rare causes as aneurism and traumatism, Bright's disease in its various forms, acute, subacute, and chronic, is the chief cause of renal haematuria ; acute nephritis is the commonest cause ; the chronic forms give rise to haemorrhage less frequently, while it is rarely or never seen in amyloid disease. It is also occasionally caused by haemorrhagic infarcts, thrombosis of renal veins, concretions in the tubules, and cancer. Ilcemoglobinuria (Haematuria, Methaemoglobinuria).- This condition is distinguished from the foregoing by the darker color of the urine, the absence of blood-cor- puscles and clots, the presence of albumen in traces, only recognized on heating the fluid by its forming a brown scum on the surface, the comparatively small sediment, and by the blood-coloring matter, usually giving the spectrum of methaemoglobin when the urine is fresh. The urine in haemoglobinuria, besides the dissolved blood- pigment and that precipitated in colored granules, occa- sionally shows in the sediment crystalline blood-pigments, hyaline and granular casts, and oxalate of calcium in fine octahedra. Its specific gravity is always less than in haematuria. The condition known as haemoglobinuria is caused by the passage of haemoglobin from the blood into the urine ; this occurs whenever there is an excess of this pigment free in the blood plasma. It is artificially produced by injecting haemoglobin into the circulation, or by the action of certain therapeutic and toxic agents, which act by the dissolution of the red blood-corpuscles, thus setting free the pigment. It has been known to follow' severe burns, the inhalation of arseniuretted hydrogen and carbonic- acid gas, and in cases of poisoning by hydrochloric, car- bolic, and pyrogallic acids, or chlorate of potash. In diseases accompanied by rapid destruction of blood-cells, such as typhus fever, malaria, and pernicious anaemia, this condition of the urine is occasionally seen. In 1862 Dr. Harley first called attention to the affec- tion called paroxysmal or intermittent haemoglobinuria. Since then numerous cases have been recorded. The disease, as the name implies, is essentially intermittent. The paroxysms are suddenly ushered in by a rigor, fol- lowed sometimes by an elevation of temperature, pains in the back and loins, and numbness of the extremities. The finger-tips, toes, and ears are frequently cyanotic, and there is a general feeling of malaise. These symp- toms are accompanied or immediately followed by a dis- charge of dark urine, when the patient becomes rapidly better, and the next urine passed may be quite free from haemoglobin. These attacks recur at regular intervals, varying with each case, or may be quite irregular. Ma- laria and syphilis are said to predispose to this affection. The attack is frequently attributed to exposure to cold or to excessive muscular exertion. Excesses of all kinds and severe mental shock have been also cited as predis- posing causes. Among animals, especially horses, a similar affection is known. The attacks are very sudden, and are usually brought on by exposure and unusual muscular strain. The symptoms are dark albuminous urine, paralysis of the hinder extremities, rigidity and tenderness of the gluteal muscles, and disturbance of the respiratory, di- gestive, and circulatory systems, followed by death in from one to five days. Sugar in Urine.-The following saccharine bodies have been found in urine : 1. Glucose (Dextrose}, or grape-sugar. 2. Levulose, or fruit-sugar. 8. Inosite, or muscle-sugar. 4. Lactose, or milk-sugar. Of these the first only is of great clinical importance ; the others occur occasionally in some quantity, and their presence in diabetic and other urines is of sufficient in- terest to merit a short notice before considering the more important subject of glycosuria. Levulose, or fruit-sugar (C6HI2OB), occurs occasionally with dextrose in urine, and causes the great discrepancy sometimes observed between the quantitative analysis of diabetic urine by Fehling's method and by the polari- scope. As the name implies, it is levorotatory, while dextrose turns the plane of polarization to the right; it also possesses some reducing action on copper. Hence, when this substance is present the copper tests show too much dextrose, and the polariscope too little. It is non- crystallizable. Inosite, or muscle-sugar (CbHi2Ob+2H2O), is sometimes found in diabetic urine, also in that of Bright's disease, and has been detected in normal urine (Cloetta, Kulz). It is said to occur in seventeen per cent, of cases of dia- betes and in eight per cent, of all cases of Bright's dis- ease ; its quantity is increased by the use of diuretics. It forms large, colorless, clinorhombic prisms and mono- clinic tables. It does not reduce Fehling's solution, but changes it to a green color, nor will it undergo fermenta- tion with yeast. It has no action on polarized light. To separate it from urine several litres of acid urine must be used. This is precipitated with neutral and basic lead acetate, filtered, the filtrate freed from lead by sulphu- retted hydrogen, and the filtrate from the lead sulphide allowed to stand twenty-four hours, to allow the uric acid to deposit. The clear liquid freed from uric acid is now evaporated to a syrup and precipitated with absolute alcohol. This precipitate is dissolved in a little hot water, three or four volumes of ninety per cent, alcohol added, and then ether until a precipitate occurs. The mixture, on standing, will deposit the crystals of inosite. This form of sugar sometimes replaces dextrose during convalescence from diabetes. Puncture of the floor of the fourth ventricle sometimes causes inosite to appear in the urine instead of dextrose. Lactose, or milk-sugar (Ci2H23On + H2O). Lactosuria was found by Hofmeister to occur in nursing women. Lactose is a crystalline sugar with stronger dextrorota- tory powers than dextrose, and, like the latter, it reduces copper salts, but is distinguished from it by not under- going alcoholic fermentation with yeast. Glucose, Dextrose, or Grape-sugar (CBIIi2OB).- The sugar most commonly present in urine is found to be identical with this grape-sugar or dextrose. It is very doubtful, indeed, whether dextrose has as yet been isolated from normal urine. Briicke, Bence Jones, Molisch, and some others claim that it is present in all urine. Bence Jones obtained as much as 0.8 to 1.7 grain per pint. These results, however, and the methods used to obtain them, have been very severely criticised. At present, the almost universal verdict re- 428 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Urine. Urine. garding the question of sugar in normal urine is "not proven ; " still it must be admitted that there is a high degree of probability that minute traces of sugar, as indeed of all the other constituents of the blood, occa- sionally find their way into normal urine. These traces are of but little interest from a clinical standpoint. If sugar be present in sufficient quantity to be of any practical interest, it can be easily detected by means of the tests now used for its recognition. Most, if not all, of the tests that follow, are sufficiently delicate and free from fallacies for practical use ; at the same time there are few, if any, that will not under some cir- cumstances give a false indication, either positive or negative. This is especially true wlien they are called upon to decide the presence or absence of minute traces of dextrose. The number of test-reactions recommended for the detection of sugar is now very great, and still increasing. The reactions given below will be chiefly those that have withstood the test of time ; any objections or possible fallacies connected with these will be noted. Physicians will find it to their advantage to be familiar with two or three tests : a rough-and-ready one that can be easily and quickly used at the bedside, and one or two others to be used as confirmatory and quantitative tests, when at leisure. Diabetic sugar may be often obtained in beautiful, well- formed crystals, by allowing a few drops of the urine to inhaled ; (3) chloral, which appears as urochloralic acid in the urine ; (4) benzoates in very large doses. Physiological experiments have demonstrated that after the administration of glycerine, orthonitrotoluol, copaiba and cubebs, reducing substances appear in the urine. Camphor gives rise to the reducing substance called glycuronic acid (C8Hio07); closely allied to this is the new acid, isolated by Dr. Marshall, and called by him glycosuric acid. Tests for Dextrose or Grape-sugar.-Moor's test consists in boiling the urine with half its bulk of liquor potass® in a test-tube ; the presence of sugar manifests itself by imparting a brown color to the mixture. This test will not detect less than 0.3 per cent., so a negative result is no proof of the absence of traces. Liquor potass® may contain lead from the glass bottles in which it is contained ; it then gives a dark color with albuminous urine, from the union with the sulphur in the albumen, to form the black lead sulphide. Boettger's bismuth test depends on the reduction by dex- trose of the oxide of bismuth to metallic bismuth, which is black. The urine is mixed with its ow n volume of liquor potass®, a pinch of bismuth subnitrate added, and the mixture boiled for a minute or two. Albumen must be removed if present, or the black bismuth sulphide will be formed and a false indication given. Briicke recommends the use of Frohn's reagent in conjunction with Boettger's test (see Hofmann and Ultz- mann, or Tyson's Analysis of Urine, for details). The fermentation test is the recognition of sugar by fermenting it with yeast, and collecting or recognizing one of the products of fermentation; viz., alcohol or carbon dioxide. The carbon dioxide may be collected by filling a strong test-tube two-thirds full of mercury and the remainder with the urine, to which has been added a little fresh yeast. The tube is carefully in- verted into a small vessel containing mercury, and al- lowed to stand for twenty-four hours in a warm place. If any carbonic-acid gas collects at the top of the test- tube, the urine contains sugar. It is as well to check the accuracy of the result by a couple of control exper- iments conducted at the same time. Two other test- tubes are filled similarly to that containing the suspected urine, but instead of urine and yeast, in one pure water and yeast are placed, and in the other the urine with- out yeast. If no gas collects at the top of either of them it is safe to conclude that any carbon dioxide gas found in the third tube is not derived from either the yeast or the urine alone, but from the fermentation of dextrose. Sir William Roberts has shown that by the ordinary method given above, urine containing 0.5 per cent, of sugar will give no indications of its pres- ence, as urine will take up its own volume of carbon dioxide. His method depends on the diminution in den- sity suffered by saccharine urine when fermented, and it combines the two advantages of ease and accuracy. He has shown that each degree of specific gravity lost corre- sponds to one grain of sugar per ounce. His mode of pro- cedure is as follows : About 4 ounces of urine are put in an 8 to 10-ounce bottle with a piece of German yeast the size of a small walnut; the bottle is closed with a nicked cork, to allow the carbon dioxide to escape, and placed on a mantel-piece or some other warm place to ferment; be- side it is placed a 4-ounce bottle tightly corked, filled with the urine, but containing no yeast. After from eighteen to twenty-four hours the specific gravity of the urine in both bottles is carefully taken, and the number of de- grees lost is ascertained. This gives at once the number of grains per ounce, from which the percentage of sugar may be calculated by multiplying the number of grains by 0.23. Example : Density before fermentation 1.038 Density after fermentation 1.013 Degrees lost 25 Grains of sugar per fluid oz. = 25 25x0.23=5.69 per cent, of sugar. Fig. 4271.-Crystals of Diabetic Suuar. (Beale.) evaporate spontaneously on a glass slide (Fig. 4271). (Beale.) It is very easily oxidized, i.e., it acts as a strong reducing agent on metallic salts, etc., and it is upon this property of the substance that most of the methods em- ployed for its recognition are based. So it must be re- membered that most of the tests, especially the copper tests, only detect the presence of a reducing agent, not necessarily sugar, in abnormal quantity. Now, urine contains many reducing agents in health, and in disease they frequently increase in quantity, and may be thus mistaken for dextrose. Among those in normal urine that will reduce copper oxide may be mentioned : (a) Uric acid ; (6) creatinin ; (c) indican (?); (d) pyrocatechin (?) (alcaptonuria). Pyrocatechin is said to be the compound that was de- scribed by Bodecker under the name alcapton, which reduces copper oxide but not bismuth, and which gives with Moor's test (vide infra) a dark color, extending from the surface down. Dr. Robert Kirk has lately found the reducing substances of alcaptonuria to be urrhodinic and uroleucic acids, and not pyrocatechin. Besides these constitutents of urine, there are a number of abnormal reducing agents, that may occasionally cause some difficulty in applying reduction-tests. These may be introduced as the results of the administration of certain drugs and therapeutic agents, such as : (1) turpentine-in therapeutic doses ; (2) chloroform-when 429 Urine. Urine. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. This process has the advantage of not being interfered with by the presence of reducing agents, such as uric acid, creatinin, etc. Its great disadvantage is that a de- lay of twenty-four hours is necessary before ascertaining the result. Indigo Carmine Test (Mulder).-A solution of sodium sulphindigotate (indigo carmine) made alkaline with sodium carbonate and boiled with a little saccharine urine becomes reduced to indigo white, and the solution, previously blue, is changed first to green, then to purple, red, and finally to pale yellow. Dr. Oliver recommends this test, and has devised a very convenient method of applying it by means of his test papers. He has also made the method roughly quantitative, the details of which can be found in Oliver's " Bedside Urine Testing." The Copper Reduction Tests.-There are three well- known tests, viz., Trommer's, Fehling's, and Pavy's, that depend upon the reduction of cupric oxide by glucose. In all these tests the reducing agents mentioned above may interfere with an accurate observation, by causing a slight precipitation of the cuprous oxide when no sugar is present. This rarely occurs, however, if the mixed test-fluid and urine are not boiled too long. The pre- cipitation by sugar should occur without prolonged boil- ing, it is sufficient to heat the solution until it boils, and continue the boiling not longer than 30 or 40 seconds. Copper solutions (in Pavy's or Fehling's test) should not be added to the boiling urine, but the urine slowly dropped into the boiling test solution until less than an equal volume is added, and the mixture again brought to the boiling point; if on cooling no suboxide is found precipitated, the urine may safely be pronounced sugar free. There must never be an excess of urine over the test solution in Fehling's or Pavy's test. Trommer's test is the ordinary mode of using copper to indicate the presence of sugar. The test is made by adding a few drops of copper sulphate solution to the urine in a test-tube and then caustic potash in excess, and boiling the mixture ; a precipitate of the yellow or red suboxide of copper indicates the presence of sugar. If the reaction is at all doubtful, a test-tube containing the urine, with a few drops of copper sulphate and an equal volume of caustic potash, should be set aside with- out previous boiling. In the course of 24 to 36 hours a precipitate of cuprous oxide will take place if sugar be present. All other organic bodies found in urine which act as reducing agents only reduce copper salts on boil- ing. Fehling's solution is best prepared in two parts, kept in separate bottles, and mixed only when required. Fehling's standard copper solution.-Crystals of pure copper sulphate, after being reduced to powder, are dried by pressure between folds of blotting-paper, and exactly 69.28 grammes weighed out and dissolved in water; 1 c.c. of sulphuric acid is added, and the solution diluted to 1 litre. Alkaline tartrate solution.-350 grammes of Rochelle salt (sodio-potassium tartrate) are dissolved in about 700 c.c. of water, and the solution filtered if not clear ; to this must be added 100 grammes of caustic soda dissolved in 200 c.c. of water, and diluted to 1 litre. The Fehling's solution is made by using these two so- lutions in equal parts, when each cubic centimetre of the mixture will be found to contain 0.03464 gramme of copper sulphate, and represents 0.005 gramme of pure anhydrous sugar (CoHiaOa). M. Schmiedeburg has proposed a modification of Feh- ling's solution, using mannite instead of Rochelle salt. This solution has proved to be very stable, and may be kept for months unimpaired. He mixes 34.634 grammes of cupric sulphate dissolved in 200 c.c. of water, with 15 grammes of pure mannite dissolved in 100 c.c. of water and 400 c.c. of caustic soda, sp. gr. 1.145, and lastly water to 1 litre. For qualitative testing, about 1 c.c. of the solution is diluted with 3 or 4 volumes of water and boiled, and the urine is added drop by drop; if no precipitate occurs when nearly an equal volume of urine has been added, again heat the mixture to the boiling point, and if still no precipitate occurs set the test-tube to one side for a few hours. The absence of a precipitate on cooling excludes the possibility of there being more than one-twentieth of one per cent, dextrose in the urine. Quantitative Estimation by Fehling's Solution.-The urine is diluted to 5 or 10 volumes with water, according to the density and other indications of the quantity of sugar present. With this solution, a burette graduated to 0.1 c.c. is filled to the zero mark (Fig. 4261); 20 c.c. of the Fehling's solution, diluted with 3 to 4 volumes of water, is boiled in a flask and the urine added 5 c.c. at a time ; with each addition the mixture is made just to boil. This gradual addition of the diluted urine is continued until the mixture begins to decolorize, when the urine is added drop by drop, till, when the precipitated oxide of copper subsides, no blue tint can be observed on looking through the flask held over a sheet of white paper. Instead of a flask, the titration may be con- veniently done in a casserole of white porcelain (Fig. 4272). The number of cubic centime tres used, divided by the number of times the urine was diluted, will give the volume of urine that is equivalent to 20 c.c. of Fehling's solution, or 0.1 gramme of sugar ; from this the amount of sugar in the day's urine may be calculated. Dr. Tyson suggests a very convenient way of approxi- mately estimating the sugar by Fehling's solution. It is very rapid and more suited to the consulting-room than the above. One c.c. of Fehling's solution diluted with 4 c.c. of water is boiled in a test-tube, and 0.1 c.c. of urine added from a small burette ; if this does not pre- cipitate all the copper on again heating, another 0.1 c.c. is added and the boiling repeated. This is continued till the solution is decolorized. If 1 c.c. of urine be required to decolorize 1 c.c. of Fehling's solution, there is 0.5 per cent, of sugar ; if 0.5 c.c. of urine be required, the sugar is one per cent. If there be much sugar the urine should be diluted with 2 to 5 volumes of water and this regarded in the estimation. Pavy's Ammoniated Copper Test.-This is a modified Fehling's solution containing ammonia, which dissolves the cuprous oxide as fast as formed, thus giving, when the reduction is completed, a colorless, clear solution. This method is more rapid, as it obviates the necessity of waiting for the subsidence of copper oxide, which is often tedious. The proportions are as follows : Metric System. English System. Copper sulphate 4.158 grms. 36.5 grains Rochelle salt 20.400 " 178 " Caustic potash 20.400 " 178 " Strong ammonia (sp. gr. 0.880), 300 c.c. 6 fl. oz. Water to 1 litre to 1 pint. Dissolve the Rochelle salt and the potash together, and the copper sulphate by aid of heat in another quan- tity of water. Mix the two, and when cool add the liquor ammoniae and dilute to one litre or one pint. It may be used in the same way as Fehling's solution for either qualitative or quantitative work; air must be excluded as much as possible, otherwise the solution again becomes blue by oxidation. Picric Acid and Potash.-In 1865, C. D. Braun (in the Zeitschrift fur Chemie} recorded the observation that picric acid became reduced to the deep-red picramic acid when boiled in an alkaline medium with any liquid containing dextrose. This observation was not utilized for urine testing until, quite independently, Dr. George Johnson revived it in 1882, and made it the basis of a very practical quantitative method. A convenient way to apply this test is to put about a grain of picric acid, i.e., what can be carried on the end of the blade of a penknife, in a test-tube graduated up to 3 drachms ; | drachm of water is added, and the acid is dissolved by heat ; now an equal volume of urine is added ; if albumen be present a turbidity ensues, which, however, does not interfere with the sugar test. To test Fig. 4272.-Porcelain Casse- role for Use in Fehling's Quantitative Method. 430 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Urine. Urine, for sugar, next add a grain of caustic potash and boil for a minute ; a rich claret-red or black color is produced if dextrose be present; under any circumstances the mixt- ure is given a slightly darker tint when the potash is added, owing to the reducing action of creatinin. Uric acid does not reduce picric acid, but the latter is reduced partially by the urine of patients taking chloral or salicy- late of soda. Quantitative Estimation.-It has been found that the depth of color produced by the action of sugar on picric acid is proportional to the quantity of sugar present, as long as the picric acid is in slight excess. Dr. Johnson has utilized this as the basis of a very ac- curate and convenient method for the quantitative esti- mation of sugar. He uses as a standard color the claret- red tint produced by boiling forty minims of a cold saturated solution of picric acid with a fluid drachm of a solution containing one grain of sugar to the ounce, mixed with half a drachm of liquor potassae, and made up to four drachms with distilled water. This tint is then that produced by one grain of sugar to the ounce diluted four times by the reagents and water. As this solution does not preserve its tint, the color is artificially imitated by a solution of ferric acetate prepared as follows (the ingredients are given in the strength of the United States Phar- macopoeia, which is the same as that of the British): u. s. Ph. Liq. ferri perchlor f 3 j. Liq. amm. acetat f § ss. Acid. acet, glacial f 5 ss. Liq. ammoniae f 3 j. Aquae destil ad f ? iv. When this artificial solution is made the tint should be compared with the standard prepared as above. It keeps for several years if not exposed to strong light. In making the quantita- tive estimation of sugar in a sample of urine, it must be remembered that the picric acid should be in proportion to the sugar. If there be six grains or less to the ounce of urine, no dilution is necessary, but it will be found that most diabetic urines will have to be diluted to five or ten volumes with water before treating them with the acid. A fluid drachm of the diluted urine is boiled for one minute with forty minims of a saturated picric acid solution, mixed with half a drachm of liquor potassae, and diluted to four drachms. This is conveniently done in a long test-tube which has been graduated to four drachms. After cooling the liquid by immersing the tube in cool water, the volume is adjusted to four drachms if any water has been boiled off, and a comparison made with the standard color. This is done by means of the simple apparatus shown in Fig. 4273, called by Dr. Johnson a picro-saccharometer. The small tube to the left contains the standard solution and should be kept tightly stoppered. The urine mixture to be esti- mated is poured into the graduated tube, which is made of the same diameter as the other, and its color compared with that of the standard solution. If the tints are the same, then the diluted urine contains one grain to the ounce ; if it is darker, then it must be diluted with dis- tilled or rain-water (not hard water) till the same tint has been obtained. The number of times the urine mixture has to be diluted will give the number of grains to the ounce. Thus, if the urine when poured in has occupied ten divisions, as it is arranged to do, and this requires dilu- tion to thirty divisions, then there are three grains of sugar to the ounce ; if to forty-five divisions, then there are 4.5 grains of sugar to the ounce of diluted urine. It will be seen that if the original urine be diluted ten times before testing, the graduation on the picro-saccharometer will give at once the grains per ounce of sugar ; if previously- diluted five times, half the number of the graduations will give the grains per ounce. The percentage of sugar may at once be calculated by remembering that a fluid ounce of water weighs 455.7 grains. The percentage then = 100 x grains per ounce. 455.7 ? ' This is an admirable method for estimating sugar in urine for one not accustomed to chemical manipulation. The general practitioner will find either this, or Sir Will- iam Roberts' quantitative fermentation method by dif- ference in specific gravity, more convenient than the older and more elaborate method of titrating Fehling's or Pavy's solution. Several new tests for sugar have recently been brought prominently before the medical profession ; among these the phenyl hydrazin test of Fischer, and Molisch's alpha naphthol and thymol tests are of sufficient interest to merit notice. The value of the former in the hands of a chemist, for the identification of traces of sugar, is un- doubted ; and as the latter is claimed to be so delicate that it easily detects sugar in normal urine diluted two hundredfold, its further study may lighten the obscurity at present surrounding the question of glucose in normal urine. Phenyl Hydrazin Test.-This test, originally' proposed by Emil Fischer, has been strongly recommended by Von Jaksch. It is thus performed : 50 c.c. of urine in a test- tube are mixed with 2 grms. of phenyl hydrazin hydro- chlorate and 1| grm. of sodium acetate dissolved in 20 c.c. of water, and the mixture heated in a warm bath for ten or fifteen minutes. If dextrose be present, among the amorphous particles in the precipitate will be found sheaves of fine yellow needles of a compound of phenyl hydrazin and dextrose. These crystals may be recognized by a lens magnifying 150 to 200 diameters, and their identity confirmed by recrystallizing them from dilute alcohol and taking their melting point, which is 204° C. Von Jaksch never found sugar in normal urine by this test, but it could be detected in cases of fever, ulcerative endocarditis, poisoning by carbon monoxide, and some other toxic gases. The reducing substance found in the urine after toxic doses of sulphuric acid and caustic pot- ash was found not to be sugar. Traces of glucose were detected in pus, and in the exudations of pleurisy and peritonitis. Alpha Napthol and Thymol Test (Molisch).-To 2 c.c. of urine in a test-tube add two drops of a fifteen to twenty per cent, solution of alpha naphthol or thymol. After mixing add an equal volume of strong sulphuric acid ; a deep violet color with naphthol, and a deep red with thymol will result, if any carbohydrate or glucoside capable of yield- ing sugar with sulphuric acid be present. The ordinary reducing substances of urine are said to give no such re- action. On diluting with water, a violet-blue precipitate is thrown down, soluble in alcohol and ether with a yel- low color, and in caustic potash with a golden-yellow color. This is said to detect 0.00001 per cent, of sugar. Molisch's views regarding the value of this test are dis- puted by Seigin and others, but it has been' too little studied as yet to enable one to determine its true value. Optical Determination of Sugar.-The polariscope (Fig. 4274) affords the readiest method of determining the quan- tity of glucose when it exceeds one per cent. It requires some practice, and the expense of the apparatus will pre- vent its use becoming general. It is not a convenient qualitative method. The process depends on the specific dextro-rotatory power possessed by glucose, the amount of deviation to the right depending on the quantity of glu- cose present in the fluid through which the light passes. If the urine be colored, it must be decolorized by pre cipitation with basic lead acetate (1 to 10) or by filtration through animal charcoal. Diabetic urine is occasionally not sufficiently colored to require this. The tube of the polarimeter, which lies between the Fig. 4273.-Dr. George Johnson's Piero - saccharome- ter. (Tyson.) 431 Urine. Urine. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. two prisms at E, D, and F (Fig. 4274), is rinsed with a little of the clear urine and exactly filled ; the glass plate is slipped on so as to exclude any air-bubbles, and the cap is screwed on, but not tightly. The tube filled with urine is now placed between the polarizer and analyzer of the instrument (L, Fig. 4274), when an optical disturbance will be observed, the extent of which will depend on the amount of sugar in solution. The polarimeter is now adjusted by means of the screw at F, which turns the analyzer till the two halves of the field of vision are equally illuminated pear and the symptoms abate after the diet has been regu- lated. This is a less serious type of the disease, and although always associated with serious departure from health, is not characterized by that " fixed tendency to death " which marks the first type. Acetone and other Oxidized Fatty Compounds.-There are encountered a number of oxidized organic bodies, asso- ciated in some way not yet explained with glucose, that are now attracting considerable attention. These are : acetone (C3II6O), diacetic acid (CiHeOs), ethyl diacetate (C6Hio03), oxybutyric acid (C4HeO3), formic acid CHaOa), and alcohol (CaH6O). This is a well-defined group of bodies which, from a chemical standpoint, are closely related one to another ; what their relations are to each other in the body we can only conjecture, but outside the body we know that oxybu- tyric acid passes by oxidation into diacetic acid, which in turn decomposes on exposure into acetone and carbon dioxide as C|H6O3 = C3H6O + COa Diacetic acid. Acetone. Carbon dioxide. Diacetic ether or ethyl diacetate decomposes easily into alcohol, acetone and carbon dioxide in presence of alka- lies, and when treated with reducing agents gives rise in turn to oxybutyric acid. Owhntwin acid anj diacetic acid (acetyl-acetic acid) are the probable antecedents of acetone in the body. They occur together, or may replace each other, in diabetic urine. The acid that gives the red color with ferric chloride in diabetic urines is not always diacetic acid. It has been shown to be due in some cases to formic acid, but more frequently to oxy butyric acid (Le- pine and Stadelmann). Acetone may be recognized in urine by direct testing, but it is, as a rule, better to look for it in the distillate. A number of tests have been devised for its recognition ; the best of these are the four following : The iodoform test (Lieben's) depends on the fact that acetone readily unites with iodine in an alkaline solution, giving rise to iodoform. Alcohol reacts in the same way, but only after some time, or when the mixture is gently warmed. To perform the test, a little urine in a test-tube is made strongly alkaline with caustic potash, and a solution of iodine in iodide of potassium is dropped in till the iodine color just disappears on shaking. If ace- tone be present the urine will assume at once a pale yellow turbidity, and gradually deposit iodoform in fine (Fig. 4275, a); the rota- tion required to produce this effect is read off and recorded. Most saccha- rometers are so arranged that the percentage of sugar is at once read ; but in Laurent's sac- charometer (Fig. 4274), which is the best, the number of degrees (in- creased by one-tenth if the urine was clarified with basic lead acetate), multiplied by 0.2051, gives the percentage of sugar. Clinical Significance of Glycosuria.-The dif- ficult question of the cause of the continuous appearance of sugar in the urine is fully discussed in the article on Diabetes. The important question for the physician to decide when a case of glycosuria presents itself, is whether the symptom is temporary or continuous. Temporary glycosuria is observed as the result of an excessive saccharine or amylaceous diet, especially among old people, whose taste for sweets sometimes survives their power of digesting them. It has been observed also after chloroform narcosis, during recovery from cholera, after paroxysms of whooping-cough, asthma, and epilepsy, and after many lesions of the brain ; also in small amount in acute febrile diseases, and after pneumo- nia, typhus fever, and acute rheumatism. In all these cases it may be regarded as a temporary or incidental consequence of some physiological or pathological dis- turbance of function, in no way connected with what is clinically known as diabetes. Experiments on the lower animals show that glyco- suria may be produced in a variety of ways, such as in- haling carbonic oxide, hypodermic injections of nitro- benzol, or injury to the floor of the fourth ventricle. Continuous or permanent glycosuria is the disease known as diabetes mellitus, of which we have two well- marked types. In one the glycosuria is intense, persist- ent, and accompanied by an excessive flow of urine ; this state of the urine is accompanied by thirst, debility, emaciation, and all the other grave symptoms that make up the clinical picture of rapidly fatal diabetes. The second type is seen chiefly in those past middle age ; the symptoms are milder, the glycosuria intermittent or not well marked, and the urine abundant at times, but sometimes quite normal; there is always a weakly con- dition of health, often dyspepsia, little or no emaciation, no marked thirst, and the glycosuria is found to disap- Fig. 4274.-Laurent's Polarimeter for Optical Determination of Sugar. Fig. 4275.-Illustrating the Use of Laurent's Shadow Polarimeter. (Ty- son.) six-sided tablets easily recognized by their odor and mi- croscopic characters. Gunning has modified the iodoform test so as to ex- clude the possibility of any iodoform being thrown down by alcohol. He uses iodine (in tincture) and a solution of ammonia. Both iodine and iodoform are precipitated, the former whether acetone be present or not; but the yellow iodoform crystals are easily distinguished. This is not so delicate a reaction as the iodoform test of Lieben. Nitro-prussiate test (Legal's): A few drops of a fresh solution of nitro-prussiate of soda are added to the urine 432 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Urine. Urine. and enough liquor sodae to give a distinct alkaline reac- tion. A carmine-red color is given to every urine, which changes quickly into a yellowish-brown ; if now two or three drops of glacial acetic acid be added, the red color comes back and the presence of acetone is indicated by an intense deep purple color, which in time also fades away. Indigo test (Bayer's) : To a mixture of a little nitro- benzaldehyde in water, add an equal volume of the urine (or better its distillate). The presence of acetone is shown by the formation of indigo-blue. This may be formed in such small quantity as to impart only a green color to the urine, from the mixture of the blue with the yellow urine, or the liquid may be turned decidedly blue if much acetone be present. A few drops of chlor- oform, shaken up with the mixture, dissolves out the in- digo-blue ; after standing, the solvent separates at the bot- tom colored deeply blue. The use of chloroform makes the test much more delicate. The mercuric oxide test (Reynolds') depends on the prop- erty of acetone to dissolve the oxide of mercury. A lit- tle mercuric oxide precipitated from mercuric chloride by alcoholic potash, is added to a few cubic centimetres of the distillate, from the urine to be tested. The mixture is filtered, and if mercury be found in the clear filtrate, the presence of acetone is demonstrated. To show the dissolved mercury, the clear filtrate is overlaid in a test- tube by ammonium sulphide ; a black ring of mercuric sulphide, at the line of junction of the two fluids, indi- cates dissolved mercury. This is a very delicate test, but less delicate than Lieb- en's iodoform reaction. V. Jaksch has made a number of observations regard- ing the relative value of the different tests for acetone. He finds the iodoform test the most delicate, detecting by it 0.0001 milligramme of acetone, Gunning's modification only recognizing 0.01 milligramme, while Reynolds' and Legal's test (nitro-prusside of sodium) gave no indication when 0.01 milligramme of acetone was present. The in- digo test of Bayer and Penzoldt reacts only when the fluid contains at least 1.6 milligramme of acetone. Quantitative Estimation of Acetone.-The writer has, by a modification of the iodoform test, made it approximately quantitative. The method is similar to that described by Kramer for the estimation of traces of acetone in methyl alcohol, and depends on the observed fact that, the quantity of iodine and alkali being constant for each reaction, variation in the quantity of iodoform produced depends on the quan- tity of acetone present. If traces only of acetone be pres- ent, two-thirds of the urine should be distilled over after acidification with dilute sulphuric acid, and the estima- tion made with the distillate. If the acetonuria be well marked, the estimation may be made directly. The so- lutions required are a normal solution of iodine, made by dissolving 126.5 grammes of iodine and 180 grammes of potassium iodide in one litre of water; and a normal caustic potash solution, i.e., containing fifty-six grammes of KOH per litre. One cubic centimetre of urine is delivered into a small separating funnel that can be closed by a stopper ; 10 c.c. of the potash are now mixed with it, and 5 c.c. of the nor- mal iodine slowly added, the mixture being well shaken. To this is added 10 c.c. of ether free from alcohol, and the mixture is again shaken. The ether will now rise to the surface, carrying with it all the iodoform ; and the aqueous solution below it having been allowed to escape by opening the tap of the funnel, the ether, or an aliquot part of it, is allowed to evaporate spontaneously on a tarred watch-glass and it, with the iodoform left behind, is carefully weighed. The weight of iodoform multiplied by 0.25 gives the quantity of acetone ; if the quantity ex- ceed one per cent, the urine should be diluted with water before estimating, and allowance made in the calculation. The writer has only examined eighteen cases, but has not found a case of acetonuria in which the acetone ex- ceeded 0.75 per cent. The presence of alcohol up to fifty per cent, of the acetone, does not affect the estimation, if the operation be performed without unusual delay. The process is very rapid, three or four estimations may easily be made in an hour in a chemical laboratory. No other method has yet been proposed for even ap- proximately estimating acetone in urine, except Salkow- ski's, which is only available when large quantities of urine are at hand. Clinical Significance of Acetone and Diacetic Acid.- Acetone in urine, as a rule, has little or no pathological significance unless derived from, or associated with, di- acetic acid. It must be remembered that diaceturia is always accompanied by indications of the presence of acetone, and while we can detect the former in the pres- ence of acetone, by the chloride of iron test of v. Jaksch, acetone itself cannot be recognized as an independent entity in fluids containing diacetic acid. Hence it was that before the recent careful investigations of v. Jaksch these two substances were regarded as having identical import. Diaceturia cannot now be regarded as other than a most dangerous symptom, whether occurring in adults or in children. Acetonuria is classified by v. Jaksch into physiological and pathological. He claims that acetone may always be detected in normal urine, but in this he is not sup- ported by others who have studied the subject. Mosca- telli and Vitali, within the last few months, have exam- ined large quantities of urine of healthy persons with negative results. They therefore regard acetonuria as always of pathological import. The writer failed to de- tect acetone in thirty examinations of the urine of healthy adults, except in one case where alcohol had been taken in considerable quantities. Baginsky finds that acetone occurs in the urine of healthy children under completely normal conditions, but in very small quantities. Von Jaksch distinguishes four forms of pathological acetonuria : (1) febrile, (2) dietetic, (3) that accompanying carcinoma, and (4) acetonsemic. Acetonuria is not only a common accompaniment of pyrexia, diabetes mellitus, carcinoma, inanition, and many cerebral troubles, but its presence in urine is some- times associated with a train of symptoms for which it seems to be alone responsible. In this affection, called " acetonaemia," the blood is supersaturated with acetone, and there appears to be a veritable auto-intoxication. In the milder cases ner- vous symptoms are not marked, but in severe cases there are seen intense excitement and delirium, succeeded by deep depression, and (rarely) coma and death (Cantani, Deichmuller, and v. Jaksch). In diabetes there seems to be no relation between the quantity of glucose and that of acetone or diacetic acid in the urine, though it has sometimes been observed that a sudden reduction in glucose, from strict animal diet, has been succeeded by an excess of the acetone bodies and marked nervous symptoms. Rossbach has made obser- vations which seem to show that an albuminous diet may, of itself, cause diaceturia. It is to diacetic acid, and not to acetone in the blood, that v. Jaksch attributes dia- betic coma; he even suggests that the name "coma diaceticum " be applied to these symptoms. Diabetic coma, however, undoubtedly occurs without acetonuria or diaceturia. The conditions under which diaceturia occurs are similar to those of acetonuria ; thus it occurs in fevers, notably typhus and typhoid, and pneumonia ; it accom- panies diabetes, carcinoma, and mental diseases; and finally, there appears to be, according to v. Jaksch, an auto-intoxication, a " diacetaemia " analogous to aceton- semia, common in children and rare among adults. So that, generally speaking, acetone and diacetic acid pro- duce similar symptoms, or occur under similar circum- stances, the appearance of the latter in the urine being of much graver import. It seems probable that the question as to whether acetone or diacetic acid should ex- ist in the blood, or be found in the urine, depends o'? the degree of oxidation of some third morbid product which is capable of forming diacetic acid. Oxybutyric acid is the only substance that has been found, under similar circumstances, that readily yields either of these sub- 433 Urine. Urine. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. stances by oxidation, but it has been too little studied to enable any conclusions other than theoretical to be drawn regarding its relation to these interesting bodies. It has, however, been found in the blood and urine of diabetic patients by Hugounenq, Lepine, and Stadelmann. Constituents of Bile in Urine, Choluria.-The two con- stituents of bile that occur in urine are the pigments and the bile salts. The former give rise to the deep colored icteric or jaundiced urine, while the latter impart no characteristic color to the excretion. Dr. Oliver applies the convenient term choluria to urine containing excess of bile elements, especially the colorless salts, and dis- tinguishes jaundiced urine by the term " pigmentous choluria." Bile Pigments.-There are three principal pigments in human bile, all of which may occur in urine, viz.: Bilirubin (CmHisNiOa), bilifuscin (Ci6H22N2O8), and biliverdin (CieHioNaOs), the last two being oxidation products of bilirubin. Unoxidized bilirubin is less commonly found in urine than are its derivatives, especially biliverdin. If biliru- bin appears unchanged in the urine, the color-tests of Gmelin and Heller are easily obtained, but when biliver- din only appears, a green color instead of the usual play of colors is observed ; if the biliary coloring matters are still further altered, Gmelin's test will give no indication whatever of their presence. Bile-coloring matters ahvays impart to urine a yellowish-brown, greenish, or brownish- red color. On shaking up the urine, the froth produced is yellow, and filter-paper or linen moistened with it be- comes similarly stained. Gmelin's test consists in applying impure nitric acid to the suspected urine by the contact method. The nitric acid (containing a little nitrous acid) is poured down the side of a test-tube containing the jaundiced urine, so as to underlie the urine. In the zone between the fluids appears, from below upward, a play of colors, green, blue, violet, red, and yellow. The green is most prominent, and the blue often absent. Modifications of Gmelin's test.-Fleischl suggests mix- ing dilute nitric acid, or sodium nitrate, with the urine, and pouring this over a layer of strong sulphuric acid in a test-tube. The play of colors is not so rapid as in Gmelin's test. Instead of applying the impure nitric acid by the con- tact method, a few drops of nitric acid with one drop of sulphuric added, may be placed on a porcelain slab, and a drop of urine brought in contact; a similar play of colors occurs at the line of junction of the fluids. Heller's test consists in adding a few drops of the urine to about 6 c.c. of hydrochloric acid in a test-tube, and after mixing thoroughly, the fluid is found to be colored either reddish-yellow or green ; if the former, ^ilirubin is the coloring matter present, but if the color is green, it is due to biliverdin. This mixture is now floated up by pure nitric acid, and between the fluids a handsome play of colors appears. In using the above tests, if the urine be very dark it should be diluted. Albumen does not interfere with the reaction, but excess of urine-indican gives a blue color, which, with the yellow of the urine, appears green by re- flected light. In this case, the bile pigment should be extracted by shaking the urine with a little chloroform, and the yellow extract mixed with water, and nitric acid added while shaking. The regular succession of colors appears, but more slowly than in Gmelin's test. Ultzmann s test develops the characteristic green color very clearly. To 10 c.c. of urine are added 3 or 4 c.c. of caustic potash solution (1 to 3 of water), and then an excess of hydrochloric acid. The mixture now assumes a beautiful emerald-green color. Altered bile pigments (bilifuscin) which do not react with Gmelin's test, color white linen or filter-paper of a brown color when they are dipped into the urine and dried. Sulphuric acid also gives with such urine a very dark color, almost black, instead of the usual garnet-red. Biliary coloring matters occur in the urine in various pathological conditions of the liver, and may or may not be accompanied by an icteric coloring of the skin. Their presence in the urine often precedes the icterus two or three days, hence the jaundice may be prognosed from an examination of the urine. These pigments are always present in phosphorus poisoning. The Biliary Salts.-These are the sodium salts of tauro- cholic and glycocholic acids, the salts of the former acid greatly predominating in human bile. In the urine, be sides these two, there appears also their common deriva- tive, cholic acid as sodium cholate. These salts were formerly recognized by the well- known test of Pettenkofer. This consists in adding a few drops of syrup of cane-sugar to the urine and then pouring in strong sulphuric acid so as to underlie the urine in a test-tube ; between the two fluids, and gradu- ally spreading throughout the urine, there appears a cherry-red or violet-red color. The temperature must not be allowed to rise too high, or the sulphuric acid will blacken the urine. This test is very unsatisfactory in- deed for the direct testing of urine; Dr. Tyson very truly observes that the detection of bile salts by the direct application of the elements of Pettenkofer's test to urine is practically impossible, even if they are present in con- siderable amount. The peculiar tint imparted to fluids containing bile salts by the elements of Pettenkofer's test is probably due to the presence of cholic acid, and not to the unde- composed bile salts. The safest way, then, to detect these salts by Pettenkofer's test is to evaporate the urine extract with alcohol, precipitate this extract with ether, dissolve the precipitated bile salts (largely now cholate of sodium) in water, decolorize with animal charcoal, and apply the test to the aqueous solution so obtained. Dr. George Oliver has recently devised a very con- venient and delicate test for these salts, which he has made roughly quantitative. The test is based on the physiological reaction that occurs in the duodenum be- tween the bile salts and the products of gastric digestion -peptone and propeptone. These soluble proteids, when poured into the intestine in an acid solution, are at once thrown down by the bile as a gelatinous precipitate along the walls of the duo- denum. This suggested to Dr. Oliver the propriety of using an acid solution of peptone as a means of detecting the bile salts. The results of a number of experiments led to the preparation of the following permanent test- fluid containing acid peptone : Pulverized peptone (Savory & Moore) gr. xxx. Salicylic acid gr. iv. Acetic acid nt xxx. Distilled water to f | viij. To be repeatedly filtered till quite clear. Twenty minims of urine containing the bile salts are added to 60 minims of the test solution ; an opalescence appears proportionate to the quantity of bile salts present. This precipitate differs from all others produced by an acidified reagent in that it is dissolved up completely by a few drops of acetic acid, and is diminished but not dis- solved by boiling. Heat sufficient to dissolve urates does not affect it. Dr. Oliver claims to be able readily to de- tect 1 part of bile salts in 18,000 to 20,000 of salt solution, and has failed to find a non-biliary substance in urine that precipitates peptone applied as directed. He finds that the bile salts in normal urine vary with the activity of the digestive organs, and may be roughly estimated at 1 in 10,000 to 15,000 of urine. These salts are excreted in increased quantity after exercise and during fasting. Clinically, his observations show that the salts are to be found abnormally increased in fevers, jaundice, func- tional and organic diseases of the liver, in anaemia (sim- ple and malarial), and in splenic leucocythaemia. Cholesterine has been found in some cases of cystic disease of the kidney. Dr. Beale has extracted it from large quantities of the urine of Bright's disease, and also separated it in crystalline form (Fig. 2290, Vol. IV.) from fat globules and casts in urine. It is easily recognized by its waxy rhombic plates when seen under the micro- scope. Fat.-The investigations of Dr. Schunck show that it 434 Urine. Urine. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. is highly probable that fat should be placed among the normal constituents of urine. It is present, however, in very minute traces in healthy urine. Schunck from 45 litres obtained 0.14 grm. of a white crystalline fat. In disease the quantity of fat is sometimes considerable, especially in the disorder recognized under the name of chyluria. Fat may be present in the urine from the passage of casts or renal epithelium that have undergone fatty de- generation ; it then may appear as fine free globules, or enclosed in the epithelial cells. Very rare indeed are those cases in which fluid fat is discharged in any decid- ed quantity with the urine. A few such cases, however, are known ; Sir William Roberts refers to several cases in which a fluid yellow fat appeared in the urine of pa- tients taking cod-liver oil. Dr. Henderson has reported three cases of heart disease in which oil-globules appeared in the urine. Dr. George Johnston refers to a case of calculous disease of the pancreas in which fat occurred in such quantity as to float on the surface of the urine in greasy flakes. Fat is very easily detected under the microscope ; the highly refractive globules, soluble in ether and black- ened by osmic acid, can scarcely be mistaken. The ob- server should carefully exclude the possibility of the fat having been introduced into the urine from the use of greasy bottles, or from oil left in the urethra after the use of a catheter. Chyluria.-This curious affection is characterized by an opaque milky or reddish urine. It is endemic in the tropics, where it is frequently associated with the pres- ence of the filaria sanguinis hominis in the blood and urine. Numerous cases of chylous urine have also been reported in England, occurring among persons who have never been in tropical countries. This urine usually has a low specific gravity ; the urea and other constituents of healthy urine are, however, nor- mal in quantity. It contains, besides the finely granular fat to which it owes its peculiar appearance, albumen, fibrin, lecithin, and often blood-disks in varying propor- tions. On standing it frequently coagulates into a jelly- like mass, or a white creamy layer may form on the sur- face. The following table, compiled by Sir William Roberts, presents an abstract of nine analyses of chylous urine by different authors : Sir William Roberts thinks the condition of the urine is caused by an actual mixture of chyle and lymph with the normal secretion. This may be due to morbid hyper- trophy of the lymphatic tissue somewhere in the urinary tract, or to aggregations of filaria in the kidneys giving rise to rupture of the lymphatics and leakage into the urinary channels. Cystin, C6H12N2S2O4=[S.C (CHS)NH2CO2H]. -This body is one of the rarer constituents of urine. It is oc- casionally found in calculi, and still less frequently as a sediment. It may be readily distinguished from some other substances which it resembles, especially uric acid, by its solubility in strong mineral acids and in am- monia without heat, its insolubility in acetic or tartaric acid, and its crystalline appearance under the microscope. Cystin is dimorphous, crystallizing in square prisms or in very regular hexagonal tablets of an iridescent pearly lustre ; these are frequently found superimposed or over- lapping each other (Fig. 4280). Cystin sediments always show the hexagonal form of crystals. Uric acid some- times assumes the same form as cystin, but maybe easily distinguished from it by its insolubility in strong mineral acid and in cold liquor ammonise. Cystin may be fur- ther identified by detecting the sulphur, of which it con- tains about twenty-six per cent. This is easily done by boiling the sediment or powdered calculus in caustic potash, thus forming an alkaline solution of potassium sulphide, which is turned black by lead acetate, and a rich purple color by nitro-prussiate of sodium. Beauti- ful specimens of cystin crystals for the microscope may be obtained by dissolving a little of a cystin calculus in ammonia, and allowing it to evaporate spontaneously. The presence of cystin in urine is not accompanied by any deviation of the other constituents from the normal state, nor does it seem to affect the health beyond the ir- ritation caused by the passage of calculi or gravel when these form. The clinical significance of cystinuria is then, wholly, so far as known at present, dependent on the danger from the formation of calculi. It has its ori- gin probably with the allied taurin in the liver, and it is said to replace the other bodies, found in the urine, that contain unoxidized sulphur. Its presence, however, does not seem to affect the total or relative quantity of sul- phates voided. The daily quantity eliminated has been estimated by Loebisch and Niemann as 0.393 grain and 0.509 grain respectively. Leucin and Tyrosin.-These two constituents occur together in urine, and are products of the decomposition of nitrogenous substances. They occur only in traces in the body during normal tissue metamorphosis, and can be produced artificially from the liver, pancreas, and spleen by chemical action. These bodies may occur dissolved in the urine, or if in sufficient quantity, tyrosin may form a crystalline deposit; the leucin, being more soluble, is but rarely deposited. If leucin and tyrosin are held in solution, they may be precipitated by evaporating the urine. Should there be much bile pigment and albumen present, as is usually the case, the fresh urine should be treated with basic lead acetate, filtered, and the filtrate freed from lead by hydrogen sulphide, again filtered and the clear fluid evaporated. If tyrosin be present, it deposits in tufts or bundles of acicular crystals (Fig. 4276) after twenty-four hours; leucin is deposited about twelve hours later in colored spheres highly refractive, and showing on care- ful illumination fine radiating striae, and also concen- tric lines (Fig. 4276). The importance to the physician of the presence in urine of these bodies depends on the fact that their pres- ence in more than traces always indicates an abnormally rapid or putrefaction-like decomposition of proteids. Hitherto they have been found to occur in small quanti- ties only in the urine of patients suffering from severe variola or typhus fever, but they occur abundantly in acute yellow atrophy of the liver and in phosphorus poi- soning. Albumen and bile derivatives, as a rule, and also occasionally oxymandelic acid (C8HeO4), accompany them. This acid has never been found except in urine containing these bodies. iw Normal urinary solids. Water > cr £ 3 tc 5 100.00 1.90 0.70 2.30 95.10 Quevenne. 100.00 99'86 U'F 89'0 ori Rogers (mean of 3 analyses). s 94.77 1.30 0.20 a 73 Bouchardt. 00'001 00'001 00'001 1.39 1.30 2.57 94.74 Beale. 86 0.79 1.40 9 RR Bence Jones. 5 -7 ce 0.99 0.60 1 RR B. Edwards. 100.00 8 4 0.20 0 17 H (Id A. Gamgee. When shaken with ether, true chylous urine loses its milky appearance and becomes clear, the fat having been carried out dissolved in the ether. The urine may sometimes be lymphous, i.e., it con- tains albumen and coagulates spontaneously, but unlike the chylous urine, it contains no fat. The urine, in short, as Sir William Roberts has shown, resembles in every particular a mixture of ordinary urine with a vari- able quantity of chyle or lymph ; the fat being held up in an albuminous emulsion. The disorder may be continuous or intermittent, the urine often remaining normal for weeks, then suddenly and without apparent cause becoming milky, and equally abruptly returning to its normal state. The attack may last a few days or a few months, or may persist for years. Occasionally the remissions and attacks observe a certain periodicity. The course and symptoms of the affection are so capricious and contradictory as to baffle all attempts at explanation. The pathology is also very obscure. 435 Urine. Urine. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Schultzen finds that in cases of poisoning by phos- phorus (in animals), " urea disappears from the urine, and is replaced by leucin and tyrosin, which, in healthy and the spiked globules of ammonium urate. These crystals are seen in a field of micrococci and rod-like bacteria, either still or in rapid motion (Fig. 4278). When the urine is abnormal from any cause, an abundant precipitate is fre- quently seen, and a knowledge of its composition may yield most important clinical information. The components of the sediment, if excreted as such, pro- duce a turbidity which, sooner or later, subsides. The rapidity of this precipita- tion is determined by the nature of the precipitate and the density of the urine. In some urines the suspended matter will not completely settle at the bottom, but remains suspended, e.g., amorphous urates in a thick albuminous urine, and bacteria. The constituents of urinary deposits may be either organized forms, such as pus-cells, epithelium casts, etc., or unor- ganized. The latter may be again sub- divided into organic and inorganic, or, according to their appearance, into crys- talline and amorphous. We may ac- cordingly classify all urinary sediments as follows : Blood-corpuscles. Mucus and pus-corpus- cles. Epithelium cells. Casts. A. Organized. Spermatozoa. Entozoa. Fungi. Tubercular and cancer tissue. B. Not Organized. In Acid Urine. (1) Organic. In Alkaline Urine. Uric acid. Acid urates of sodium and potassium. Cystin. Tyrosin. Fat. Urate of ammonium. Fig. 4276.-Acicular Crystals of Tyrosin and Globules of Leucin. (Peyer.) organisms, are converted into urea." This substitution also occurs in acute yellow atrophy of the liver. Urinary Sediment.-Normally, urine shows but a light mucous cloud w'hen freshly voided. This becomes more apparent after the urine has stood some time, and consists, as already stated (see reaction of urine), of blad- der mucus containing a few epithelial and mucous cells, but of mucus having the usual glairy character there is no visible quantity in normal urine. During "acid Calcium oxalate. (2) Inorganic. Phosphates of calcium and magne- sium. Triple phosphates. Calcium carbonate. The non-organized deposits are either amorphous or assume a crystalline form. The amorphous elements of these sediments are the mixed urates, the phosphate and carbonate of calcium, and fat. The other substances are crystalline. These differ from the organized deposits in not showing any definite cellular structure. The organic non-organized deposits, when heated on a piece of tin or platinum foil, are either wholly vola- tile, as uric acid, cystin, tyrosin, fat, and ammonium urate, or they swell up, burn, and leave a very small resi- due, as in the case of the urates of potassium and cal- cium. Fat, when burned, evolves the pungent odor of acrolein ; c y s t i n gives a blue sul- phurous flame and an intolerable sulphurous odor ; while ammonium urate evolves the pungent fumes of ammonia. These substances are all insoluble in acetic acid, except the urates, which dissolve, but quickly deposit crystals of uric acid. As shown in the table, urate of ammonium is the only organic deposit found in alkaline urine. Uric acid deposits may be distinguished by the naked eye as a crystalline precipitate, colored of a reddish-brown, Fig. 4278.-Amorphous Granular Urates and Ammonium Urate (sodium urate?). (Tyson.) Fig. 4277.-Some Forms of Uric Acid Crystals. (Neubauer.) fermentation " a deposit usually appears, containing to- rulae, amorphous urates or uric acid, and a few crystals of oxalate of lime (Fig. 4258). Later, when ammoniacal fermentation sets in, the character of this sediment com- pletely alters. The acid amorphous urates and uric acid are neutralized and dissolved, and in their stead are de- posited the large colorless crystals of triple phosphates, 436 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. trine. Urine. resembling red-pepper grains, and commonly called " sand " or " gravel." The commoner forms of crystals A sediment of amorphous urates indicates that their proportion to the water of the urine is too high, but not of necessity that there is an excessive quantity of uric acid excreted. Urine of high density, as a rule, deposits urates when moderately acidified, instead of urfc acid. The occasional appearance of urates, or of uric acid, has no patho- logical import; but when constant or very frequent, some derangement of the digestive functions is usually indicated. Acid sodium urate is sometimes crystal- line (Fig. 2319) when it may assume the form of groups of opaque prisms or hedgehog crystals, but, as a rule, it is amorphous. Acid potassium and calcium urates are amorphous, and occur under similar con- ditions to the sodium salt; the former is comparatively soluble in water, the cal- cium salt is very insoluble. Calcium urate leaves after ignition a residue of calcium carbonate. Acid ammonium urate is the only urate that occurs in alkaline urine; it crystallizes in smooth spherules, " thorn- apple " crystals, which appear quite dark by transmitted light, or occasionally in short bone-like, or dumb-bell crystals lying singly or in crosses. The crystals with long curved spines (Fig. 4279) oc- curring in neutral or ammoniacal urine, are very characteristic. These are, by some authors, wrongly called sodium urates. The occurrence of this sediment has no special significance, it is merely an incident in ammoniacal fermentation of urine. Urine that contains cystin is usually pale and the deposit is gray or dirty yel- low, and largely composed of microscopic hexagonal plates often overlapping (Fig. 4280). In acid urine, cys- Fig. 4279.-Showing the Different Forms of Ammonium Urate. (Peyer.) are seen in Figs. 2317, 2318 (Vol. IV.), and Fig. 4277. The latter illustration shows most of the forms of uric acid crystals usually met with in natural sedi- ments. They are almost invariably colored, and are thus distinguished from all other simi- lar crystalline deposits. The rough and point- ed forms of uric acid crystals (Fig. 2317), especially if in groups, are of peculiar signifi- cance, as they are almost always an accom- paniment of renal calculi (Ultzmann). Albumi- nuria and hsematuria frequently accompany their appearance. They are, besides, a com- mon cause of painful micturition. Urates.-The urates of sodium, potassium, and calcium appear together in urine as amor- phous mixed acid urates during the acid fer- mentation. The conditions which favor a precipitation of urates are moderate acidity, concentration, and cooling of the urine. The acid salts of uric acid are much less soluble than the neutral ones, and they are more soluble in warm water than in cold ; hence, the precipitate of urate disap- pears on warming the urine to 40° or 50° C. Amorphous urates are generally conceded to be made up of mired urates containing an ex- cess of uric acid above that required to form acid salts with all the bases present. This de- posit is loose and powdery, varying in color from a fawn to a pink-orange or bribk-red, from the urinary pigments carried down with the precipitate. They deposit slowly, leaving a film on the sides of the glass. Microscopi- cally, the deposit is seen to be composed of discrete or aggregated particles without defi- nite form (Fig. 4278), which disappear on warming and give uric acid crystals when an acid is added. " They occasionally assume masses which, from their shapes, may be mistaken for casts. Fig. 4280.-1. Cystin. 2. Gonorrhoeal Thread. 3. Spermatozoa. tin is usually accompanied by oxalate of lime ; in alka- line urine by an abundance of triple phosphates and cal- 437 Urine. Urine. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. cium phosphate; when decomposing, this urine always evolves sulphuretted hydrogen gas. Cystinuria is usu- ally an hereditary disorder. (See Cystin.) Tyrosin precipitates are sometimes accompanied hy the spheres of leucin (Fig. 4276), but, usually, the latter are not deposited unless the urine is concentrated. (See Leucin and Tyrosin.) Fat is a very rare precipitate, except in chyluria. If The crystals of ammonw-magnesium phosphate (triple phosphate) are large, colorless, triangular prisms with bevelled ends. The common " coffin-lid crystals " (Fig. 4282, 2) and other forms seen in the illustration are chief- ly modifications of this arising from the replacement of the edges of the crystal by planes, or from the abbrevia- tion of the prism. The fern-leaved and star-shaped crys- tals (Fig. 4283, 1) are rarer forms that gradually change into the typical form. Calcium phosphate is generally amorphous [Ca3(PO4)2] in alkaline urine, but is also precipitated in a crystalline form (CaII(PO4)] as wedge-shaped crystals arranged in bunches like rosettes, with the points of the wedges to the centre. Dr. Beale figures spherules and rude dumb- bell forms of calcium phosphate. The amorphous phos- phate (bone earth) (Fig. 4282), is usually associated with triple phosphate crystals in alkaline urine ; the crystalline calcium phosphate, on the other hand, forms a precipitate characteristic of neutral rather than of alkaline urine. Neutral or feebly acid urine, when heated, becomes turbid from precipitated earthy phosphates. This opacity, be- ing easily cleared up by a drop or two of acid, should never be mistaken for coagulated albumen. Calcium phosphate forms a very common variety of urinary cal- culus. Carbonate of calcium, is generally amorphous, and only seen in crystalline form in human urine when voided as gravel or small calculi. The granules are readily de- tected by their solubility with effervescence in mineral acids. The Organized Elements found in deposits are best detected by the microscope and are, for the most part, fully described in the article on Microscopy (Vol. IV.), to which the reader is referred for fuller details. Urine that contains blood-corpuscles in sufficient quan- tity to form a visible sediment, will always give the reac- tions for albumen and blood-pigment. If the blood is not coagulated in the urine the corpuscles form a reddish- Fig. 4281.-Octahedra-envelope Crystals, Disks, and Dumb-bells of Oxa- late of Lime. (Beale.) the turbidity of a sample of urine be due to fat, it is cleared up when shaken with ether. (See Fat in urine.) Among the inorganic deposits, calcium oxalate is the only one that occurs in acid urine, but it is frequently seen in alkaline urine as well. These deposits, as a class, are distinguished by not being burned away when heated on platinum foil. They are usually turned black when first heated, from the admixture of organic matter, but only a small proportion is burned off. They are all soluble in hydrochloric acid and reprecipitated by alka- lies, calcium carbonate being alone decomposed by the acid. Oxalate of lime gives a very scanty, almost in- visible, precipitate ; under the microscope the crys- tals are found to be very minute and to consist of two forms, either the "envelope crystals," which are regular octahedra or dumb-bell crystals (Fig. 4281). The former, owung to position, may assume the appearance of an elongated octahedron or of a parallelogram with crossed lines, and the dumb- bells may appear like disks or ovoids. It is a curious fact that the dumb-bell crystals are usually seen in urine containing an excess of mucus. Schunck says they are crystals of oxalurate of lime. Oxalate of lime is soluble in acid sodium phos- phate, but not in the neutral salt; hence, as the urine gradually loses its acidity, but before it be- comes alkaline, the oxalate is quite thrown out of solution. Excess of oxalic acid in urine usually means excessive metabolism, so we find accompanying deposits of oxalates an excess of urea, phosphates, and urates in the urine. Large and constant de- posits of oxalic acid obviously indicate a liability to oxalate-of-lime calculus (mulberry calculus). A much wider significance has been attributed, by some authors, to this deposit. It is described by Drs. Prout, Bird, Begbie, Ralfe, and others, as co- existent with a peculiar train of nervous and dys- peptic symptoms indicating the so-called oxalic acid diathesis. Sir William Roberts, on the other hand, is convinced " that oxaluria arises from a variety of causes-many of them not accompanied by any appreciable departure from health-in which the assimilation of food or the disintegration of the tissues goes on imperfectly, and that it is impossible to assign any constant train of symptoms as the cause or the con- sequence of oxaluria." Earthy phosphates form the characteristic precipitate of ammoniacal urine. Fig. 4282.-1, Fern leaf crystal of triple phosphate ; 2, common forms of the same. Amorphous phosphates in lower left, and neutral phosphate crystals in the upper right side of the field. (Peyer.) brown precipitate which rapidly changes if the urine is alkaline. The appearance of the blood-cells under the microscope depends on the density and chemical reaction of the urine. They swell up, become globular, and are difficult to detect in very light urines, but are crenated and contracted in urines of high specific gravity. In al- kaline urine they are rapidly decolorized, look like hya- 438 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Urine. Urine. line rings, and require a well-regulated light for their identification. Urine containing pus has an opaque, milky appearance not accompanied by an excess of mucus, as is commonly the case with that from the bladder. The bursting of an abscess into the pelvis of the kidney, or in the urinary tract, causes a very sudden appearance of a large amount of pus. Small plugs or threads of mucus and pus-cells containing the rounded cells from the prostate, are characteristic of prostatic disease (Fig. 4280). Similar threads are also derived from the urethral glands in old standing gonorrhoea, and may be seen floating in the urine of such cases after all other symptoms of the dis- ease have left. Epithelium found in urinary sediments may be derived from any part of the urinary passages. Three or four varie- ties of cells are easily distinguished. Round cells may have been shed from the male urethra, the bladder, or the uriniferous tubules. They are about twice the size of pus-cells, have a single nucleus visible without reagents, and are usually flattened. Columnar, oval, and tailed epithelia are derived from the su- perficial layer of the pelvis of the kidney (the deeper layer is composed of round cells), the ureters, and urethra. Pave- ment epithelium and flat cells are derived from the bladder or vagina. Those from the vagina are large, frequently wrinkled, and overlap each other in groups of two or more. In alkaline urine these cells lose their characteristic shape, swell up, and become transparent. Casts or cylinders are derived from the tubules of the kidney, and are formed of coagulated matter-fibrin, or some other proteid, to which may be attached cells of epithelium (epithelial casts), or blood- corpuscles (blood casts); or they may be quite transpa- rent and vitreous, requiring careful focusing and a good Fig. 4283.-Crystalline Neutral Phosphate of Calcium. (Peyer.) when voided, and gives a creamy-white, or yellow-white sediment on standing. In acid urine the cellular ele- ments of the pus are easily made out as opaque, yellowish, spherical cells, gran- ular on the surface, and about one-third larger than red blood-disks. In concen- trated urine the cells are reduced in size, whereas by the addition of water, or better, dilute acetic acid, the cells swell up, lose their granular appearance, and at the same time their nuclei become visible. In alkaline urine the cells be- come dissolved, and a viscid coherent mass is found at the bottom of the con- taining vessel, which does not easily flow out. The conversion of pus into a vis- cid mass by alkalies is known as Donne's test for pus. This slimy mass must not be confounded with mucus. The latter is rarely visible in urine except from the presence of epithelial detritus or crystals of oxalates, etc., and it never forms a coherent mass. The supernatant fluid in a purulent urine will always answer to the tests for albumen. The significance of purulent urine de- pends on the source and quantity of the pus. Gonorrhoea is one of the common- est sources of pus in the urine of men ; the quantity is usually small, and most is passed with the first urine voided. Pus from cystitis is usually indicated by the frequent micturition and the ammo- niacal urine with the gelatinous precipi- tate. Suppuration in the pelvis of the kidney may be located either by the pain in the loins, or from the nature of the epithelial elements found associated with the pus. Pus from the kidney is usually Fig. 4284.-Epithelial and Mixed Casts. (Peyer.) 439 Urine. Urticaria. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. light for their identification. Hyaline (Fig. 4286) and waxy casts are composed of the cementing substance of the ordinary casts ; the latter are much denser and resem- ble molten wax (Fig. 4287). Casts may also contain the granular debris of degenerated epithelium, in larger or Koch's tubercle bacillus (B. tuberculosis) can be de- tected in the urine of patients suffering from tuberculous disease of the genito-urinary organs. Its recognition is of the highest diagnostic value, and has been used for the differential diagnosis between abdominal typhus and Fig. 4285.-Blood casts. smaller quantity, forming the so-called granular casts, which may be slightly granular or almost opaque. Debris from blood may give them a yellow or reddish tint. In fatty degeneration the epithelium imbedded in the cast may contain highly refracting particles of oil, or the fat may be in the form of oil-drops in the matrix of the cast. These fatly casts are easily distinguished under the mi- croscope. Masses of epithelium-cells from the tubules may be ag- gregated so as to form moulds or cast-shaped masses. These are simple exfoliations of the cellular contents of the tubule, and occur often with the other form of epi- thelial cast. Long-branched moulds of the urini- ferous tubules composed of mucus are sometimes seen ; these are easily distinguished by their extreme length and their diminution in diameter as they divide. These are not accom- panied by albumen and are due to renal irritation, apparently extending from some seat of inflammation lower down the urinary passages; they are frequently seen to accompany inflam- mation of the bladder (Tyson). The observer, in examining for casts, should allow the urine to stand in a conical glass (Fig. 4250) for some time, as these structures subside very slowly. A very large cover-glass should be used and several slides searched, with a low power at first; slides are now easily obtained, with a shallow con- cavity ground into one surface, which are very convenient for this purpose. Spermatozoids, when present in quan- tity, form a light flocculent cloud, but there is rarely anything to indicate their presence. A higli power (400 diameters) is necessary for their recog- nition. They are then seen as small oval bodies with delicate tails (Fig. 4280, 3). Their recognition is often of great importance in medico-legal cases. The schizomycetes fungi are the most important of the vegetable growths found in human urine. The gonococcus, or the micro- coccus of gonorrhoea, forms little colonies in groups of two or four punctiform spherules on the pus-cells of gon- orrhoeal cystitis and urethritis (Fig. 2315, Vol. IV.). They are easily stained by the basic aniline dyes, and their recognition is important as affording a certain means of diagnosing between simple and specific ure- thritis. Fig. 4286.-Hyaline Casts (X210). (Tyson.) acute miliary tuberculosis (for methods see Micro-organ- isms, Vol. IV.). Bacteria swarm in urine that is decomposed or has un- dergone the alkaline fermentation. They render the urine turbid and do not fall as a sediment, except in part. Opacity due to bacteria is not removed by filtration, but Fig. 4287.-Waxy Casts. (Peyer.) such urine may be cleared up by precipitation with the magnesia mixture. Saccharomyces urines occurs in single oval cells or in chains of oval cells, many with buds attached. It is seen usually in acid urine and more commonly in warm weather. The allied yeast fungus (S. cerevisiae) is very abundant in diabetic urine. Besides these forms there are many others which, like 440 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Urine. Urticaria. the penicilium glaucum and the oidum lactis, are to be re- garded as accidental growths. A rare fungus, the sarcina urines, allied to the sarcina ventriculi, but smaller, is occasionally developed in the bladder and found in urine. It is composed of cubes arranged in one plane, looking like minute corded bales of goods under the microscope. Entozoa are but rarely found in urine. Echinococcus hooks and cysts have been found. The eggs and larvae of the distoma hosmatdbium are sometimes present in the urine of persons suffering from haematuria in tropical countries. Associated with chyluria are often seen the larval forms of the, filaria sanguinis hominis. Isolated cancer-cells and pieces of cancerous tissue are oc- casionally seen in urine. The cells (Fig. 4288) are large, fluid and the deposit again allowed to settle; from this the clear supernatant liquid is again poured off and more preserving fluid added. The precipitated elements may now, after subsidence, be drawn up in a pipette and mounted or preserved in a bottle of the fluid for future use. Of the various fluids used, glycerine and carbolic acid is perhaps the most generally useful. Water and glycerine are mixed in such proportions as to form a fluid of a specific gravity approximately that of urine (1.020); to this one per cent, of carbolic acid is added. A solution of chloral hydrate, ten grains to the ounce, or Beale's solution of naphtha and creasote (see Beale's " Microscope in Medicine," 4th edition, p. 53), are also useful fluids. Urine may be preserved in hot weather, or for the pur- poses of transportation, by adding to the bottle a little salicylic acid-about one grain to the ounce. This in no way alters the microscopic appearance of the sediment or interferes with the chemical reactions of the fluid. R. F. Ruttan. URTICARIA. An inflammatory disease of the skin, or perhaps rather, as Auspitz calls it, a stasis der mato- sis, characterized by the presence of wheals of a whitish or reddish color, accompanied by sticking, pricking, tin- gling sensations. The lesions are apt to come out sud- denly and to disappear again in a very short time, so that a patient seeking advice is often unable to show a sign of the disease, excepting scratch marks, even when repeated visits are made to the physician, although he may have been tortured and disfigured by it between times. The wheals are of various dimensions, some- times as small as a split pea, sometimes as large as the palm of the hand, averaging in size that of the finger-nail. The smaller lesions are usually round, but the larger ones may be very irregular, crescentic or linear, and they often assume a grotesque outline, They may be barely elevated above the skin, or may rise to an eighth of an inch, or even more in height. They may be soft or firm to the touch, and whitish or pinkish in color. On the face the urticaria rash may cause great temporary de- formity. The lip, or half the lip, for instance, may within a few minutes swell out to a great size, and re- main so for an hour or more. The eruption burns, stings, and tingles, as if the skin had been stung by nettles ; hence the popular English name of the disease "nettle rash;" in this country it is generally called "hives." Sometimes these sensations of burning and tingling are merely annoying ; at other times they may prove distressing to the last degree. Rubbing and scratch- ing commonly aggravate the disease, bringing out new wheals. The lesions of urticaria frequently change their local- ity, the eruption appearing now in one part of the body, and now in another. It occurs at all ages and in both sexes. Its duration depends entirely upon the presence or removal of the exciting cause. There are several varieties of urticaria : 1. Urticaria papulosa, which occurs commonly among children, in the form of widely dispersed flat or acuminate papules, from the size of a pin-head to that of a split pea, which appear suddenly and last for hours or days. It is at- tended by severe itching. 2. Urticaria haunorrhagica, which is, in fact, urticaria occurring in the seat of a pur- puric eruption. 3. Urticaria bullosa, where the wheals are transformed into blebs, which may assume some of the characteristics of pemphigus. 4. Urticaria tuberosa, or "giant urticaria," occurring in the form of firm, more or less persistent nodes or tumors, of the size of a large walnut or even that of an egg, resembling somewhat ex- aggerated tumors of erythema nodosum. Urticaria may be acute or chronic. The acute variety is usually, though not invariably, ushered in by slight febrile symptoms, languor, headache, depression, gastric disturbance, furred tongue, etc. The rash appears sud- denly, and may involve the whole body, or a portion only, accompanied by intense, and almost intolerable, burning and stinging sensations. In a variable time, from one hour to a day, the symptoms subside and the often caudate, with large nucleus containing nucleoli (Fig. 4288, B), and sometimes with vacuoles (Be). These generally come from villous cancer of the bladder, frag- ments and cells of which are seen in the illustrations. Cancer tissue is rarely well enough preserved for identi- fication. Various forms are seen ; a well-preserved piece of tissue will often show the characteristic dendritic formation of the villous growth, as seen in Fig. 4289, A ; B, represents a portion of this growth more highly mag- nified, and D, the epithelial cells from the same. Frag- ments like those illustrated from villous tumors of the Fig. 4288.-Cancer Tissue and Cells. (Ultzmann.) Fig. 4289.-Villous Cancer Tissue and Cells of the Same. (Ultzmann.) bladder are the commonest forms of cancer tissue seen in urine. Preservation of Organized Sediments.-It is often neces- sary to preserve sediment for subsequent examination or for demonstration purposes. This may be done in sev- eral ways by means of certain preservative fluids. One of the best methods is to allow the sediment to deposit in a large conical glass (Fig. 4250), and after pouring off as much as possible of the clear urine, the sediment and urine are mixed with two volumes of a preservative 441 rterin^Displa' e1-^' REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. eruption disappears, without leaving a trace, except in the form of scratch marks. Chronic urticaria may con- tinue for months and years, or, indeed, as long as the cause exists. The individual lesions, which are usually small, come and go, as in the acute form ; crop after crop may appear, the skin being hardly ever free from them. The patient's general health may be apparently good. The causes of urticaria are of a very diverse character. Certain external irritants and poisons to the skin, as the stinging-nettle, jelly-fish, leeches, caterpillars, fleas, bed- bugs, and mosquitoes, are not infrequent causes. The external applications of some medicaments, as arnica, turpentine, iodine, etc., the influence of intense cold, and of the electric current, may be mentioned in this category. The ingestion of some drugs, as copaiba, cubebs, turpentine, valerian, chloral, salicylic acid, etc., may give rise, in certain individuals, to urticarial erup- tions. Other influences are the irritation of tape-worm, the passage of gall-stones, the puncture of echinococcqs cysts, applications to the genito-urinary tract in either sex, surgical operations, septicaemia, and malaria. Among internal causes, gastric and intestinal derange- ments are by far the most common. An overloaded stom- ach, excess in wine, beer, or highly seasoned food, may occasion an attack ; while certain articles of food, as fish, oysters, clams, crabs, lobsters, pork, especially sausage, oatmeal, mushrooms, raspberries, and strawberries, are all apt to bring out the eruption in certain individuals. In most cases of urticaria a certain idiosyncrasy seems to exist. Any irritation of the bowel, as from worms in children, may bring out the eruption. Sudden emotion or mental excitement may also produce it in certain per- sons. The disease is intimately connected with the ner- vous system, and patients who suffer from chronic urti- caria are apt to be persons of more or less depraved nervous organization. The exact pathology of urticaria is not yet understood. Recent writers, Unna in particular, regard the quaddel of urticaria as an elastic oedema caused by an obstruction to the efferent lymph-channels arising under the influ- ence or " command " of the nervous system. Microscopic examination of exsected lesions shows change only in the collagenous tissue, particularly about the larger blood- vessels. At these points numerous enlarged lymph- channels are met with, while in the upper layers of the skin many enlarged lymphatic capillaries are seen. The exudate in the urticaria quaddel is for the most part in the lower layers of the skin. Unna explains these ap- pearances by supposing a cramp-like contraction of the larger veins with muscular walls so as to produce a stasis in the lymph-channels, beginning at the deeper layers and working up toward the surface. The diagnosis of urticaria rarely presents any difficulty, because the lesions are so peculiar in appearance, and be- cause of the characteristic burning and stinging sensa- tions. The small lesions, as found in children, may be mistaken for eczema, but a few scratches with the finger- nail on the skin of any part of the body will arouse urti- carial red or white bands and streaks, which show an irritable condition of the skin, and are very characteristic. The treatment of urticaria depends greatly for its suc- cess upon the discovery and removal of the cause. When this is suspected to be some gastric disturbance, the pre- cise articles of food of which the patient has been par- taking should be inquired into; their quality, as to freshness, etc., should also be a matter of scrutiny. The possibility of the patient having eaten anything unusual should be considered, as should also the previous inges- tion of medicine. An emetic may be given in acute cases, if any food which is suspected of being the cause has been recently ingested. In other cases the bowels may be freely opened by a saline purgative, in order to remove irritating matters from the alimentary canal. The diet should be of the most simple and unstimulating character, and the subsequent internal treatment should be directed against the digestive difficulty. The treat- ment in any given case must depend upon the result of a careful investigation into its nature and cause. Among medicines, the laxative mineral waters are often advantageous ; Hunyadi Janos, Ofener Racoczy, Fried- richshall, or Hathorn, the latter preferably drank at the spring in Saratoga. The alkaline waters, as Vichy, or Saratoga Vichy, may also at times be used with advan- tage. Diuretics are often of value. Quinine is a most useful remedy whether malaria be present or not. Ar- senic is sometimes of service when other remedies fail. Iron, also, is useful. Bromide of potassium, chloral, and other sedatives may be required to give rest and calm to the nervous system, often shaken by long-continued suffering. The preparations of opium should generally be avoided. Among other remedies to be tried in diffi- cult cases, may be mentioned the following : sulphate of atropia, in doses of .0005 to .001 Gm. (7^ to -/a grain), morning and evening ; sulphurous acid in drachm doses, diluted with simple syrup ; salicylic acid in 1.30 Gm. (20 grain) doses thrice daily ; and chloride of ammonium in 0.65 to 1.30 Gm. (10 to 20 grain) doses, thrice daily. External treatment is of importance to calm the burn- ing and tingling pain of the eruption, which is at times almost unendurable. Alkaline baths, followed by sooth- ing pow7ders, such as are described under the treatment of acute eczema, will be of use. Sponging with vinegar and water, or alcohol alone or diluted, often gives relief ; it should be employed frequently. Carbolic acid, one part, with glycerine, two parts, and water, thirty parts, forms an excellent lotion in many cases. Chloroform diluted in wash or ointment is very good. Dilute am- monia water is usefid in some cases; in others a satu- rated solution of benzoic acid in water will give relief. When one local remedy fails another should be tried. Irritating under-clothing should be avoided, and the pa- tient should sleep in a cool room with light bed-covering. The prognosis in urticaria varies in each case. If the cause is a temporary gastric derangement, its removal will soon result in a cure. If, however, the urticaria is chronic and dependent upon some derangement of the nervous, digestive, or generative system of long stand- ing, it is apt to prove very stubborn. Bibliography. Kopp : Die Trophoneurosen der Haut. Wien, 1886. Unna: Beitrage zur Anatomie v. Pathogenese der Urticaria Simplex und Pigmentosa. Monatsh. f. prakt. Derm. Erganzungsheft 1, 1887. Schwimmer: Die Neuropathischen Dermatosen. Wien, 1883. Lasserre: Des Conditions Etiologiques et la Pathologie de 1'Urticaire. These de Paris, 1876. Arthur Van Harlingen. URTICARIA PIGMENTOSA. This curious skin affec- tion was first described by Nettleship, and later by Til- bury Fox, the latter giving it the name of xanthelas- moidea from its resemblance to xanthelasma. It is, however, urticarious in its original form, and the name urticaria pigmentosa given by Sangster seems most ap- propriate in the present state of our knowledge. The disease occurs in infants, showing itself some- times even a few7 days after birth, and apparently tends to disappear in early youth, though one death has been recorded. It does not appear to be hereditary. It may occur upon any part of the surface, although the trunk is usually first attacked and bears the brunt of the dis- ease. The lesions resemble those of urticaria on their first ap- pearance, but the wheals or nodules persist longer and give place to permanent nodules which are deeply pigmented, or to pigmentary stains. On these, new wheals may be artificially excited by irritation, or sometimes occur spon- taneously. Itching is a marked symptom. The treat- ment is that of chronic urticaria. Arthur Van Harlingen. USTILAGO, U. S. Ph. (Corn Smut, Corn Ergot, etc.), " Ustilago Maydix, Leveille ; order Fungi, grown upon Zea Mays Linn. Order Graminea." This well-known blight of Indian corn grows upon various parts of the plant-stem, leaf, sheaths, tassels, but especially upon the forming ears. It forms early a fleshy, irregular mass of mycelium imbedded in a jelly-like substance, and at- 442 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Urticaria, [ments. Uterine Displace- tains upon the ears, which it transforms or destroys, a size equalling that of a cocoa-nut, more or less irregularly globular. At maturity it develops into a black, dry, crumbly, or powdery mass of spherical, tuberculated spores enclosed in a cellular pouch. It has an unpleasant musty odor and taste. This ripe mass of spores is the portion used, and it is collected in midsummer, simply freed from impurities and dried. As obtained, it is a mass of powder and shreds of membrane nearly as black and quite as dusty as powdered charcoal. Corn smut has been before the medical profession for more than twenty-five years, and was considerably no- ticed and urged into use from 1876 to 1880, since when it has rather dropped out of use than increased. Composition.-A rather elaborate investigation of its constituents was made at the instigation of the Commis- sioner of Agriculture, and reported by him in 1880 (Therapeutic Gazette), but much of it relates to ash and ultimate constituents which do not throw much light upon its action. It appears, however, to have a general composition resembling ergot and, like that substance, to contain a fixed oil (4 + per cent.), a volatile alkaloid, doubtful Sclerotic Acid (5| per cent.). Action and Use.-Of the physiological investigations into the action of Ustilago, that of Mr. Mitchell is the most recent and thorough. He found that in frogs it soon acted as a narcotic, destroying consciousness; it then paralyzed the sensory centres in the spinal cord, and afterward, if the dose were toxic, the motor centres and nerves (Therapeutic Gazette, 1886, p. 223). His investiga- tions naturally did not touch upon the action for which alone it is therapeutically employed, namely, that upon the uterus. Upon this point, however, there is abun- dant, although not very critical, clinical evidence. It has been used within the past dozen years by numerous practitioners, a number of whom have reported their experience in some medical journal or another. These generally agree that it acts decidedly upon the parturient uterus, increasing the force and frequency of its contrac- tions, and allowing the complete normal relaxation be- tween the pains-that is, it is a true oxytocic. Nearly all observers speak particularly upon this point and con- trast it favorably with ergot, which, in full doses, pro- duces tonic cramp of the womb. Ustilago has also been given in menorrhagia, bleeding fibroids, and other trou- bles which may be relieved by increasing the tension of uterine tissue. Dose, in infusion or fluid extract, from one to three or four grams (gr. xv. ad lx.). Allied Plants, Etc.-See Ergot. IK P. Bolles. UTERINE DISPLACEMENTS. Historical. - The most ancient writers have described procidentia uteri, and Hippocrates recognized several degrees of the de- formity. It is therefore strange that, in modern times, backward and forward displacements were unnoticed until the middle of the eighteenth century, attention then being called to the subject on account of the trouble caused by retroversion of the pregnant uterus. Only a few isolated cases of retroversion of the non-pregnant uterus had been accidentally discovered before the pres- ent century. According to Schroeder, Schweighauser (1817) was the first to recognize and state that retrover- sion was quite as common in the non-pregnant as in the pregnant uterus. J. W. Schmitt (1820) soon followed, and described anteversion as a great rarity. It was not until Sir James Simpson (in 1843) brought into use the uterine sound, that the frequency of deviations of the uterus became generally known. It is in very re- cent times only that the bimanual examination has come into general use and given the greatest impulse to the study of uterine displacements. Among others who have contributed to this subject are Cusco, Graily Hewitt, B. Schultze, and in this country, Meigs, Hodge, and Thomas. Preliminary Considerations. - There have been great differences of opinion among the writers on uterine pathology, and great confusion in the minds of their followers. This has been due to the fact that each writer has insisted that his particular discovery was the keynote to all uterine disease. One considered all the trouble due to inflammation, another to displacement, another to diseases of the ovaries. Many of these writers have made valuable contributions, but have usually overestimated their importance. Only about forty years ago, Dr. J. H. Binnet, of London, convinced almost everybody that "inflammation" was the cause of all woman's sufferings, and that even if a displacement ex- isted it was not of much importance ; for, he said, if we cure the inflammation the displacement will not cause any trouble. Since that time it has been proved beyond a doubt, that a displacement often causes the so-called inflammation or congestion, and that the only permanent cure for the "inflammation" is in correcting the dis- placement. Graily Hewitt (" Diseases of Women ") has now adopted an extreme view in this direction, and con- siders that flexions or deformities of shape are by far the most usual cause of uterine symptoms. He goes so far as to say that, " the large majority of the discomforts, pains, and inconveniences complained of by patients and referred to the generative organs, can be traced to, and shown to be dependent upon, the presence of mechanical changes in the uterus, and to the effects of such mechanical changes." Hewitt certainly exaggerates the importance of the mechanical theory, and most of the authorities on this subject do not agree with his con- clusions. Thomas, for instance, says, " No one of ex- perience will question the fact that a disorder of position of the uterus will often result in subsequent disorder to nutrition and sensibility But admitting this is merely admitting the propriety of regarding displacement as one of many untoward influences which may disorder the innervation, circulation, and nutrition of the uterus ; not making it the chief factor in the production of uterine diseases" ("Diseases of Women," p. 32). According to Schultze, versions and flexions, in themselves, give rise to but few primary symptoms. The important symptoms arise secondarily from the so-called complications-me- tritis, endometritis, perimetritis, etc.-which are caused by the displacement. These very same complications may also exist primarily and cause a displacement. So much is clear, that the accidental coexistence of the dis- placement and of the so-called complications is rare. Often they have the same cause ; but most commonly the complications are either cause or effect of the displace- ments. And in this case, the discovery of which is the cause leads to the correct treatment. Where the so-called complications are the primary cause, they should be treated with the displacements. When the complications are due to the displacements, the latter should be treated even if the complications are inflammatory. For exam- ple, if a posterior parametritis is a cause of anteversion, the principal attention should be paid to the parametritis. Also, if debility is the cause of anteversion, the principal attention is to be directed to the debility. If a retrover- sion is the cause of perimetritis, causing adhesions, the retroverted uterus must be raised in spite of the local peritonitis, for in this way, by removing the cause, the more important secondary disease is cured. The result of our knowledge in this direction, up to the present time, so far as it can be summed up in a few words, is, that displacements may, but rarely do, exist without causing symptoms ; that they usually cause more or less serious trouble by disturbing the uterine cir- culation, thus causing congestion, etc., by rendering the escape of secretions and the entrance of seminal fluid difficult, by causing disturbance of neighboring organs through dragging, pressure, and friction, and by exciting local peritonitis. Displacements often secondarily affect the nervous system, causing reflex neuroses, and after a time general neurasthenia. Although we cannot follow Graily Hewitt to the con- clusion of his mechanical theory, we are indebted to him for insisting on what he calls a condition of "undue softness " of the uterine tissue. This he considers to be a malnutrition of the uterus due to " chronic starvation." He says : " The age of puberty is one of great growth and development. Much nutritive material is required to build up the frame aud to provide for the great 443 Uterine Displacements. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. increase in bulk and in weight which the transition from the condition of the girl to that of the woman involves. The patients who present this softness and atonic condi- tion of the uterus are almost invariably, according to my experience, to be convicted of non-observance of the laws of supply and demand. They are found to have either taken too little food, or to have largely and profusely ex- pended their vital forces at this critical age, or to have erred in both particulars. From fourteen to seventeen years of age seems to be the time during which, for the most part, mischief is done in this way, and it is fortunate if errors of this kind do not leave their mark on the in- dividual for the remainder of life." Hewitt considers that this undue softness can hardly be called a disease in the ordinary sense. Yet his expe- rience indicates that it is a powerful factor in the produc- tion of disease. Its importance is this, ' ' that the uterus being thereby more pliable than usual, is apt to become altered in regard to its shape, and this alteration of shape may become permanent after the condition of undue soft- ness has disappeared." The symptoms which he attributes to undue softening are pain during locomotion, or pain produced by move- ment of the body, and also sickness or nausea. There can be no question that " chronic starvation" is a most important cause of uterine disease. But in Amer- ica, at least, we usually observe associated with, and often caused by, this chronic starvation a general condi- tion of neurasthenia and debility. With the debility comes an "undue softening" of all the muscles of the body including the uterus, and with the neurasthenia there are aches and pains in all the important nerve-sys- tems. It makes very little difference whether we call it "undue softness" or "want of nervous tone." The question is, how important is this undue softening, and what treatment shall be adopted ? Certainly the typical neurasthenic, with inherited neu- rotic tendencies, may have neurotic pains in her heart, or head, or pelvis, with frequent micturition, inability to walk, and nausea. If she is examined, an undue softness of the uterus with a moderate anteflexion is often found. These patients recover completely without local treat- ment under the so-called "rest-treatment" of Weir Mitchell. If they are treated locally, the pessary usually retards recovery by being an additional source of nervous irritation. We are therefore disposed to take a more hopeful view of " undue softness" of the uterus than Dr. Hewitt, and to consider that when it causes only mode- rate degrees of anteflexion or version, it can be safely and successfully treated on general principles (tonic and rest) without a pessary. Let it be here said that all agree that retroversion soon causes a pathological change, and does not right itself with the return of general strength, but grows worse; it should, therefore, be treated locally. In this connection, attention should be called to the fact that patients suffering from displacements (or any other uterine disease) almost always become secondarily neur- asthenic. This should always be guarded against, and when it appears, the local treatment should be subordi- nated so far as possible to the general rest-treatment, un- less a great source of nerve-irritation can be overcome in a short time. All this, of course, involves the very difficult question as to the general or local treatment of all sorts of dis- eases, the solution of which question, as it stands to-day, being that the extreme views on both sides are wrong; that a judicious combination of both gives the best re- sult ; and that it requires the best of good judgment and tact to arrive at exactly the right combination in a given case. Anatomical.-Before considering the displacements, it is important to establish the normal position of the uterus. This is by no means easy, as the very numerous treatises upon this subject by anatomists and gynaecolog- ists will testify. Various methods have been employed in investigating this question. 1. Examinations of the Fresh Cadaver, or of Frozen or Spirit-hardened Sections.-By this method many anatom- ists have fallen into error. Braune, Luschka, and others, have figured the uterus, from actual sections, as normal with the fundus in the hollow of the sacrum, i.e., in re- troposition. Gynaecologists know, from clinical observa- tion, that the fundus lies forward over the bladder, and that the os looks backward. It is now well established that after death the uterine tissue becomes flabby from want of blood circulation, and that the uterus changes its position in consequence of a change in the intra-ab- dominal pressure. The gravitation of the heavy uterus with the floating up of the gas-filled intestines are very evident sources of error. For these reasons it is evident that the normal position of the uterus must be studied on the living subject. 2. Bimanual Examination.-This is the best method, and practically everyone must establish by this examina- tion his own ideal of the normal position. 3. Examination by the Sound.-By this method, Schultze and others have made some very elaborate measurements to determine the exact angle of the nor- mal uterus. This accurate knowledge becomes necessary on account of the enthusiasm for mechanical treatment of anteversion. According to Schultze and Van deWarker, the normal position is as shown in Fig. 4290. When the bladder Fig. 4290.-Normal Position of Uterus, a, Direction of traction of utero- sacral ligaments ; b, direction of intra-abdominal pressure. (Schultze.) and rectum are empty, the virgin uterus lies with its fundus behind the symphysis pubis, the os about three- fourths of an inch anterior to the promontory of the sacrum, the vagina and cervix forming almost a right angle, and in a woman who has borne children the angle is even more acute. In the erect posture, the long axis of the uterus is almost horizontal. Graily Hewitt differs essentially from this view. He places the os uteri in about the same position, but holds that the fundus points much higher, at about the umbilicus. This dif- ference of opinion has such an important bearing on the mechanical treatment of anteversion, that I will quote from Hewitt his statement of the case : " Schultze, fol- 444 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Uteri ne Displacements. uterus in this position in perfectly healthy women, that he must unhesitatingly agree with Schultze and Van de Warker in considering the uterus, as shown in Fig. 4290, to be in nearly its normal position. To restate the case as we believe in the true light. In the normal uterus the body is bent on the cervix at an obtuse angle, varying in value. This angle is much more obtuse in women who have borne children, and most acute in virgins. When the bladder is empty the uterus lies with its anterior surface touching the poste- rior aspect of the bladder, no intestines intervening. The os looks downward and backward. The uterus is slightly twisted, as a whole, on its long axis, the vagi- nal portion toward the left and the fundus toward the right. The uterus is retained in its position by the vaginal walls and muscles of the pelvic floor, notably the levator ani, by the pelvic fascia, which encompasses the upper portion of the cervix, the utero-vesical ligaments, and the sacro-uterine ligaments. According to Schultze, these folds of Douglas (so-called sacro-uterine ligaments) contain strong muscular fibres, and help to draw the uterus backward and upward (Fig. 4290, a). These folds are often inflamed or atrophied, and play an important part in causing uterine dis- placements. The connective tissue between the bladder and uterus is found to be an important support, and its pathology plays a part in dis- placements. The broad ligaments are also important means of support. The round ligaments help to keep the uterus forward, but probably offer no direct support. Finally, we have the general attachment of the areolar tis- sue of the pelvis. The normal uterus is, of course, very movable, its movement depend- ing upon the movements of the body, the varying fulness of the bladder and rectum, the respiration, and intra-ab- dominal pressure. Dr. Van de Warker has studied these movements, and given his re- sults in a very valuable paper. When the bladder and rectum are empty the pelvis is filled with small intestines, w'hich, as the bladder and rectum fill, are gradually pushed up into the ab- dominal cavity. As the bladder fills, the uterus is gradually straightened up and pushed back behind it, and when the bladder is very full the uterus is pushed back under the promontory of the sacrum (Fig. 4291). When the bladder is emptied the uterus falls forward again. When the rectum is full the cervix is pushed forward. The intra-abdominal pressure has an especially important influence in moving the uterus and in holding it in its normal position. In ordinary respiration the uterus is pressed down at every inspiration, and lifted with every expiration. If a patient is asked to cough while the cervix is exposed to view with a Sims specu- lum, the importance of the abdominal pressure is easily realized. When the uterus is in its normal position the intra-abdominal pressure is directed in such a manner as to hold the body forward (see Fig. 4290, b). But when it is retroverted, this same pressure continually drives it down into the pelvis (Fig. 4295). The influence of the weight of the uterus upon its position becomes more im- portant in proportion to its increase and to the relaxation of its connections. It is, therefore, evident that there are physiological as well as pathological displacements. "The former is transient, and passes away when the cause has ceased to operate ; the latter is persistent, and produces perma- nent alterations in form, position, and structure. It is difficult to draw the line between these two. The path- ological condition is frequently due to simple overstep- ping of the limits of the physiological." Displacements are classified according to their direc- lowed by Van de Warker, contends that the uterine body becomes anteverted as the bladder is emptied (Fig. 4290), and assumes a more upright position when it is full. Such is not the conclusion my observations have led me to form. It appears to me that the space created be- tween the uterine body and the symphysis pubis by the evacuation of the bladder is normally filled by the descent of the intestines upon the bladder, and that the uterus, when in a state of health, remains, as a rule, comparatively unaffected by emptying the bladder. Schultze's experiments on living subjects appeared to him to show that when the bladder is empty the uterus follows it; but we have no proof that the experiments were performed on subjects really in a state of health, and they are opposed to the results of my own observa- tions. Martin expresses his opinion as adverse to that of Schultze, also, in respect to his supposed version of the uterus on emptying the bladder. The notion of ante- version being natural, is favored by the circumstance that there is a slight natural anterior cur- vature. It is also favored by the circumstance that what I should term abnormal antever- sion and flexion are common. . . . My observations have led me to the conclusion that w'hen the body of the uterus persistently occupies a position, such as would be con- sidered natural by certain of the authorities above cited, symptoms of a troublesome character are always observed and indicate the abnormality of the position the uterus occupies. In conclusion, after comparing various opin- ions and testing them by the results of personal observa- tion, my opinion is that, in a state of health, the uniin- pregnated uterus has a nearly median position in the pelvis ; that it is incorrect to imagine that the fundus, in a state of health, encroaches materially on the space de- voted to the bladder ; and that it is incorrect to suppose that, in a state of health, the os uteri is so low down as to rest on the floor of the pelvis." The important point of dispute here is whether the normal uterus falls forward on the empty bladder, or whether this condition, when observed, is to be called anteversion. The author has so commonly found the Fig. 4291.-Position of Uterus. A, With bladder and rectum empty; B, C, D, according to distention of bladder. (Van de Warker.) 445 Uterlne Displacements. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tion. They are, ante-version and flexion, retro-version and flexion, dextro-version and flexion, sinistro-version and flex- ion ; elevation, descent, and prolapse. In many cases the displacement does not exist as a simple one, but several are combined-as, for example, one may have anteflexion with retroversion. General Remarks on Treatment.-In the treatment of displacements the cause should always be most care- fully looked into and attended to. As has been seen, the commonest cause of displace- ment is debility and want of tone-"chronic starvation." In this class of cases, rest, forced feeding, fresh air, and tonics should be the principal remedies. Regular move- ments of the bowels are very important. In a case of real neurasthenia the Weir Mitchell treatment should be adopted. Among tonics for the uterus, aloin, strychnine, and ergotin are the best. When the general health is improved, gymnastics, which strengthen the diaphragm and abdominal muscles, are very usefid as increasing the suction-power of the abdomen. Electricity, general and local, is also useful in repairing loss of tone. Postural treatment is important, and will be described later. Pessaries are used, in general, to lift the uterus so that the natural circulation may be restored, and the congestion relieved. Pessaries can be successfully em- ployed only by physicians skilled in their use, and with patients possessing intelligence enough to obey instruc- tions. Pessaries should always be fitted to each individ- ual case, and the smallest pessary capable of accomplish- ing the desired result should be used. If a pessary does not accomplish the desired result, it should be removed immediately. Every patient wearing a pessary should understand how to remove it in case of pain. When a patient wearing a pessary returns to the physician, he should try to discover two things : 1. Is the pessary do- ing any harm ? 2. Is the pessary doing any good ? The harm to be feared and watched for is, lest it should cause a local peritonitis, as evidenced by pain and tenderness on examination, or lest it should chafe or cut the vaginal mucous membrane, which can be seen by speculum ex- amination. In either case it should be removed. If the pessary holds the previously misplaced uterus in posi- tion, it is doing good ; if not it should be removed. A pessary should be removed and cleaned every one or two months. Patients wearing pessaries should always use the hot vaginal douche, at least twice a week, to keep the pessary clean, and when the uterus is congested and ten- der, twice a day, in the following manner : The patient should lie on the back with the clothing loose, and with the hips raised on a pan to catch the water. In this po- sition the vagina should be irrigated with two gallons of hot water (at 110° to 118° F.), which should be allowed to run so slowly as to consume some twenty minutes. As the patient improves, the pessary should be reduced in size, and every effort made to get rid of it. The con- tra-indications to the use of pessaries are, the absence of indications, and the presence of any acute inflammation of the uterus or adnexa, or of the vagina. Operative treatment is not infrequently necessary, usually for distortion due to congenital malformations, or to displacement due to injuries at confinement, etc. Also, of late, it has been resorted to in order to effect a permanent cure. In these operations the strictest anti- septic precautions should be taken, as these parts are especially liable to infection on account of their anatom- ical relations. Finally, as the patient recovers, she should be trained out of her invalid habits. Anteversion. Pathological Anatomy and Etiology.- In anteversion the normal flexion of the body and cervix is straightened and the os looks more directly backward, while the fundus is lower than normal (Fig. 4292). This usually occurs when the uterus is enlarged, heavy, and hard. When there is a general relaxation in the at- tachment this displacement may become so very marked that the examining finger meets the fundus low in the vagina, while the cervix is so far back that it is difficult to feel. In this position the fundus often presses heavily on the bladder and may become adherent to it. Antever- sion is the usual position taken by the enlarged uterus, and is always to be found in the early months of preg- nancy ; therefore the usual causes of enlargement are also causes of anteversion, viz., chronic metritis, fibroid growths in the fundus, subinvolution, lacerated cervix, etc. Pelvic inflammation may also draw the fundus for- ward or the cervix backward ; and, according to Schultze, posterior parametritis is a common cause by shortening the folds of Douglas (Fig. 4292). Ruptured perineum and cystocele may tend to increase anteversion by weakening the support. Symptoms. - As anteversion occurs most commonly when the uterus is enlarged, the symptoms are often sim- ply dragging and backache caused by the heavy uterus, or the symptoms of chronic metritis or of subinvolution. When the anteversion is due to perimetritis or para- metritis, the symptoms correspond to those processes. In other words, simple anteversion in itself causes few if any symptoms. Thomas and Hewitt consider that ina- bility to walk, or pain on walking, may be due to ante- version. Frequent micturition is often noticed in these Fig. 4292.-Extreme Anteversion, the result of chronic metritis and pos- terior parametritis. (Schultze.) cases, and when the uterus is adherent to the bladder this symptom may become very troublesome. Finally, we may have every variety of nervous symptoms, when ante- version exists, coincident with a general neurasthenic con- dition. Diagnosis.-The diagnosis is very simple. Bimanual examination should be practised while the patient is lying on the back with the knees drawn up. (This method of examination should be practised in all cases of displace- ment.) The fundus will be felt very distinctly through the anterior vaginal wall. The cervix will be found high up and pointing backward, and the uterus will be found hard and straight, lying low down behind the pubes. It is important to note the presence or absence of inflamma- tory and other complications in and around the uterus. If there be found present extensive inflammatory depos- its, rendering it difficult to make out the exact position of the uterus, it is better to postpone an accurate diagnosis until the inflammation has subsided. Treatment.-Anteversion in itself rarely requires any treatment, therefore the latter should be directed to the cause of the anteversion. That is, if the uterus is enlarged 446 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Uterine Displacements. and anteverted on account of a lacerated cervix, this con- dition should be treated at once, and the same rule applies to subinvolution, endometritis, perimetritis, or posterior parametritis. To support the uterus, plugs of cotton soaked in glycerine, placed in the anterior vaginal cul-de- sac, are very useful in reducing the sensitiveness of the parts and to test the relief obtained by lifting the uterus. For a pessary, Gehrung's and Graily Hewitt's are the best. Vide Figs. 4303 and 4304. Anteflexion. Pathology and Etiology.-Anteflexion is, strictly speaking, a distortion of the uterus, and con- sists in the bending forward of the body or cervix, or both. As before mentioned, the normal uterus is more or less anteflexed. The pathological condition is merely an exaggeration of the normal, and there is a great differ- ence of opinion as to where the normal flexion ends and where the pathological begins. The seat of the flexion is usually where the cervix joins the body. This, however, may be somewhat higher or lower (Figs. 4293 and 4295). The uterus may be in varying de- grees of rotation or version, and at the same time ante- flexed (Fig. 4294). Every possible degree of flexion Hewitt and Thomas, pain on locomotion. As flabby anteflexion occurs usually in debilitated or neurotic per- sons, we usually have also the symptoms of those affec- tions. Frequent micturition often exists, and may be due either to the general neurasthenic condition, or to the traction on the bladder by the cervix which is held Fig. 4294.-Retroversion of Anteflexed Uterus. (Munde.) by posterior parametritis, or to the pressure of an in- flamed fundus uteri. Rectal symptoms, such as diar- rhoea, obstruction, or irritability, may be present and due to the posterior parametritis. There are two theories con- cerning the production of the dysmenorrhcea, called the obstruction or mechanical theory, and the congestion theory. According to the first, the blood is poured out into the uterine cavity, but cannot readily escape on ac- count of a narrowing of the canal caused by the bend in Fig. 4293.-Anteflexion of Uterus. (Munde.) may be found, from a very slight bend to one where the uterus is rolled up like a ball. Anteflexion may be congenital or acquired. In the congenital form (the commonest and most troublesome), the uterus is usually small and imperfectly developed, with a small pointed cervix and narrow external and in- ternal os. There is also another degree of this form which might be called anteflexion due to arrested devel- opment. Acquired anteflexion is primarily due to want of muscular tone in the uterus itself. This, as above mentioned, has been called "undue softening" of the uterus due to malnutrition. According to Dr. Hewitt, when this undue softening is present, any sudden in- crease of abdominal pressure, such as might be caused by a fall, or even a gradual pressure, may often bend the uterus forward on itself. According to Schultze (Fig. 4296), shortening of the utero-sacral ligaments (usually inflammatory) is a common cause, as it is also in antever- sion. Fibroid and ovarian tumors may also be a cause. At the point of flexion the uterine wall may become atro- phied, and the uterus may also become permanently fixed by adhesions. Symptoms.-The most important symptoms usually as- sociated with anteflexion are dysmenorrhcea and sterility, and we have occasionally menorrhagia and leucorrhcea after the uterus becomes enlarged; also, according to Fig. 4295.-Anteflexion of Cervix. (Munde.) the uterus, so that the uterus is excited to contract vio- lently and painfully to drive out the blood. As the vio- lent contraction is repeated every month, the uterus finally becomes enlarged and inflamed, which, of course, increases the pain. This theory is favored by the fre- quent good results of dilatation. According to the con- 447 Uterine Displacements. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. gestion theory, the uterus becomes congested on account of the disturbance in the circulation caused by the ilex- By the bimanual examination the fundus is found bent forward on the eervix. This condition is not infre- quently mistaken for retroversion ; for in a patient with fat or rigid abdominal walls, sometimes the fundus uteri cannot be felt bimanually, in which case the fact that the cervix is pointing in the vaginal axis suggests a re- troversion. Under these circumstances one must de- termine the position of the fundus by passing a probe or sound. If it is a case of anteflexion the probe will curve forward. Passing a sound is also useful in these cases to determine whether the canal is open or narrow, and likewise to ascertain the size of the uterus, and whether the lining membrane is very sensitive or too vascular. The sound should, however, never be passed except for a definite purpose. The uterus is often found far back near the posterior pelvic wall. In such a case the pres- ence of posterior parametritis or perimetritis is probably the cause, and should be carefully determined by both vaginal and rectal examination. Treatment.-The moderate degrees of anteflexion do not require any mechanical support; as debility and malnutrition are the usual causes, they should be treated by food, rest, fresh air, tonics, and electricity locally. The severe forms (usually congenital) are exceedingly difficult to cure. If parametritis or perimetritis is pres- ent, it should be first treated and cured before any in- strumental treatment is used. Old adhesions can be lengthened by massage. Whatever theory we may adopt as to the cause of dysmenorrhcea and sterility, they are the two most im- portant symptoms which call for treatment. Various methods of treatment have been used. We will begin by describing the one which, so far as our present knowl- edge goes, is the best, i.e., the one which gives the best results and involves the least risk. This method consists in forcible dilatation of the uterine canal with a strong pair of dilators. It has lately been brought into general use by Dr. Goodell, of Phila- delphia. For this operation he uses Ellinger's dilators (Fig. 4297), and a much stronger pair which he has had made. (Fig. 4298.) The blades open parallel and do not feather. This operation is done by Goodell with the patient lying on the back, the cervix being exposed with a bi- valve speculum. It is also often done with the pa- tient in Sims' po- sition. As in all operations for this deformity, all in- flammatory p r o - cesses must first be excluded, es- pecially the pres- ence of pus in the tubes or ovaries. The patient being etherized, the vagina and cervix should be thoroughly sponged with corrosive sublimate solution 1 to 2,000. Antiseptic precautions are especially impor- tant, and the instruments and hands should be carefully cleaned. The cervix being exposed, the canal is at first dilated with the small dila- Fig. 4296.-Anteflexion of Uterus. Shorten- ing of Utero-sacral Ligaments, a, Direc- tion of shortening of ligaments; b. direction of intra-abdominal pressure. (Schultze.) ion, and this congestion causes a painful exudation of the blood from the uterine substance, or even painful uterine contractions. Obstruction undoubtedly exists in certain cases, but it has too often been in- sisted on as being the only explanation of Fig. 4297.-Ellinger's Uterine Dilators. the pain-probably the truth embraces both theories. There are undoubtedly cases in which the pain is due to either one or both of these causes, but in the majority of cases it is not due to obstruction. Schultze repeatedly passed a sound to the fundus uteri, during an attack of most violent dysmenorrhoea, without a drop of blood following its withdrawal, thus showing that there was no obstruction. Sterility also may be due to the fact that it is difficult for the spermatozoa to traverse a narrow and tortuous canal, to the unfavorable condition of a congested uterus to receive them, or to salpin- gitis, oophoritis, or parametritis. Schultze believes that the fixedness and rigidity of the angle in congenital anteflexion, are due to metritis and parametritis; also that dysmenorrhoea and sterility are the results of inflammation. Diagnosis.-The cervix (often small and conical) is usually found pointing in the direction of the vagina ; on tracing the cervix forward the finger finds a sulcus or sharp angle where it joins the body of the uterus. Fig. 4298.-Goodell's Powerful Dilators. tors. If they do not pass readily they are opened a little to stretch the lower part, then pushed further in and again opened, and so on until they pass the internal os. If the internal os is too narrow for the small dilators, a probe is passed in and followed by a pair of sharp-pointed scissors which are opened to stretch the opening. The larger dilators are 448 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Uterine Displacements. then used. The dilatation is done slowly, about fifteen minutes being consumed in opening the blades to the point marked, one and one-fourth inch. They are then held at this point for ten minutes longer. The patient should be kept in bed for a week or ten days after the eration. The cervix should be plugged with a cotton tent soaked in perchloride of iron, to prevent haemorrhage and to prevent the healing of the freshly cut surfaces. After a few days this tent should be removed and the canal kept open by a glass stem. Only a few years ago this operation was in general use, but it has now- been almost entirely abandoned, owing to the fact that many patients died from haemorrhage or from septic poisoning, also because of the great difficulty experienced in keeping the canal open after the operation. The operation as above stated has al- most entirely given way to the forcible dilatation, and is now only reserved for those few cases in which dilatation cannot be done. Various pessaries have been devised for holding the flexed uterus straight. The stem pessary which is placed in the uterine canal, works to the best mechanical advan- tage in straightening the uterus ; it also affects favorably the dysmenorrhoea and sterility, but it has been show-n to be dangerous to life, and has not infrequently given rise to pelvic peritonitis. The advisability of the use of the intra-uterine stem has been under discussion for the Fig. 4299.-Hanks' Uterine Dilator. operation. By this operation the canal and the entire uterus are made broader and shorter, and the flexion is thereby straightened out to a certain extent. Even if the canal is not especially narrow, the chances of im- pregnation are increased, as it is well known that after a long sterility one accidental pregnancy is usually fol- lowed by several more on account of the free opening of the canal. As to results, Dr. Goodell reports that he operated on 122 single women ; of these 34 were not again heard from. From the 88 heard from 55 were cured, 25 improved, and 8 not at all improved. He op- erated on 148 married women ; 85 were heard from, and of these 59 were cured, 21 improved, and 5 unimproved. Fig. 4301. -Sims' Knife. last thirty years, and some of the very best gynaecolo- gists have written monographs advocating its use. Most authorities have, however, been shy of it on account of the dangers above referred to. The great increase of our knowledge, of late years, in regard to the danger of the extension of endometritis to the tubes and ovaries has, I think, given the final death-blow to stem pessaries. I shall therefore not recommend their use. The use of vaginal pessaries in anterior displacements is a much disputed subject. Graily Hewitt and Thomas are enthusiastic as to their value, while Emmet, Schroede, Winckel, Hart and Barbour, Goodell, and others, consider them of no use. As there is an infinite variety of opinions on this subject, and an in- finite variety of pessaries in use, we shall speak here only of the most useful forms, and the reader is referred Fig. 4300.-Lines of Incisions in Flexure of the Body. (After Emmet.) Of the 85, only 72 were capable of having children, and 14 of these became pregnant. There were no deaths, and only a few cases of slight pelvic inflammation. These results are wonderfully good. Although those who have followed Dr. Goodell are not equally enthusi- astic, yet this operation has been accepted as the best treatment now known for dysmenorrhoea and sterility due to anteflexion. In mild cases, or where the patient is unwilling to take ether, the same result may be accom- plished by dilating a little at several sittings with the small dilators, or with a series of graduated dilators. (Fig. 4299.) This dilatation and straightening of the uterus were formerly accomplished by the use of sponge tents, later by tupelo or lami- naria tents. But this method has proved too dangerous on account of septic infec- tion, and lias been abandoned. In certain very difficult cases (Fig. 4300), and in cases where the uterine tissue has become too hard to dilate, Sims' cutting operation is to be recommended. In this operation the patient is placed in Sims' position, the perineum being retracted with Sims' speculum. The posterior lip is divided backward in the median line to B, D, then the triangular portion, A, B, D, is to be incised by means of the ball-and-socket knife (Fig. 4302). The uterus being steadied with a tenaculum, the knife is turned over and the anterior wall at the bend is cut in a direction corresponding to C, D (Fig. 4300). Strict antiseptic precautions should be used in this op- Fig. 4302.-Posterior Section of Cervix. (Sims.) for further information to the article on Pessaries in Vol. V. As anteversion and anteflexion often exist in combination, and as they are practically the same thing so far as they are affected by a vaginal pessary, very nearly the same pessary may be used for both. The cor- rect principle of these pessaries is to distend the anterior vaginal cul-de-sac, thereby lifting the fundus uteri and drawing the cervix forward. The lifting of the con- gested fundus, so as to restore the natural circulation, is 449 Uterine Displacements. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. probably the essence of whatever usefulness they pos- sess. Dr. Emmet goes so far with this idea as to say that it is equally good practice, or even better, to lift the uterus with an ordinary re- troversion pessary, which, of course, while lifting the whole uterus, increases the anteversion. Anteversion pessaries are often recom- mended for the so-called bladder symptoms in these cases. It should be remem- bered that the bladder symp- toms are usually of nervous origin ; also, that a vaginal anteversion pessary presses the bladder directly against the uterus, and that the pes- sary pushes up against the bladder harder than the ute- rus pushes down. An anteversion pessary is indicated where we find the uterus large, congested, ten- der, and crowded down low in the pelvis. In such cases, after a few weeks of rest and the use of hot vaginal douches, if there is no pelvic peritonitis present, it is well to begin by supporting the uterus with a roll of cot- ton soaked in glycerine, placed in the anterior vaginal cul-de-sac. After a week or two of cotton tampons, a pessary, either a Gehrung's (Fig. 4303), or a Graily Hewitt's cradle pessary (Fig. 4304), may be introduced. Gehrung's pessary is especially useful if the case is complicated with a cystocele and partial pro- lapse, but Hewitt's pessary is, on the whole, the most satisfactory one in anteversion. In introducing this pessary, the large ring is to be in- troduced first, the bar being at this time close to the meatus. The bar is then pushed inward under the urethra, giving the instrument a rotary motion ; once in the vagina with the bar uppermost, the pessary takes its should be bent upward. Dr. Thomas has made several forms of anteversion pessaries. The form most in use has been called the open cup pessary (Fig. 4306). " It is introduced open. Upon pulling upon the bow which pre- sents at the mouth of the vagina, the piece which sustains the ute- rus falls back, and it can readily be withdrawn by patient or phy- sician." Fowler's pessary (Fig. 4309) is also of use in certain cases, es- pecially when there is a lacerated cervix, as it supports the uterus, and protects and rolls in the eroded surfaces of the cervix. All of these pessaries require the greatest skill and care in their introduction and manage- ment, otherwise they are worse than useless. Retroversion and Retroflexion. Pathological Anatomy and Etiology.-As retroversion and retroflexion almost always exist to- gether, and cannot be sepa- rated either by symptoms or for treatment, they will be here considered as prac- tically one and the same disease. Retroflexion is one of the commonest and most im- portant of gynaecological affections. As the uterus becomes naturally retro- verted with a full bladder, it is difficult to state exact- ly wdiere the pathological retroversion begins; but this much seems clear, that the intra-abdominal press- ure in health falling on the posterior surface, tends to press it forward and hold it in place (vide Fig. 4290). There must be, therefore, a certain inclination of the uterus at which the intra-ab- dominal pressure may, by a very slight variation, strike cither on the anterior or poste- rior uterine wall. The moment that the uterus is unable to re- cover its position with an empty bladder, and begins to be influ- enced by the abdominal pressure igainst its anterior wall, a series cf changes are set in motion which invariably result in a pathological retroversion (Fig. 1310); that is, the fundus uteri is gradually crowded down into Douglas's fossa, where it be- comes congested and tender. The cervix is usually directed forward in the axis of the va- gina, or may even be directed toward the bladder. The whole uterus is lower in the pelvis, and, in cases of long standing, enlarged. The body is often bent backward on the cervix with varying acuteness of angle, thus consti- tuting retroflexion. The ovaries and tubes must go backward with the uterus, and are occasionally found down in Douglas's fossa, be- side or even under the ute- rus. The bladder no longer has the uterus resting upon it, and is often distorted in shape and dragged upon by the retro verted organ. The utero-vesical pouch is obliterated. The rectum is pressed upon by the fundus uteri. The broad ligaments are twisted, the round ligaments are lengthened, and the folds of Douglas must be stretched to allow the cervix to Fig. 4306.-Thomas's Ante- version Pessary. Fig. 4303.-Gehrung's Anteversion Pessary. Fig. 4304.-Graily Hewitt's Anteflexion Pessary. Fig. 4307.-Same Instrument in Po- sition. Fig. 4308.-Same Instrument as Introduced and Removed. Fig. 4305.-Shows Graily Hewitt's Pessary in Position. Fig. 4309.-Fowler's Pessary. proper position with the bar in the anterior cul-de-sac under the fundus (see Fig. 4305). The posterior ring occasionally presses on the rectum, in which case it 450 Uterine Displacements. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. go forward, and admit the fundus into Douglas's fossa. Should the peritoneal surfaces become inflamed, as often happens, the uterus becomes glued by adhesions in its abnormal position ; thus we have retroversion with ad- hesions. Retroflexion may be congenital. Schultze attributes puerile retroflexion to a congenital shortening of the an- terior vaginal wall. Retroversion may be caused by the contraction of an anterior parametritis (Fig. 4311). By far the most common predisposing cause is child- bearing. Here we often have relaxation, elongation, and traction upon the sacrouterine ligaments, together with an increased weight of the uterus in a person of lax mus- cular tone. According to Schultze, when the sacro- uterine ligaments become inflamed, the cervix is drawn back, causing anteflexion (Fig. 4296), but later they may turition, painful and difficult defecation, sterility and abortion, symptoms of chronic pelvic peritonitis, pain and burning in the pelvis, and, finally, numerous second- ary nervous and reflex symptoms. Leucorrhcea and menorrhagia are due to chronic in- flammation of the mucous membrane, which is caused by the condition of passive congestion of the whole uterus, the result of the displacement. Dysmenorrhoea is probably owing to the same cause. Rectal disturbance results from the proximity of the tender fundus uteri. Straining at stool often presses the fundus against the rectum, so that it acts like a valve and obstructs the rec- tum. Frequent micturition is due to traction on the bladder, caused by malposition. Sterility in an uncomplicated case of retroversion is due to the unfavorable position of the cervix and to the diseased condition of the mucous membrane. Abortion is due either to diseased mucous membrane being unfa- vorable for the development of the ovum, or to the fact Fig. 4310.-Retroversion of Uterus with Relaxation of Sacro-uterine Ligaments. (Schultze.) Fig. 4311.-Retroflexion of the Uterus from Anterior Fixation of the Cervix. (Schultze.) become atrophic and fallow the cervix to push too far forward, and thus cause retroversion (Fig. 4310). According to Winckel, about ten per cent, of all retro- versions occur in nulliparae and unmarried women. ' Chronic constipation causes permanent dilatation of the rectum, which pushes the cervix forward and stretches the utero-sacral ligament, thus helping to cause retrover- sion. Any increase of weight in the uterus, as pregnancy or subinvolution, increases the tendency to retroversion. The hyperplasia of the cervix due to laceration may cause retroversion. The pressure of tumors is a com- mon cause. Retroversion may occur suddenly from a strain or fall, but usually takes place gradually, and is most often due to want of muscular tone. The uterus may be drawn down into retroversion by inflammation, but this is prob- ably very rare, as recent cases are never adherent. On the other hand, a retroverted uterus often causes local peritonitis and thus becomes adherent. Symptoms.-The following is a list of the many dis- turbances commonly expressive of posterior displace- ments of the uterus: Backache, difficult locomotion, leucorrhcea, dysmeuorrhoea, menorrhagia, frequent mic- that, as the uterus grows it cannot rise out of the pelvis, and, becoming congested or even strangulated, expels its contents. Difficulty in walking is not easy to explain, as the uterus does not press directly on the nerves. It must, therefore, for the present be classed under the reflex phenomena, with gastric derangement, etc. Diagnosis.-By vaginal examination the cervix is found low down and pointing in the line of the axis of the vagina, or even upward. The fundus is felt in the pos- terior vaginal cul-de-sac, continuous with the cervix, and between the two is found a sulcus, more or less marked, according to the degree of flexion. On bimanual exami- nation the fundus is absent from its normal forward po- sition, and in a thin patient can be felt lying backward, low down under the promontory of the sacrum. Vari- ous kinds of tumors appear in Douglas's fossa, which may be mistaken for the fundus uteri, as faecal impaction, fibroid tumor, parametritis, prolapsed ovary, etc. When there is doubt, the uterus can be drawn down by a ten- aculum in the cervix, so that a finger in the vaginal pos- terior cul-de-sac or in the rectum can palpate the whole uterus, and trace the connection between body and cer- vix. If there is still doubt, the position of the fundus 451 Uterine Displacements. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. can be determined with certainty by passing a sound, which will curve backward in retroflexion. While ex- amining a retroverted uterus, it is most important to dis- cover whether it can be replaced, or is fixed in its posi- tion by adhesions ; this is determined by making steady pressure upward on the fundus, and observing whether it gives way before the finger ; but it will be more accu- Munde's cuts are introduced to show the various stages of this method. They are drawn to represent the patient on the back, but the operation is really done on the left side. The plates are, however, here turned upside down, to give a better idea of the way in which gravity and at- mospheric pressure act. The uterus can also usually be replaced by bimanual Fig. 4312.-Replacement of Retroverted Uterus by Two Fingers of Right Hand, with Patient in Sims' Position. (Munde.) Fig. 4314.-Same; third step. ^Munde.) rately determined when attempts are made to reduce the displaced uterus. Treatment.-The uterus should be returned to its nor- mal position and held there (usually by a pessary). There are several methods of reduction. The simplest and best wTay is to place the patient in Sims' position on the left side, with the clothing around the waist made loose. In this position there is a tendency for the pelvic contents to gravitate forward toward the table, while air is sucked in, distending the vagina when the perineum is retracted. The operator stands behind the patient, facing her, and introduces the first two fingers of the right hand into the vagina, with the palmar surface toward the rectum ; he then pushes his finger-tips high manipulation with the patient on the back. By this method the uterus is lifted up with the fingers of the left hand in the vagina, until it can be caught above the promontory of the sacrum with the right hand, from the outside, and pulled forward under the pubes. The retroverted or retroflexed uterus can usually be easily reduced by either of the above methods, but not infre- quently the fundus is swollen and impacted in the hol- low of the sacrum, or caught by the folds of Douglas in such a way as to make reduction very difficult. If these methods do not succeed, the patient should be put in the knee-chest position (Fig. 4315), because in that position gravity and atmospheric pressure act as in the Sims po- sition, and even more forcibly. Dr. Campbell, of Augusta, Ga., has systematized this principle as a practical method of reducing and treating retroversion. During the whole treatment of retrover- sion it is advantageous to have the patient practise this reduction by posture every day. The patient should be up into the posterior vaginal cul-de-sac, and with the backs of his fingers lifts the fundus uteri forward out of the hollow of the sacrum. When the fundus is high up in front of the promontory of the sacrum, the fingers are transferred to the cervix, which is pushed back into the hollow of the sacrum, while the patient is asked to take deep breaths or to cough. In this way the fundus is pushed up and falls forward out of the pelvis, and the cervix assumes its natural position. Fig. 4313.-Same ; second step. (Munde.) Fig. 4315.-Knee-chest Position ; showing Displacement of Uterus and Intestines. (Campbell.) directed to take this position in bed, and to open the lips of the vulva, so as to admit air into the vagina ; after re- maining in this position for four or five minutes she may sink down into Sims' position, and remain there as long as is consistent with comfort. Even without a pessary this manoeuvre will do much to counteract the evil re- sults of a retroversion, and in certain cases may prove efficient treatment. When a pessary is being worn it 452 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. t'terine Displacements. serves to take the pressure off the instrument, and to restore the circulation. In this way it often gives great relief from the crowding down and dragging feeling which comes on after standing. With the patient in this position the uterus may be pushed out of the pelvis with the finger; or, with a Sims speculum in position (Fig. 4316), the cervix is drawn forward so as to disengage the fundus from the Douglas folds, when it can often be pushed forward by a cot- ton stick made to press in the posterior vaginal cul-de-sac. The same thing may be accom- plished with the finger in the rectum (Fig. 4317). The lifting forward of a retroverted uterus on a sound was formerly a fa- vorite method of reduc- tion, and various instru- ments have been devised to take the place of the sound. Dr. Emmet's Re- positor (Fig. 4318) is a most ingenious instrument, and is the best. This instru- ment is like the human finger in that it is capable of reported from the reduction with a sound, and as the other methods before described are safer and equally effective, many of the best authorities have nearly, if not quite, abandoned this operation. As the dan- gers of perforation and peritonitis are so very ob- vious, it will only be necessary to say that if this method is used it should be done with the greatest caution. If all these methods of reduction fail, one may conclude in a general way that the uterus is bound down by adhesions ; it should at least be treated as if such were the case. The sub- ject of retroversion with adhesions will be treat- ed fully later on. When replaced, the uterus should be re- tained in its normal po- sition by a vaginal pes- sary. Of these the best form is Hodge's (Fig. 4319), or some of its modifications, notably Albert Smith's (Fig 4320). In those rare cases of recent hnrVwnw dislocation caused by a fall or some similar accident, it is hpRt not to annly the pessary at once, but to wait for a time to see if the uterus will re- main in its normal posi- :ion after reduction. In such 3ases the patient should be directed to avoid carefully all lifting or straining move- ments, and to avoid lying on the back. She should also be di- rected to take the knee-chest position every day (wide Fig. 4315). If the uterus remains in good position for two wreeks it is quite probable that it w'ill continue so. In this case at- tention should be given to general health, gymnastics, etc. In all ordinary cases which have come on gradually, or have existed for a long time, immediate support will be necessary. If the uterus is very tender, as often happens in these cases, or if there is doubtful tenderness about the organ, it is often best to hold the uterus in position by packing the vagina light- ly with plug- gets of cotton soaked with glycerine (Fig. 4321) until the ten- derness has diminished and the proper circulation has been re-estab- lished. After a time a pessary may be tolerated. A pessary should be carefully fitted to each particular case. Fig. 4316.-Replacement of Retroverted Uterus by Air-pressure. (Campbell-Monde.) Fig. 4319.-Hodge's Retroversion Pessary. Fi«. 4317.-Replacement of the Uterus with Vulsella and the Finger in the Rectum. The patient is in the knee-chest position. (Hart and Barbour.) doubling up in one direction, while it is perfectly rigid in the opposite direction. The advantage of this is that it finds its way into a flexed uterus, and on being turned over and pushed on it straightens and re- places the uterus ; then, by virtue of the finger- Fig. 4320.-Albert Smith's Retroversion Pessary. Fig. 4318.-Emmet's Uterine Repositor. joints, it can be removed one joint at a time without again retroverting the uterus. As there have been bad results With the patient on the side the length of the vagina should be measured, the curve and width necessary to 453 Uterine Displacements. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. hold the uterus should be estimated, and a pessary pre- pared on the general model of Smith's, embodying these measurements. The best pessary for this preliminary moulding (block tin was used by Sims) is a very ingen- ious instrument made by Otto & Sons, of New York. It is made on the Smith pattern of an elastic wire spring, covered with soft rubber. It can be bent and set in any shape, and still remains elastic. Such a pessary is moulded to fit the case in hand, and its shape can readily be changed as occasion may require. It is easily intro- duced on account of its compressibility, and is less objec- tionable than the unyielding hard-rubber pessary in case there is tenderness. The soft-rubber covering, however, becomes foul with the vaginal secretions after a time ; it is, therefore, not so suitable as a permanent support. When the pa- tient has become accus- tomed to, and is com- fortable with, such a pessary (which usually happens after a month or two) it should be copied in hard rubber. This hard-rubber pes- sary is to be wrorn per- manently, and should be examined and cleaned as often as once every two months. Great skill and judgment may be required to fit a pessary properly. It should hold the uterus forward without causing pain or discomfort. Retroversion pessaries act by distending the posterior vaginal wall and putting the sacro-uterine ligaments on the stretch, thus drawing the cervix back toward the sacrum and allowing the fundus to fall for- ward by its own weight. The uterus should not therefore rest on the pessary, but be balanced by it. A pessary should always be of the very smallest size that will hold the uterus in position, in order to avoid stretching and weakening the vagina. There should always be room enough between the pessary and the vaginal wall at any point to admit the finger. As we have seen, retroversion is due to stretching of the sacro-uterine ligaments, and its treatment consists in making them taut again by a pessary; therefore, w e must be very careful not to overstretch these liga- ments by the pessary, and the posterior arm, which goes behind the cervix, should be as short and small as will hold the ute- rus. This is a very im- finger of the right hand is then passed into the vagina, and the posterior arm of the pessary hooked over behind the cervix. There are innumerable varieties of Hodge pessaries bearing the names of the inventors, and, indeed, every gynaecologist has made an immense variety of shapes to fit his own special cases. One of the most useful forms is Dr. Thomas's bulb pessary (Fig. 4323). It is long and narrow', with a bulb on the posterior bar ; it is retained by its antero-posterior curves, and not by its width ; it is usually made in hard rubber, but Otto & Sons make it in the above-mentioned elastic style (Fig. 4324). It is most useful where there are tender adhesions-or a pro- lapsed ovary in Douglas's fossa, as the bulb distributes the pressure and prevents cut- ting. These last two forms are not in- tended for the simple cases, but they are useful for the difficult cases where the uterus presses heavily on account of in- creased size and weight, and is hard to keep in place. In a few cases the posterior vaginal cul-de-sac is not deep enough to admit the poste- rior bar of a pes- sary ; this is a very awkward diffi- culty to contend ■with, and is best overcome by packing the cul-de-sac with glycerine cot- ton tampons. If there is a lacerated cervix it should be repaired without delay, because this lesion may help to produce a retroversion in two ways : First, by keeping the uterus enlarged ; and, secondly, because the large hypertrophied cervix is forced into the axis of the vagina ; this, in a rigid uterus, must cause the body to fall backward. If the perineum is lax or slightly ruptured, the pessary can usually be kept in place by making the anterior end quite wide, but any extensive laceration should be oper- ated on at once. When the pessary is fitted, the patient should suffer no pain from it-in fact, should feel a relief after a time. She should return to the physician every month or two, according to indications. At such times she should be examined bimanually, to see if the uterus is held in posi- tion, and also with a Sims speculum to see if the pessary is chafing or cutting. She should be instructed to re- move the pessary if she has pain, and to know that an increase in the white discharge, especially if it becomes bloody, usually means that the pessary is cutting, and that she should then return immediately. There is no doubt that the puerperal Fig. 4321.-Uterus Sustained by Cotton. (Thomas.) Fig. 4323.-Thomas's Retroflexion Pessary. Fig. 4324.-Elastic Bulb Pessary. state is a favorable time for curing retroflexion. The uterus should be placed in anteversion soon after the eighth day, and the patient be directed to lie on the side as much as possible ; after two weeks she should take the knee-chest position every day. Operative Treatment of Retroflexion.-Although pessa- ries are of great service in the treatment, and often lead to a cure, of retroflexion, yet there are certain cases in which they cannot be used-sometimes on account of a tender and troublesome prolapsed ovary ; occasionally on account of a malformation of the vagina (absence of a Fig. 4322.-Ilodge's Pessary in Position. (Fritsch.) portant point, for a permanent cure can only be hoped for when these ligaments have regained their tone. As soon as the general health and tone of the patient im- proves, attempts to shorten the posterior arm of the pes- sary should be made. A retroversion pessary is best introduced with the patient on the left side. The perineum being pressed back, the pessary is pushed into the vagina; the fore- 454 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Uterine Displacements. posterior cul-de-sac); occasionally on account of a special nervous irritability or unwillingness on the part of the patient to be treated with pessaries, and for various other reasons. For such cases various operative methods of treatment have been proposed and tried. These opera- tions are also proposed to accomplish a permanent cure and to avoid the nuisance of wearing a pessary. Short- ening the round ligaments, and sewing the fundus uteri to the abdominal wall by laparotomy, are the two most important of these operations. The Alexander-Adams operation consists in dissecting down upon the external abdominal rings, catching up the fibres of the round ligaments as they pass through the ring, pulling out as much of them as will restore the displaced uterus to its normal position (three or four inches), and stitching the shortened round ligaments to the pillars of the external ring. Dr. Alexander first performed this operation in 1881, since which period it has been done a great many times, but there still exists a great difference of opinion as to its value. At the Ninth International Medical Congress, held in 1887, Dr. Alexander presented the results of his whole experience. Of 84 cases, one died of pyaemia and peritonitis. "Thirty-one private cases were for retroflexion and its attending trouble, the prolapse, which frequently accompanies the backward displacement, being only secondary. Of these 31, 20 are anatomical and therapeutic successes ; 5 are anatomical successes and the patients are much relieved ; 2 are ana- tomical successes and therapeutic failures; and 4 failed in both respects." The anatomical failures were usually due to accidents in the healing of the wound, and the au- thorthinks they can be wholly avoided. Of the hospital cases, 27 were for retroflexion ; of these, 23 were anatom- ical and therapeutic successes ; 3, anatomical and partial therapeutic successes; 1, anatomical success and therapeu- tic failure, but cured later by removal of the cystic ova- ries. He says: "Anatomical cures of retroflexion by shortening the round ligaments are the most certain re- sults of the operation, 54 cases out of 58 being successful, as far as I know." In regard to its effect on pregnancy, he says: " Two of my cases of retroflexion are pregnant at the present time and have not suffered as yet; one is at the third month, the other at the eighth month; one has been pregnant twice with no inconvenience, and with- out any return of the retroflexion for which the opera- tion was performed." Among the operations performed there have been a few cases where hernia has been caused, but this bad result can probably be avoided by sewing up the external ring at the time of the operation. The following description of Alexander's operation is taken from his paper on "The Treatment of Backward Dis- placements of the Uterus and of Prolapsus Uteri, by the New Method of Shortening the Round Ligaments," 1884. The pubes is shaved. An incision about two inches in length is made along the course of the inguinal canal, beginning from the spine of the pubes. The bleeding vessels are secured by pressure-forceps. When the glis- tening tendon of the external oblique muscle has been exposed, the external abdominal ring must be found. The inter-columnar bands, oblique fibres in the aponeu- rosis immediately above the ring, will aid the operator in his search. The orifice of the ring is occupied by a little mass of connective and adipose tissue. The pubic spine and the ring can be felt with the finger in the wound. The inter-columnar bands are then cut across in the di- rection of the inguinal canal. A fleshy mass of fat now bulges forward. This mass is the end of the round lig- ament very near its termination in the tissues of the mons veneris. If there is any difficulty in recognizing the ligament, the inguinal canal may be opened up for half an inch. Fasciculi of the internal oblique may be taken from the round ligament. An aneurism-needle is then passed under the whole of this tissue, so as to raise it out of its bed in the inguinal canal, when it may be grasped by the fingers. The operator must make sure that he has got the whole of the tissue of the ligament. Care must be taken not to split or tear the ligament with forceps. The end of the round ligament is now gently pulled, and separated by scissors or director from bands of connective tissue which bind it to adjacent structures. When the adhesions have been freed the ligament can be pulled out, and appears as a strong white cord. Care must be taken, as there is some danger of breaking it, and it often pulls out easily ; the traction should also be interrupted by periods of rest, to avoid strangling the blood-supply. The ligament already exposed may now be left, covered by an antiseptic towel, and the other one exposed by the same process. When both ligaments are free the uterus should be raised by a hand in the vagina. After the ligaments have been freed they come out read- ily for a certain distance, and decided resistance is felt, accompanied by movements of the replaced uterus. Any further traction pulls up the broad ligament and the uterus, and finally is met by the resistance of the oppo- site ligament till the uterus is lifted to the abdominal wall. Now, this lifting of the uterus is an unnatural pro- cedure. That organ never hangs suspended under any conditions, and to suspend it by the ligaments must lead to failure. All we can do is to replace the uterus in its normal position, and this occurs generally when the de- cided check upon the pulling out of the ligaments takes place. The ligaments are then drawn moderately tight and stitched to the pillars of the rings with fine catgut. This closes the ring and fixes the ligaments. Dr. Alex- ander always introduces a drainage-tube. Then a Hodge pessary is placed in the vagina. The tube is removed on the second day, but the patient is kept in bed three weeks or longer. The indications for the operation are, first of all, that the uterus can be brought forward. If there are adhe- sions which hold the uterus in retroflexion, this opera- tion would not be indicated, and yet, even under these conditions, Alexander and Polk have reported a certain degree of success. The operation is best adapted to the poor and to -working-women who cannot give care and time to treatment with pessaries, to women 'of the wealthy and leisure classes in whom pessaries only give temporary or partial relief, when constant medical at- tendance cannot be obtained, or when the treatment by pessaries seems unadvisable for any reason. The opera- tion is often done in conjunction with other operations. Dr. Doleris, of Paris, often performs amputation of the cervix, anterior and posterior colporrhaphy, and shortening of the round ligaments at one sitting. To sum up, this operation is of great value in a case of chronic replaceable retroflexion in which treatment by pessaries is for any reason impracticable. Mr. Tait and others think the operation dangerous, and operators have often failed to find the ligaments. But, in spite of all the objections which have been raised against the operation, we consider it a valuable addition to our resources. Ventral fixation, or "hysterorrhaphy," consists in opening the abdomen by median laparotomy and stitch- ing the uterus to the anterior abdominal wall. There have been two exhaustive articles on this subject by Howard Kelly, of Philadelphia-the first on " Hysteror- rhaphy " in the Amer. Jour, of Obstetrics, vol. xx., Janu- ary, 1887, and the second in the Amer. Jour, of the A fed. Sciences, May, 1888 ; and one by Sanger on " Operative Treatment of Retroversio-flexio Uteri," in the Central- blatt fur Gynacoloyie, Nos. 2 and 3, 1888 ; to which the reader is referred for details. Koeberle first did this operation (1877) by sewing the ligature stumps after cas- tration to the abdominal wround. Since then the uterus has been stitched to the abdominal walls in various ways, both with and without removal of the ovaries. The re- sults have been good, although a uterus adherent to the abdominal walls is really in an abnormal position. But the risk of an abdominal section is too great for a case of uncomplicated retroversion, and it will never come into general use for such cases. Ventral fixation should, we think, be reserved for those cases of retroversion in which the abdomen is opened for some other complica- tion, as for removing adhesions, or ovaries, or tubes. The fixation can in such cases be done in addition to the original laparotomy, if necessary ; and even here it will often prove unnecessary, for the ligatures after castra- 455 Uterine Displacements. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tion so shorten the broad ligaments as to hold the retro- verted uterus forward. This has been observed in three cases operated upon by the author, and recorded in the Boston Med. and Surg. Journal, April 5, 1888. The uterus has been stitched to the abdominal wall in various ways by different operators. Sanger considers it important to use several stitches, and therefore passes one through the round ligament and two through the anterior layer of the broad ligament; these stitches are the uterus and rectum, and then either the pus becomes fatty and is absorbed, or the abscess breaks. When the abscess is emptied healing takes place by the union of its two walls, which are the uterus and the rectum In this way the uterus may become retroverted and bound firmly to the rectum by a very dense mass of adhesions (Fig. 4326). The membranes resulting from peritonitis may become like ligaments and bind the uterus to the rectum (Fig. 4327). When two inflamed surfaces of peritoneum on different Parietal peritone- um retroflected outwards. -Abdominal sutures. -Corpus uteri. Abdominal wall. Fig. 4326.-Retroversion with Adhesions. (Adapted from Winckel.) D, Douglas's fossa obliterated by a mass of adhesions, result of ab- scess ; B, bladder; V, vagina; U, uterus ; R, rectum. organs come in contact they are often glued together. In this way the least firm adhesions are formed. Ad- hesions vary greatly in size and toughness. The large, tough ones are the result of often repeated attacks of peritonitis. If no fresh attack occurs the adhesions tend to disappear very slowly. From being constantly stretched and worn by the respiratory and other move- ments, they may finally be absorbed. In spite of this fact many adhesions persist for a lifetime; hence their importance to gynaecologists. The causes of this disease are various. Merely the condition of retroversion may be the cause of a local peritonitis, and hence adhesions. Any local peritonitis may form such adhesions about a uterus in normal po- sition as to cause retroversion. The causes of local peri tonitis are, then, the causes of adhesions. Among such causes Heitzmann considers irregularity and other an- omalies in menstruation as common, and therefore any change in the uterus, tubes, or ovaries which causes these irregularities, such as stenosis, congenital anteflex Fig. 4325.-Manner of Stitching Uterus to Anterior Abdominal Wall. Stitches through uterus tightened. Abdominal wound open. (Sanger.) then passed through the peritoneum of the abdominal wall just above the pubes and tightened (Fig. 4325). Retroflexion with Adhesions.-The peritoneal surface of a retroverted uterus often becomes inflamed. If this occurs, the result may be that the uterus becomes more or less firmly fixed by peritoneal adhesions, in which case the symptoms of retroflexion become aggra- vated. Not only this, but when the uterus is once fixed in retroflexion by adhesions, successive attacks of local peritonitis usually follow. These attacks may recur after any slight provocation, such as jarring, going about during menstruation, taking cold, etc., until the patient is exhausted by pain, or general peritonitis is im- minent. She is then obliged to go to bed, where she will often improve for a time, but when she gets up the local peritonitis usually begins again, and she finds her- self no better than before. This sort of thing may go on for years, or the patient sometimes gives up trying to go about, and becomes a confirmed bedridden invalid. This disease is associated with great pain and tender- ness in the vagina and all about the pelvis, causing in- ability to walk and a decline in the general health. The nervous system suffers, as a matter of course. There is often sterility, and should the uterus by chance become impregnated, a miscarriage is almost certain to follow, the common result of which is another sharp attack of local peritonitis with the production of more adhesions. If, however, a miscarriage does not occur and the patient goes to full term, the adhesions are gradually absorbed as the uterus increases in size. From this we see that retroversion with adhesions is a progressive disease ; that it tends to grow worse where there is no treatment. Pathological Anatomy and Etiology.-The peritoneum of the female pelvis may become inflamed at any point where it covers the various pelvic organs. Inflamma- tion of the peritoneum is associated with the exudation of fluid and the formation of fibrous adhesions. When pus is exuded it is often shut off by membranes between Fig. 1327.-Retroversion with Adhesions. (Winckel.) A, A, Adhesions on the stretch ; B, bladder ; D, Douglas's fossa: R, rectum; 1', vagina. ion, etc.; also taking cold during menstruation. Any ca- tarrhal inflammation of the uterus may extend through the tubes to the peritoneal cavity. This most frequently happens with gonorrhoeal endometritis ; ovaritis itself may be a cause, as may be also the rupture of a Graafian follicle. The rubbing of a prolapsed ovary may be a cause. Parametritis may cause peritonitis by direct ex- tension. There are various traumatic causes, such as di- rect injury to the peritoneum, falls, coition, the use of the vaginal douche, pessaries, and any intra-uterine in strumentation, such as passing a sound or dilating with 456 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Uterine Displacements. tents. Septic absorption from wounds of the uterus or vagina may cause septic peritonitis. The last and most common cause is parturition and abortion. Diagnosis.-The diagnosis of retroversion with adhe- sions is arrived at by first establishing the presence of a retroversion (by touch or probe); the adhesions may then be felt through the posterior vaginal cul-de-sac (see Fig. 4329). In certain cases their presence can only be determined by a failure to replace the uterus by the various manoeuvres described above. A strong, firm adhesion is evident, and cannot easily be overlooked. The difficulty is that one not skilled in reducing retroversion may sometimes be led to suppose that the uterus is adherent, when it is merely pressed down and caught be- hind the promontory of the sacrum. This mistake will, however, soon become evident if the treatment here described be applied. Treatment.-There are various methods of treating this disease: (1) By repeatedly packing the posterior vag- inal cul-de-sac with tampons in such a manner that the adhesions, being gradually stretched, bro- ken, and absorbed, the ute- rus is pushed into its nor- mal position. (2) By gradually lifting the body of the uterus by a series of pessaries, begin- ning with a small one ; larger ones being placed as the uterus is lifted higher. (3) By gradually stretch- ing and tearing the adhesions by lifting the body of the uterus with the finger a little at each sitting; massage treatment. (4) By forcibly tearing up the adhesions, under ether, at one sitting. (5) By opening the abdominal cavity, tearing up or cutting the adhesions, and stitching the uterus to the an- terior abdominal wall. The first of these methods is the proper one for most cases, as it is the surest and safest. This method of re- placing the uterus, by packing the vagina, was first de- scribed by Dr. Taliaferro in a paper read before the Medical Association of Georgia, in 1878, on "The Ap- plication of Pressure in Diseases of the Uterus." This method has the great advantage that it can be applied where the parts are excessively sensitive. The second and third methods can be useful only when the adhesions are not strong, and where there is comparatively little tenderness. The fourth method is useful where there are a few iso- lated strands (even stout strands), and where there is no active inflammation. The fifth method should be reserved for the severe cases in which the other methods have proved ineffect- ual, or where there is reason for inspecting the condition of the ovaries and tubes. Treatment by Packing the Vagina.-To pack the vagina, the patient must be placed in the semi-prone or knee- chest position. The latter position should be used in the more difficult cases, and the former in ordinary cases, as it is much easier for the patient. A Sims speculum being passed, small bits of absorb- ent cotton, wrung out in glycerine, are packed into the posterior vaginal cul-de-sac. Each bit is placed with dressing-forceps held in the right hand. It is then pressed back, as hard as occasion may require, with the blade of the speculum held in the left hand (tide Fig. 4328). When the posterior cul-de-sac is full, the vagina is packed full of the same tampons, to hold those placed in the cul-de-sac close up against the fundus uteri. At the outlet of the vagina the cotton is pressed back toward the rectum, away from the point where the urethra passes under the pubic arch, as pressure on that point may cause retention. The packing being thus placed piece by piece, the result should be that, as a whole, the mass will ex- actly conform to the shape of the vagina, exerting a firm, even, and constant pressure against the fundus uteri. It will, of course, require some practice to do this w'ell. The packing should be removed every three to five days, with the patient in the same position. On removing the packing we find the post-vaginal cul-de-sac somewhat deeper, for the pressure, when properly applied, tends always to wedge the uterus away from the rectum. Before replacing the packing it is a good plan to try to determine how much has been gained, and where the adhesions still bind. This is best done, with the patient in the semi-prone position, by hooking the cervix forward with a tenaculum held in the left hand, then passing the forefinger or two fingers of the right hand high up into the posterior vaginal cul-de-sac (the palm being toward the pa- tient's back), and pressing the uterus forward with the back of the finger. In this way the adhesions can be put on the stretch over the ends of the fingers, and a good estimate of their strength and position be formed (Fig. 4329). We then proceed to re- pack the vagina as before. The pressure should be exerted directly backward into the posterior cul-de- sac, against the remaining adhesions. If the force is directed too far forward, the result is that the cervix and bladder are raised and tipped forward, while the fundus remains fixed and un- moved. The ability to get the pressure exactly in the right direction is a matter of skill, and requires practice. The question of how tightly the packing is to be placed must remain a matter of judgment in each case, at each packing. This judgment will depend upon the condition of the vaginal wall and upon the increasing or diminish- ing tenderness of the adhesions. In a general way, it is best to begin with a light packing, and increase the press- ure each time until the vagina is packed as hard as it can be, unless some contra-indication becomes manifest. The possible dangers from too tight packing are peritonitis and sloughing, or rupture of the vagina. As a matter of experience, most physicians pack too loosely rather than too tightly. Even when there is considerable tenderness, a well-fitting tight packing gives the most relief. Some patients get immediate relief when the first pack- Fig. 4328.-Manner of Placing the Cotton Tampons in the Treatment of Retroversion with Adhesions. (Elliot.) ing is applied, and are perfectly comfortable during the whole treatment. Others have constant pain and dis- comfort. If the treatment is painful, the patient must be very carefully managed. A nervous woman, who has often had attacks of pelvic peritonitis, will complain loudly. It is sometimes very difficult to distinguish be- tween hypenesthesia and real tenderness. In such cases, when the physician has decided that there is no increas- ing local peritonitis, it is important to persist with the packing in spite of the protestations of the patients. One soon learns the peculiarities of each individual. It is, of Flo. 4329.-Method of Testing the Adhesions. (Elliot.) 457 Uterine Displacements* REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. course, very important to stop packing at the slightest in- dication of increasing or fresh local peritonitis. In the case of a feeble and nervous patient, it is necessary to be- gin with a light packing, making sure that you are doing no harm, and at the same time, holding the patient under strict and strong control, to push the treatment forward, packing tighter and tighter, until the uterus is forced into its normal position. No routine practice can be laid down for such cases. The packing must be removed before each menstrua- tion. The treatment is to be continued until the fundus uteri can be pushed well forward ; the uterus can then easily be held in position by a pessary. If, however, the adhesions are very resisting and the patient becomes somewhat run down by the treatment, a convenient time to rest is when the fundus has been raised just above the promontory of the sacrum. At this point the uterus can be held for a time with a Thomas bulb pessary, or with a soft-rub- ber bulb pessary (yide Fig. 4324). The pressure of the packing may cause constipation ; if so, the bowels must be regulated by a cathartic. As before stated, the packing acts by mechanically forcing the posterior vaginal cul-de-sac up into Douglas's fossa, and thus separating uterus from rectum. Some of the adhesions are torn off, others are so stretched and pulled that, being deprived of blood-supply, they finally wither and are absorbed. The packing is applied, as above stated, in the knee- elbow, or semi-prone position, when the contents of the pelvis are hanging forward into the abdomen and the vagina is at its greatest length. Consequently, when the upright position is resumed, we have a mass of cot- ton wedging its way up behind the fundus uteri, and the weight of all the organs tending to pull the cervix down- ward. These two forces twist the retroverted uterus into its normal position. The uterus, as above stated, having become passively congested, is large and tender. The packing exerts an even pressure against the organ, which partially empties it of blood, so that when the packing is removed the cer- vix appears smaller and wrinkled. The packing acts in this respect like a well-applied bandage on a swollen limb, and often gives the greatest relief. As the uterus becomes less congested and is raised higher in the pelvis, the attacks of perimetritis (before referred to) become less frequent and less severe, and finally do not recur. The carefully applied pressure seems also to exert a favorable influence on the inflamed peritoneal surface. The author has become so impressed by this fact that he often begins packing when there is considerable tenderness, and finds that this treatment is frequently much the quickest cure for chronic local peritonitis. In packing, every fourth or fifth plugget is dipped in iodoform to keep the cotton sweet. The patients may walk about during the treatment, for in this way the ad- hesions work loose faster. But certain debilitated cases should be kept in bed. The general health is usually somewhat pulled down during the treatment; or, on the other hand, it may often be improved by the immediate comfort caused by relief from dragging, etc. It is hoped that this manner of packing will not be confounded with the ordinary cotton pessary for sim- ple retroversion, or with the practice, which is not uncommon among physicians, of loosely placing a few tampons in the vagina. This sort of thing is, of course, entirely inadequate. The method here described is in- tended for the treatment of an important disease, and when really firm adhesions are present the packing must be delicately and understandingly applied, each bit of cotton being placed with precision ; otherwise it is worse than useless. Treatment by Forcibly Tearing up the Adhesions, under Ether.-There are certain cases which, for various rea- sons, are not well adapted to the method of treatment just described ; for such the following may be tried. The treatment by forcibly tearing up adhesions under ether at one sitting has been fully discussed by B. S. Schultze in an article in the Zeitschrift fur Geburtshulfe und Gynakologie, 1887, Heft I., Band xiv. By Schultze's method, after thoroughly emptying the bladder and rec- tum, the patient is placed in the dorsal position under ether. The index and middle fingers of the left hand are passed into the rectum to a point above the sacro-uterine ligaments. The thumb of the same hand is then passed into the vagina. The uterus is now pushed up out of the hollow of the sacrum until the fundus is above the promontory, when the fundus may be grasped by the other hand through the abdominal wall. The adhesions can now be palpated and broken. According to Schultze, they give way with surprising ease. The uterus may even be torn off from the rectum (see Fig. 4330). The Fig. 4330.-Manner of Forcibly Tearinsr the Adherent Uterus from the Rectum. (Schultze.) patient is kept quiet in bed with ice-bags on the abdo- men for several days after the operation. According to Schultze, the results of this procedure are good. This is certainly a valuable method, but it is probably not applicable to cases during active inflammation, or to cases in which the uterus is held by very strong, old ad- hesions. Erick, of Baltimore, also reports seven cases treated in this way. After tearing up the adhesions the uterus must, of course, be held in position with a pessary. This method, so highly recommended, has not received the sanction of gynaecologists, and is at present to be reserved for cases in which the uterus is held by a few old, and not sensitive, strands. Treatment by Laparotomy.-There are a few cases on record (seven or eight) which have been successfully treated by opening the abdomen and tearing or cutting the adhesions. In these cases the uterus has usually been stitched to the anterior abdominal wall. Polk, in the American Journal of Obstetrics, June, 1887, reports four cases. He placed a drainage-tube in Douglas's fossa to prevent recurrence, and he considers this the only relia- ble w'ay of treating such cases. Sanger and others also advocate the operation, but not the use of the drainage- tube. Schultze has proposed to open Douglas's fossa from the vagina, and in that way break up the adhesions and replace the uterus; then, enclosing the wound, to shorten the sacro-uterine ligaments, so as to keep the ute- rus in anteversion. The operation of opening the abdominal cavity and tearing up the adhesions is certainly a practical and use- ful procedure, but it should be reserved for the cases which suffer severe symptoms and cannot be cured by any other more mild treatment. When it is desirable to inspect or remove the ovaries or tubes by laparotomy (as will often happen in these cases, because diseases of the tubes so often cause retroversion with adhesions), the ad- 458 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. U terine Displacements, hesions should be broken up and the uterus raised and stitched to the abdominal wall. Literature. Schweighausen: Ueber einige phys. u. prakt. Gegenst. Nurnberg, 1817. Kiwisch: Beitr. z. Geburtsk. Wurzburg, 1848. Simpson : Selected Obst. Works. Diseases of Women. Edinburgh, 1872. Bennet: On Inflammation of the Uterus. London, 1840. Hodge: On Diseases Peculiar to Women. Philadelphia. 1860. Schroeder ; Handbuch der Krankheiten der Weiblichen Geschlechtsor- gane. Leipzig, 1879. Thomas : On the Diseases of Women. Emmet: Principles and Practice of Gynaecology. Hart and Barbour: Manual of Gynaecology. Graily Hewitt: Diseases of Women. American Edition. (Sims.) Winckel: Diseases of Women. American Edition. (Parvin.) Savage : Illustrations of the Surgery of the Female Pelvic Organs. Lon- don, 1863. Matthews Duncan : Diseases of Women. London, 1883. Schultze: Ueber Diagnose und Losung peritonaaler Adhasionen des retro- flectirten Uterus, etc. Zeitschrift fur Geburtshulfe und Gynakologie, 1887, I. Heft. Schultze: Sammlung klinische Vortrage. Volkmann, No. 176. Schultze : Centralblatt fiir Gynakologie, 1878, No. 11, and many others. Munde : The Curability of Uterine Displacements, American Journal of Obstetrics, October, 1881. Minor Surgical Gynaecology. New York, 1885. Huge ; Zeitschrift fiir Geburtshulfe und Gynakologie, B. II. 1878. Skene: American Journal of Obstetrics, vol. vii., 1884. Van de Warker: The Relation of Symptoms to Versions and Flexions, Transactions of the American Gynaecological Society, 1879. On the Normal Position and Movements of the Unimpregnated Uterus, Amer- ican Journal of Obstetrics, vol. x., p. 314. Foster: A Contribution on the Topographical Anatomy of the Uterus and its Surroundings, American Journal of Obstetrics, vol. xiii., p. 30. H. F. Campbell: Transactions of the American Gynaecological Society, vol. i., 1876. Sanger: Ueber operative Behandlung der Retroversio-flexio uteri. Cen- tralblatt fiir Gynakologie, Nos. 2, 3, 1888. Polk: American Journal of Obstetrics, June, 1887. Hadra: American Journal of Obstetrics, 1884, p. 365. Goodell: Lessons in Gynaecology, 1887. Alexander : The Treatment of Backward Displacements of the Uterus and of Prolapsus Uteri, by the New Method of Shortening the Round Ligaments. 1884. Alexander : The Results of the Experience Gained in Six and a half Years of the Operation of Shortening the Round Ligaments for Uterine Displacement. Read at the Ninth International Medical Congress. Annals of Gynaecology, No. 3, 1887. Kelly : Hysterorrhaphy, American Journal of Obstetrics, January, 1877. Hysterorrhaphy, American Journal of the Medical Sciences, May, 1888. Thure Brandt: Gymnastiken sasom botemedel mot kvinliga underlifs- sjukdomar, etc. Stockholm, 1884. (French Translation.) J. IF. Elliot. UTERINE DISPLACEMENTS: ALEXANDER'S OPE- RATION FOR THE RELIEF OF CERTAIN DISPLACE- MENTS. The history of the operation of shortening the round ligaments for certain uterine displacements has had its parallel in many departments of science other than medicine ; conceived with enthusiasm, forgotten with contempt, years later rediscovered, and made a suc- cess. To the French unquestionably belongs the first idea of the procedure. In 1840, Alquie, of Montpellier, presented to the Academy of Medicine in Paris a memoir entitled, " The Shortening of the Round Ligaments as a Remedy for Displacements of the Uterus." Alquie had before this brought himself into great unpopularity in the pro- fession by a book which he had written on " Conserva- tive Surgery." In this work he denounced the "great audacity " of certain operators, among whom were such surgeons as Dieffenbach, Recamier, Larrey, Lisfranc, and Dupuytren. The Academy referred the memoir to a committee, who, after long delay, pronounced the pro- cedure impracticable. Alquie never performed the op- eration upon the living, but demonstrated it satisfactorily upon the cadaver. Some years after, Aran, in his " Traite des maladies des femmes," referred to the idea of Alquie, but dismissed it as an operation which, if not impossible, yet presented serious difficulties and dangers. Twenty years after Alquie, the Belgian surgeon, Deneffe, advo- cated shortening the round ligaments for prolapsus uteri, and attempted a case which was a failure. Schultze in 1851, in his treatise on " Uterine Displace- ments," spoke of the operation, which he attributed to Aran. Walter Rivington, of London, has in his turn claimed the priority in a note published in the British Medical Journal of February 18, 1885. Therein he tells how, fifteen years before, he had a case of strangulated hernia in a woman who had also a procidentia uteri. In making the incisions for the hernia operation, he took occasion to draw out the round ligaments, and found that the uterus could by them be brought up to the pubes. But practically the idea had been laid aside until, in December, 1881, William Alexander, of Liverpool, shortened the round ligaments in a case of retroversion, and published in April, 1882, in the Medical Times and Gazette, his first article upon the subject. The proced- ure had occurred to Alexander as a practicable measure for the relief of certain cases in the crowds of suffering working-women who thronged his Workhouse clinic. The conception of the operation did not come to Alex- ander through any foreign suggestion. He distinctly says that he never heard of Alquie or Aran till after his success caused journalists to refer to them, and that he claims "absolute originality." For eighteen months previous to Alexander's first operation, Adams, Demon- strator of Anatomy in the University of Glasgow, had been publicly demonstrating to his students the opera- tion upon the cadaver, and in June, 1882, he published his first article. Hence arose the question of priority. But this has been practically settled in favor of the man who first successfully shortened the round ligaments upon a liv- ing woman, namely, Alexander, of Liverpool. Yet the French still call the operation the " Alexander-Adams." Anatomy and Physiology.-The chief agent in re- taining the uterus in position is the subperitoneal pelvic cellular tissue. This is made up of fibrous connective tissue with an addition of elastic and smooth muscular fibres, and is of special importance in its relations with the uterine blood-vessels. These latter portions are strengthened by additional trabecular filaments, so dis- posed as to support the vessels and defend them from the effects of sudden strain incidental to the various movements of the body. In the classical experiments of Savage, when he dragged the uterus down by vulsel- lum, the utero-sacral ligaments (regarded by Aran as the only true ligaments of the uterus) were the cause of the first arrest; and complete prolapse was only possible when the cellular-tissue connections with the pelvis and peritoneum had been forcibly separated. While in de- scent of the uterus the rectum does not usually follow the vagina, in the case of the bladder it is the reverse ; the alar mesentery also, because of its pelvic attach- ments, does not follow the vagina, though its base-line is much elongated. In descent of the uterus, the primary vascular trunks have to take a new direction, and are lengthened and straightened ; and were it not for the fibro-elastic structure of these cellular processes sur- rounding them, retention of reduced prolapse would be impossible. The utero-sacral ligaments hold the cervix to the pos- terior and upper part of the pelvis. When these liga- ments suffer relaxation or elongation, the cervix slips downward and forward, the fundus tips backward and descends. The round ligaments cannot be better described than as by Dr. Rainey, quoted by Mr. Adams from the "Transactions of the Royal Society''for 1882. "The so-called round ligaments of the uterus may be said to arise by three fasciculi of tendinous fibres : the inner, from the tendon of the internal oblique and the transver- salis, is near to the symphysis pubis; the middle fas- ciculus arises from the superior column of the external ring near to its upper part; and the external fasciculus from the inferior column of the ring, just above Gim- bernat's ligament. From these attachments the fibres pass backward and outward, soon becoming fleshy in the inguinal canal. They then unite into a rounded cord, which crosses in front of the spermatic artery. It then gets between the two layers of the peritoneum forming the broad ligament, along which it passes backward, downward, and inward to the anterior and superior part of the uterus. Here its fibres may be said to be inserted. After passing between the layers of the broad ligament 459 Uterine Displacements. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. to about the distance of an inch and a half from its su- perior part, the round ligament degenerates into fasciculi of granular fibres, mixed with long threads of fi bro-cel- lular tissue. Besides muscular fibres, the round liga- ments contain numerous vessels, nerves, and absorbents. The fibro-cellular tissue is in considerable quantity-so great, indeed, as to lead the superficial observer to over- look the presence of muscular fibres. It would be sup- posed that the muscular structure of the ligament would render it friable, but it has been found capable of con- siderable traction, drawing the fundus up to the external ring with no perceptible laceration. The tenacity is un- doubtedly due to the fibro-cellular constituents." Beunier (L'Union Med., 1885, xl.), from dissections on sixty-two subjects of different ages presenting normal or nearly normal conditions of the genital apparatus, as- serts that the round ligament exists constantly in all sub- jects. He has made trials of traction which prove that the round ligament offers a resistance relatively considerable. Drs. Wright and Polk have made careful tests of the strength of the round ligament (New York Medical Record, July 3, 1886). They found one ligament break at five pounds, having stretched to twice its length, while another was broken at four and three-fourths pounds. Observations show that the round ligaments are func- tionally of no great importance. In such of the lower animals as have the uterus above the pubes, as the dog and the sheep, the round ligament passes from the uterus to the last rib and aponeurosis of the diaphragm, drawing the uterus up and elongating the vagina. Vel- peau, Maygriers, and Rainey agree that this elongation facilitates the passage of seminal fluid toward the os uteri. In the human subject, " the function of the round ligament is generally agreed to be to prevent the fundus from being pressed too much backward, to aid in pre- venting the entire body from being prolapsed and resting with undue weight upon the rectum, and to facilitate the process of parturition by fixing and maintaining the ute- rus in due relation to the pelvis during the pains of labor." The contraction of the round ligaments during labor has been frequently observed (Sinclair). It is fur- ther possible that the round ligaments aid in preventing the gravid uterus from falling backward and pressing upon and obstructing the action of the lower intestine. Alexander tells us that when the natural resilience and coaptation of the surrounding organs fail, then the round ligaments are the chief agents in maintaining the normal position of the uterus. Alexander also reiterates the teaching that no displacement can take place so long as the axis of the uterus is at right angles to the axis of the vagina, and the small intestines fill up the compartments in front and behind the uterus and broad ligaments ; but that when a weakening or loss of the perineum occurs, the vaginal axis is first changed, and there occurs an ap- proximation of the axes of the uterus and vagina. The force of the intestines, which formerly kept the uterus right by impinging upon its posterior surface, now falls upon the top or anterior surface, pressing the organ with every inspiration into retroversion or prolapse. Alexander holds that by shortening the round liga- ments, not only is the uterus brought into normal posi- tion, but also the displaced broad ligaments, so that the intestines enter behind them, and the intra-abdominal forces drive the fundus toward the pubes. He claims that the new position demands really no more strain on the ligaments than the normal position ; that by natural straining they are rather released from tension than otherwise, because the fundus is now pressed toward the pubes ; and that it is only when abdominal pressure is relaxed, and in certain positions of the body, that any strain upon the ligaments takes place. Alexander asserts that, so far as purposes of strength are concerned, one ligament would be always sufficient; but, as he has shown on the dead subject, if one round ligament be pulled out we find the broad ligament on that side well placed, the uterus hanging away and the opposite broad ligament twisted backward. The intestines will fall behind the broad ligament and uterus on one side, and over the broad ligament and uterus on the opposite side; "one half tends to beat the womb down and the other half to sup- port it." " With both shortened, from both theoretical and practical experience, I believe that it is impossible for failure ever afterward to occur." Doleris does not agree with Alexander as to the anatomi- cal disadvantages of shortening one round ligament only ; indeed he advocates it, rather than drawing up both. His preference rests upon the action of the bladder when the ligaments are shortened. He believes that where there is cystocele, shortening the round ligaments, far from lessening it, actually increases it at first. Since the bladder cannot rise when distended, but must extend dowrnwTard as a subpubic pouch, or laterally, it is im- possible that this lateral or downward distention of the bladder should not finish by exercising a traction upon the neck of the uterus, tending to reproduce the displace- ment. This is, presumably, by the stretching of the round ligaments. Doleris is assured that one ligament sustains the uterus sufficiently, while it deviates the body to one side. Indications.-It is indicated to shorten the round ligaments for cases of 1. Retroversion and retroflexion which have resisted other means of treatment, and which may be reduced upon the sound. 2. Prolapse, especially of the third degree. Usually presenting also indications for the accessory operations mentioned below. 3. Anterior displacements of an extreme degree, either flexion or version, especially anteflexion combined with retroversion. 4: Ovarian prolapse. Suggested as a suitable indica- tion by Alexander and Kellogg, but entirely on theoreti- cal grounds. A careful examination, if necessary under ether, should decide whether any adhesions or contractions exist which would render throwing the uterus into anteversion a practical impossibility. If any such are found, the op- eration is contra-indicated. Though it has been done in spite of such conditions, the cases have generally been failures. Many cases of posterior displacement where a pessary could not be borne, though correcting satisfactorily the displacement, have been considered suitable for the op- eration, and have been greatly benefited thereby. Alexander felt that this operation was especially adapted for women of the working classes. Their life renders uterine displacements particularly distressing, and their persistent return for dispensary treatment shows their eagerness for relief. To women of this class an operation is less formidable than the indefinite bondage of a pessary. Among the higher classes, women of wealth and indolence, uterine prolapse is less fre- quent ; hence the suffering from displacements touched by this operation is less, and pessaries are more accepta- ble. Accessory Operations.-All authorities recognize the desirability of closing a fissure in the cervix if such exist ; of restoring the supports from below if the peri- neum be ruptured ; and where the cystocele or rectocele is extreme, of performing an anterior or posterior col- porrhaphy. It is desirable that any or all of these opera- tions should precede the shortening of the round liga- ments. The obvious inconvenience of making them sub- sequently hardly needs to be referred to. Some operators have successfully performed one or more of these acces- sory operations at the same sitting at which the liga- ments were shortened. But, as the latter proceeding is at best a somewhat prolonged one, it is not advisable, ex- cept in the hands of most dexterous surgeons, to attempt such a combination. Operation.-The preliminary preparation should be as careful as for a laparotomy. The bowels and bladder should be well emptied, and the best possible antiseptic precautions taken. After the patient is under the influ- ence of the anaesthetic, the pubic hair should be closely shaved. The usual antiseptic washing of the parts com- pletes the preparations for the incisions. The operator feels for the pubic spine as a guide to 460 Uterine Displacements. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the external abdominal ring. The incision begins just external to the spine, and is carried obliquely upward parallel to Poupart's ligament for two or three inches, more or less, according to the thickness of the layer of fat. Imlach uses a very short incision, one-half inch, but Alexander cautions against limiting so much the room to work in. On cutting through the superficial fascia, a few superficial veins will be opened. The upward and outward extension of the incision will meet the super- ficial epigastric artery, which, if cut, must be tied. It is generally unnecessary to extend the incision so far. The varying depth of fat is divided down to the apo- neurosis of the external oblique, whose glistening surface will be readily recognized. The tendon must be well cleared in the region of the ring, leaving a space in the centre of which is the opening with its pouching con- tents. Alexander says, " The chief point to insure suc- cess in finding the ligament is to expose well, in the first instance, the glistening tendinous pillars of the ring and its contents." A director is slipped under the mass issu- ing from the ring, and it is raised with the forceps. Upon its upper surface is seen the genito-crural nerve, which is sometimes mistaken for the round ligament. Alexander directs that as soon as possible the nerve be divided, as well as the fascial bands which bind it to neighboring tissues. The ligament usually lies beneath this bundle of fat, smooth muscular fibres, fascial fibres, vessels, nerves, and absorbents ; but sometimes it is found on top or in the middle. To extricate the ligament is now the delicate task. Gentle traction brings out the mass as far as is convenient. Then with forceps the tis- sues must be carefully teased apart until the fleshy, gray- ish-red cord is found. The ligament may often be iden- tified by a very tortuous small vein which runs upon its surface-the vein of the round ligament. The fleshy, reddish-gray form is the commonest type of the liga- ment ; but it may be a white, fibrous cord, or a bundle of small fibres connected by fat. It is this latter form which is usually not recognized in those cases where the " ligament could not be found." This form of the lig- ament is very friable. It is probably a state of fatty de- generation. The first form of the ligament usually grows larger as it is followed up the canal, or drawn out. Within the canal will be found, in close connection with the ligament, the prolongation of the peritoneum, the canal of Nuck. This must be carefully stripped away from the ligament as it is drawn down. If the ligament is not readily found at the external ring, it is advised to slit up the inguinal canal and search for it higher up. But to one who has carefully studied the dissection upon the cadaver (without which preparation no one should attempt the operation) it is rare not to find the ligaments readily. In old subjects they may be at- rophied, in some others they may be very small and brittle, but, according to Alexander as well as others, they are never absent. After freeing the ligament well on one side, a sponge wTet with the bichloride solution is placed on tlie wound. The incision is then made on the other side and the second ligament drawn out. An assistant now introduces the finger into the vagina and puts the uterus into anteversion. If there be a flexion, it is straightened on a sound, which is left in place until the ligaments are sutured. With the uterus thus held up, the operator pulls out both ligaments three to four inches, until the assistant feels the traction on the fun- dus, and knows that it is well up to the pubes. The se- cure fixation of the ligaments to the pillars of the ring is the next step. On the success of this part of the operation depends the freedom from danger from her- nia, which Alexander believes to be a real one ; and largely, the permanency of the new position of the ute- rus. Usually the ligament is sutured in with the pillars of the ring, and the slack disposed of in various ways, according to the fancy of the operator. It may be cut off, or packed into the wound ; carried to the median line and fastened over a plate above the pubes ; or thrust through the fascia and sutured to an incision in the me- dian line just above the pubes. Dr. Charles Carroll Lee urges strongly the desirability of suturing the ligament to the periosteum of the pubic spine. A method origi- nated by Dr. Robert Abbe, described at the Practitioners' Society and reported in the New York Medical Journal of March 17, 1888, commends itself as of special secu- rity. Dr. Abbe uses the slack of the ligaments to suture together the pillars of the external ring, or the sides of the inguinal canal if it has been slit up. If any part of the ligament is left in the wound for " padding," great care must be taken to see that it has not been bruised by manipulation. The external wounds are closed by deep and superficial sutures, and drainage-tubes are in- troduced. An antiseptic dressing with spica bandage is then firmly adjusted. A double lever retroversion pes- sary or an air pessary should be put in before the patient leaves the table. If a flexion exists the intrauterine stem will be introduced, to be left in place some time. After-tbeatment.- The conditions for which the operation is performed are almost invariably cases of long standing. The vascular changes, and the return to normal of the connective-tissue surroundings of the uterus, after it is fixed in its new position, will be events covering a considerable period of time. After-treatment must be applied in the light of these new conditions. The period of decubitus must be prolonged until the ligaments are firmly united to the pillars of the ring. According to Alexander, this time is usually about three ■weeks. It is still better to add a fourth week in bed, if the patient can be controlled. During this time in bed the uterus will be supported by a pessary or vaginal tampon. The second period may be called the period of involution. During this time the contraction and con- solidation of the subperitoneal pelvic connective tissue (if it has been a case of prolapse) is going on. If it has been a case of version or flexion, then again there must be an adaptation of the connective-tissue padding to the new position of things, a stretching in one place and contraction in another. During this latter period, which should be considered at least a year, it is now generally conceded that it is best to have the patient wear a pes- sary ; though Alexander retains the support only four months, and others dispense with it altogether. It is hoped always that primary union will be obtained in the wounds. If such is not the case, the incisions are to be treated like any suppurating wounds. Cases are re- corded where fistulous tracks have resulted, and also where an extension of the suppurative process has re- sulted in a fatal cellulitis or peritonitis. Patients must be cautioned against straining efforts, against coughing, excessive fatigue in walking or stand- ing, for at least six months ; and conjugal relations must not be resumed under two months. Results.-Alexander very suggestively refers to the results of the operation of shortening the round ligaments, as "anatomical successes," and "therapeu- tic successes." Some cases will be but one or the other, more will be both, and a very few will be neither. No record of results is of value under less than six months or a year after the operation. The anatomical results may be spoken of as both immediate and remote. The immediate anatomical success is to bring the fundus up to the pubes ; the remote anatomical success consists in its permanent retention there. Since the object of the operation is to alleviate the suffering caused by the dis- placement, the surgeon cannot feel satisfied, no matter how perfect anatomically the work may be, if the patient still contends that she feels no better. The therapeutic success occasionally requires some time to declare itself. It will depend upon the relief from the mechanical press- ure of the displacement, and upon the results of the altered conditions of the pelvic circulation. Upon these new circulatory conditions depend the involution in the uterus, the adnexa?, and the surrounding connective tis- sue. In some cases no relief follows the operation. This may be due to the presence of old adhesions which were not recognized, to the hopeless habit of pain, or to morbid changes in the nerve-trunks which are past re- pair. There are several cases on record where a laparotomy, some months subsequent to the operation, enabled the 461 Uterine Displace- Uterus. [mentM. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. surgeon to verify the position of the uterus. Dr. Polk had occasion, in one of his cases, to remove a large fibroid ten months after the ligaments were shortened, and found the fundus well up to the pubes. Dr. Abbe (New York Medical Journal, March 6, 1888) also had a case in which, six months after the operation, he opened the abdomen to remove the ovaries, and found the uterus in the position placed by the shortening of the round liga- ments. The anatomical failures, recorded so frankly by several operators, seem to be explained in some cases by an un- familiarity with the technique, and in others, unques- tionably by an elongation of the ligaments. There has been some disfavor shown the operation in certain quarters. It is not often performed in Germany. Winckel does not consider the results either particularly good or promising. He claims that in time there ought to be trouble from the anteversion. Smith (Can. Med. Rec., 1886, 7, xv.) believes that the good results come from the involution set up and the long rest in bed. He claims that the immediate anatomical result cannot be permanent, and that, if the shortening of the round liga- ments will not keep the uterus from rising during preg- nancy, it will not keep it from falling. Alexander's results (" Trans. Gynaecological Section of the Ninth International Medical Congress," 1887) are the most instructive to review, since he has performed the operation the greatest number of times. Since December, 1881, he has shortened the round ligaments in 84 cases. Of these 84, 1 died of pyaemia and peritonitis, while 4 others were too recent to be included in the statistics ; 35 were private cases, in only one of which was there trouble ; 31 of the private cases were for retroflexion and prolapse. Of these 31, 20 were anatomical and therapeutic successes, 5 were anatomical successes, 2 were anatomical successes and therapeutic failures, and 4 failed in both respects. Of the 4 failures, in one the recoil of the uterus drew the ligaments back before union had taken place ; in another non-union resulted from attempt to do without the drainage-tube. The hospital cases were 27 for retroflexion and 9 for prolapse. All of these were entirely successful as far as could be ascertained. In 12 cases the perineum was closed ; 2 cases of retroflexion became pregnant. Other writers have been less painstaking in recording results, and therefore an analysis of such records can be at best but imperfect. J. H. Kellogg (Annals of Gynaecology, Boston, Decem- ber, 1887) publishes 25 cases of Alexander's operation : For retroversion with prolapse of one or both ovaries, 15 cases ; for retroversion and retroflexion with prolapse of one or both ovaries, 6 cases ; for complete procidentia, 2 cases ; for anteflexion with retroversion and prolapse of ovaries, 1 case ; for extreme anteversion, 1 case. All these were extremely chronic cases. Two cases of pos- terior displacement were not perfect successes. Exten- sive adhesions existed in both, and in one, one of the ligaments could not be drawn out. One of the cases of procidentia was an anatomical and therapeutic success until an imprudence of the patient caused some re- turn of the displacement. The other cases were prob- ably all both therapeutic and anatomical successes. The author advocates the operation for prolapsed ovaries even when such indication alone exists. He believes that his case of anteversion is the only one on record. He notes the involution set up not only in the ligaments themselves, but also in the uterus and adnexa. Gardner (Australian Medical Journal, October 15,, 1886) reports 20 cases. Of retroflexion simply, 3 cases ; results perfect ; one became subsequently pregnant. Of retroflexion with prolapse of both ovaries, 8 cases, all perfect; one subsequently pregnant. Of retroflexion with prolapse of one ovary, 2 cases, perfect. Of retro- flexion with "malposition" of both ovaries, and marked signs of cellulitis, 1 case, perfect in result. Of retro- flexion with prolapse, 2 cases, both perfect anatomically as well as therapeutically. One of these had had three subsequent pregnancies, at the time of the report. Of procidentia, 3 cases ; one was the author's first operation, it was imperfectly performed and was both an anatomical and a therapeutic failure. One of the two remaining was a therapeutic but not an anatomical success. The third was perfect. In the twenty cases there were no deaths, and four afterward bore living children. The author concludes his paper by asserting that the radical cures for flexions are, first, pregnancy, and second, Alexander's operation. Imlach (Centralbl. fur Gyn., November 17, 1886) has done the operation 36 times ; 27 cases were posterior dis- placements, 11 were prolapse. All were good results except 2, which were not therapeutic successes. One patient who before operation had habitually miscarried, has since gone to term. Polk (New York Medical Record, July 3, 1886) pub- lishes the report of 15 operations ; 10 were for posterior displacements, 3 for procidentia, anti 1 for anteflexion with prolapsed ovaries. Of the posterior displacements, 6 were successful both anatomically and therapeutically ; 2 had adhesions, and were not therapeutic successes; 1 was perfect anatomically but not therapeutically, and a fourth one was a therapeutic success only. The one case of anteflexion with prolapsed ovaries gave a perfect result. Of the three cases of procidentia (the displace- ment which, in its relation to this operation, Polk says interests him most), 2 are reported as perfect results, and as to one, it is not specified. C. C. Lee (New York Medical Journal, March 3, 1888) has done the operation about nineteen times. He reports 3 cases of prolapse ; 2 of these were entirely successful ; but the third case, where the prolapse was complicated by a heavy subperitoneal fibroid, was not a therapeutic, though an anatomical, success. Reid, of Glasgow ("Trans, of the Ninth International Medical Congress," 1887) has operated thirteen times and is well satisfied with his results. At the Congress, Reid reported 8 cases, of which 6 were completely cured, 1 much improved, and 1 a therapeutic failure. He re- gards the dangers of the operation as hernia, relapse into former condition of displacement, peritonitis, and celluli- tis. Reid endorses the teaching that "correcting the position of a badly displaced uterus is the first step, and a very important one, in the permanent and thorough cure of the otherwise diseased conditions of that organ and the appendages." Strong (Boston Med. and Sury. Jour., February 16, 1888) reports 6 cases. Of these, 2 for retroversion with retroflexion were entirely successful ; of the remaining 4, which were for prolapse, 3 were also entirely success- ful. The round ligaments in the fourth case seemed to possess " some abnormal tendency to elongation ; " at the time of operating, seven inches were pulled out on each side, and six and a half months afterward the uterus be- came entirely procident again. Riasentsev (see discussion in "St. Petersburg Obst. and Gyn. Assoc.") describes 7 cases operated upon by Professor Slavjansky. One of prolapse with retrover- sion, and 3 of retroflexion, were successful. One case was not finished, for some reason not stated ; and 2 are recorded as unsuccessful, in what respects is not speci- fied. Burt (Annals of Gyn., Boston, December, 1887) re- ports 2 cases, 1 of retroversion and 1 of procidentia, both of which were eventually completely successful. The retroversion case felt but little better till after three months, and then began to improve rapidly. Winslow (Maryland Med. Jour., September 3, 1887) reports 3 cases, 2 of prolapse and 1 of retroversion, all entirely satisfactory. Munde (N. E. Med. Monthly, May, 1885), who was the first surgeon in this country to perform Alexander's operation, has recorded 4 cases. Three of these were retroversions, 1 retroversion and prolapse. Two cases were completely cured ; 2 were unsuccessful from "fail- ure to find the ligaments." Herman (Med. Times and Gaz., London, 1885) reports a fatal case. The displacement had been a procidentia, in a virgin. The wound communicated with the perito- neum, and the patient died of acute general peritonitis. 462 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Uterine Displace- U ter us. [ments. Lediard (Brit. Med. Jour., 1884) reported 4 cases of procidentia. In 2 of these cases the operator could find but one ligament; the other 2 were both anatomical and therapeutic successes. Miller (Glasgow Med. Jour., 1884, xxii.) has reported 2 cases of prolapse, both of which were cured. Macfie Campbell (Liverpool Med. and Chir. Jour., July, 1883), one of the early operators, reported 4 cases. Of 3 cases of prolapse, 2 -were completely successful, 1 failed from presence of adhesions. One case of extreme retro- version with prolapse was entirely cured. Fowler (Annals of Surg., 1886) records 2 cases of posterior displacement. One case of retroversion was an entire success, and six months afterward the patient be- came pregnant. The second case was retroversion with retroflexion ; the version was rectified, but not the flexion. As the previous dysmenorrhoea was relieved, this can be counted as a therapeutic success. In the New York Medical Uncord of March 3, 1888, I have reported 2 cases of procidentia, -whose results were entirely satisfactory. Conclusions.-A careful study of the anatomy of the parts, of the mechanics of the pelvic organs, and of the conditions of the pelvic circulation, cannot but interest the student of this operation ; and a thoughtful consid- eration of cases presented by competent and conscien- tious surgeons cannot but impress him with the genuine therapeutic value, in well-selected cases, of Alexander's operation. Bibliography. 1882. Alexander: Med. Times and Gaz. London, April, 1882. Adams: Glasgow Med. Jour., June, 1882. 1883. Alexander: Liverpool Med. Clin. Jour., iii., 1883. Campbell: Liverpool Med. Clin. Jour., iii., 1883. Gardner: Australian Med. Gaz., 1883-84. Lediard : Brit. Med. Assoc., August, 1883. 1884. Lediard: Brit. Med. Jour., i., 1884. Miller: Glasgow Med. Jour., 1884. Manrique: litude sur l'Op6ration d'Alex. Paris, 1884. Gardner : Australian Med. Jour., vi. Melbourne, 1884. Gardner: Glasgow Med. Jour., xxii., 1884. Allan : Brit. Med. Jour., June 7. 1884. Elder: Brit. Med. Jour., ii., 1884. Reid : Brit. Med. Jour., ii., 1884. Burton: Brit. Med. Jour., November, 1884. 1885. Durand-Fardel: Gaz. Med. Paris, January, 1885. Mass6: Gaz. Hebdom. des Sc. m6d. de Bordeaux, vi., 1885. Rivington: Brit. Med. Jour., i., 1885. Tissier: Rev. Obst. et Gyn., April, 1885. Alexander: Annals of Surg.. i. St. Louis, 1885. Soc. Clin, de Par.: France M6d., June, 1885. Mangiagalli: Gaz. d. osp., vi. Milano, 1885. Mangiagalli: Gaz. Hebd. d. Sc. m6d. de Bordeaux, 1885. Schramm: Centralblatt fur Gyn., ix., 1885. Munde : N. E. Med. Monthly, May 15, 1885. Alexander: Med. Press and Circ. London, 1885. Campbell : Liverpool Med. and Chir. Jour., July, 1885. Deneffe: Presse M6d. de Belgique, xxxvii. Bruxelles, 1885. Deneffe: Ann. Soc. de Med. de Gand, Ixiv., 1885. Obst. Soc. Edin.: Edin. Med. Jour., September, 1885. Alexander : Med. Chron., ii. Manchester, 1885. Herman : Med. Times and Gaz. London, 1885. Polk : Phil. Med. Times, xv., 1884-85. Sinclair: Edin. Med. Jour., September, 1885. Parrish : Am. Jour. Obst., September, 1885. Alexander : Brit. Med. Jour., ii., 1885. Zeiss: Centralblatt f. Gyn., 1885, No. 44. Alexander: Brit. Gyn. Jour., i. London. 1885. Doleris: L'Union M6dicale, November, 1885. Nancrede: Phil. Med. and Surg. Rep., 1885. Beunier: L'Union Medicale, xi. Paris, 1885. 1886. Polk: Am. Jour. Obst., xix., 1S86. Harrington : Boston Med. and Surg. Jour., 1886. Riasentsev: Russ. Med., iv. St. Petersburg, 1886. Schauta: Wien. Med. Bl., 1886. Polk: N. Y. Med. Rec., July3, 1886. Decaye: Nouv. Diet, de Mdd. et Chirurg. Prat. Paris, 1886. Fowler : Annals of Surg.. 1886. Dol6ris : Nouv. Arch. d'Obst. et de Gyn., i. et seq. Paris, 1886. Tillaux: Gaz. des Hdp. Paris, 1886. Heydenreich: Semaine Med., vi. Paris, 1886. Gardner : Austral. Med. Jour., viii., 1886. Keith : Trans. Edin. Obst. Soc , 1885-86. Mynter : Buff. Med. and Surg. Jour., xxvi., 1886-87. Smith : Canada Med. Rec., xv., 1886-87. Slaviansky : Verhandl. d. deutch. Gesellsch. f. Gyn., i. Leipzig, 1886. Zeiss: Same. 1887. Ashby : Maryland Med. Jour., xvi., 1886-87. Ashby : Obst. Gaz., x. Cincinnati, 1887. Ashby: Med. and Surg. Rep., Ixi. Philadelphia, 1887. Pozzi: Gaz. Med. de Paris, iv., 1887. Swift: Med. and Surg. Jour., cxvi. Boston, 1887. Bouilly : Bull, et Mem. Soc. de Chir. de Paris, xiii., 1887. Marchand : Rev. de Clin., 1887. Kellogg : Annals of Gyn., December, 1887. Winslow : Maryland Med. Jour., 1887. Collins: Trans. Col. Med. Soc., 1887. Burt: Annals of Gyn. Boston, December, 1887. 1888. Lee : N. Y. Med. Rec., March, 1888. Nammack: N. Y. Med. Rec., March, 1888. Practitioners' Soc.: N. Y. Med. Jour., March, 1888. Strong: Boston Med. and Surg. Jour.. 1888. Beunier : Gaz. des Hop., Ixi. Paris, 1888. Elizabeth Stow Brown. UTERUS, CONGENITAL MALFORMATIONS OF THE. Development.-The uterus is formed by the approximation and fusion of the middle portions of the Mullerian ducts. The upper portions remain distinct, constituting the Fallopian tubes, while the lower unite and form the vagina. A vertical partition separates at first those parts of the ducts of Muller which go to make up the uterus and vagina, but this subsequently disap- pears, and the two canals become one. At a later period in the course of development, at the lower end of the middle third of the tube thus formed, the cervix appears, dividing the genital canal into uterus and vagina. The tissues at the summit of the middle third and between the points of origin of the Fallopian tubes likewise thicken, and the fundus uteri comes into existence. The insertion of the round ligament separates the upper from the middle third. It is interesting to note that in the lower animals de- velopment regularly stops short at various points in the scale of progression, which ultimately ends in the forma- tion of that which in the human female is a perfected genital canal, so that what in the latter are termed abnor malities, in the lower animals are the normal characteris- tics. At birth the cervix is longer and thicker than the uterine body, and this state of affairs persists throughout childhood. At puberty rapid growth occurs, and this condition is reversed, the cervix then appearing as an ap- pendage to the body. By the twentieth year the genitalia have reached their full measure of development. General Etiology.-Congenital malformations of the uterus are owing to a non-appearance of the elements which go to make up this body, to an arrest in their de- velopment, or to their complete destruction by nutritive disturbances, pressure changes, etc. Classification and Nomenclature of Varieties. -The whole subject of congenital malformations of the sexual passages has been thrown into much confusion by the varying methods of arrangement and classification adopted by different authors, and still more so by the complicated and pedantic terminology that has been em- ployed. The same name has been given to different con- ditions, and the same condition has received different des- ignations. The classification and nomenclature which follows is that of Muller ; it is at once the simplest and the most comprehensive. I. Complete Absence of the Uterus : Defectus Uteri. Anatomy.-Complete absence of the uterus, a condition rarely met with in viable subjects, is by no means uncommon in monstrosities incapable of life. Whenever encountered, other evidences of a serious blow to the progress of development are almost always present in some portion of the genital apparatus. The individual, in voice, habit, and general conformation adheres to the female type, but the organs which characterize the woman may, alone or in combination, be entirely wanting, or else may exhibit all grades of rudimentary development. Thus, with absence of the uterus it may be impossible to discover any trace of ovaries, tubes, vagina, or mammary glands ; yet these structures may be present, though in a sufficiently undeveloped condition to render the proper 463 Uterus. Uterus. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. performance of the functions severally peculiar to them a matter of doubt or of impracticability. Still, though this is true only of those in whom life is possible, the re- maining organs characteristic of the female may be nearly a solid, fibrous mass, the size of a hazel-nut, located at the point normally occupied by the womb, may be all that there is to indicate an attempt at uterine formation. If development has proceeded a step further, a solid, narrow, flat, laterally extend- ed band composed of mus- cular tissue, with the tubes ascending and the round ligaments descending from it, may be encountered ; or a fibrous mass without a neck, and solid, but still having the general conformation of the uterine body, has been ob- served, from the upper angles of which the round ligaments originate and extend down- ward into the inguinal canal. In the uterus bipartitus, which exemplifies the next stage in progression toward the typical organ, two separate, round, solid, vertically placed bodies, composed of muscular and connective tis- sue, lie between the bladder and rectum. Occasionally these two bodies unite toward their lower extremities, forming a mass not unlike the cervix in shape, which is in immediate relation below with a rudimentary vagina, while above they still remain independent, like two di- Fig. 4331.-Rudimentary Uterus. (After Veit.) a, Fused but solid por- tion of the uterus; b, b, uterine horns; c, c, round ligaments; d, d, tubes; e, e, ovaries. Fig. 4334. perfect in their construction, and some, though rarely all, may correspond entirely with the normal type. The ex- ternal genitals have been observed to be either normal or poorly developed, and in adults occasional absence of the pubic hair has been noted. Etiology.-Defectus uteri is dependent either upon an entire absence or complete destruction of the median portions of Muller's ducts. Diagnosis.-The recognition of the abnormality under d'0'"100'™ °11'- rounded with the ut- most difficulty, and it is never warrantable to assume positively in a given case, even after negative results have been obtained from careful abdomi- no-rectal palpation, as- sisted by a sound in the bladder, that no traces of a uterus ex- ist ; for even upon the post-mortem table errors have arisen, and the rudiments of a bilobed uterus have been mistaken for the Fallopian tubes, or a hollow rudimentary uterus for the vagina. Treatment.-No treatment will, of course, be of any avail. II. Atrophy of the Uterus ; Uterus Rudimen- farius.-Anatomy.-Between defectus uteri and uterus rudimentarius there is often no very great hiatus in the scale of develop- ment, for the more decided forms of the latter malformation may be almost Fig. 4335. Figs. 4334 and 4335.-Rudimentary Uterus. (After Langenbeck.) b, Bladder; f, uterus-like body. Fig. 4332.-The Same, in its Relation to the remaining Pelvic Organs, u. Uterine rudiment. verging horns, and are usually solid, but may present a slight hollow enlargement lined by mucous membrane at or near the point of origin of the round ligaments. To this latter abnormality the name uterus rudimentarius bicornis has been given, although some prefer the term uterus rudimentarius bipartitus. With uterus rudimentarius, which is not confined to Fig. 4333.-Solid, Bow-shaped (Rudiment of a Uterus. (After Nega.) a, The ribbon-shaped uterine rudi- ment ; 6, b, round ligaments; c, c, oviducts; d, d, ovaries. Fig. 4336.-Uterus Rudimentarius Bipartitus or Bicornis. (After Rokitansky.) a. Vagina; b, tubes; c, ovaries; d, enlargement of the horn ; e, round ligaments: f, point of union of the two horns; g, cellular tissue traversed by muscle-fibres which simulate the uterus in form. indistinguishable from complete absence of the womb. Thus the presence of a slight indefinable thickening on the posterior surface of the bladder, or at the junction of the imperfectly developed broad ligaments, or again, of monstrosities, but occurs also in viable subjects, the ex- ternal genitals, vagina, tubes, ovaries, and mamma; may exhibit the same variations in structure which have been alluded to in speaking of defectus uteri. 464 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Uterus. Uterus. Etiology.-The cause which produces the rudimentary conditions just described operates during the very earli- est stages of foetal development, and as the exact time of its appearance and the degree of its activity vary, so a variation in results, though always within certain limits, will be observed. In defectus uteri the elements from which the uterine body is to be formed are wanting or have been obliter- ated, but in the present instance they have appeared, but have been more or less destroyed, at divers periods of their development, by nutritive disturbances of differing intensities. 11 should not be forgotten, however, that there may be growth of even the lowest rudi- mentary forms. Physiology ; Symptoms. - Al- though in ab- sence of the ute- rus and in atro- phy of the organ the general conformation peculiar to the female and her desire for the opposite sex are preserved, yet there is such an imperfect development of other or- gans that the functions characteristic of woman do not come into play at ill. The condition of the ivaries will determine the existence of ovulation. Menstrual moliminamay, but menstruation cannot, occur, and vicarious haemorrhages are rare. Sexual in- tercourse is possible when the vagina is not too seriously involved, and even then the urethra may be utilized for this purpose. Conception is, of course, impossible. Diagnosis.-It is not difficult to confound absence of the uterus with atrophy of the organ, when development has been arrested at a very early stage. Even on the most careful examination mistakes have been made by the most skilful among diagnosticians. In any doubtful case, to determine the presence or exact condition of the womb, the patient should be thoroughly anaesthetized, and the bladder and rectum should be empty. A sound or a silver catheter is introduced into the bladder , the finger of one hand is passed into the rectum, and the other hand is placed upon the abdomen ; the entire length of the ca- theter or sound can now be felt between the hands if no uterus, or only an ex- tremely rudimentary one, is present. Any solid mass lying in the median line between the rectum and bladder is probably a rudimentary uterus. The tubes usually occupy a somewhat lat- eral position, but may be mistaken for uterine cornua. The ovaries, by their sharply defined boundaries, size, shape, mobility, and situation can be more or less easily recog- nized. The more advanced forms of atrophic uterus are not difficult to map out, and, in any event, examination is often facilitated by palpation through the posterior blad- der wall, if the urethra has been dilated by previous at- tempts at cohabitation. Treatment.- If menstrual molimina occasion severe suffering, castration is a justifiable procedure. The ru- dimentary uterus has also been extirpated. III. Absence or Atrophy of the Cervix Uteri : Defectus Cervicis Uteri et Cervix Uteri Rudi- mentaria.- Anatomy.-Numerous grades of this de- formity may be encountered. The entire cervix is absent, or a solid fibrous mass or band replaces the normal struct- ure. When its formation is more perfect the internal os is alone closed, or the external os may be thus affected, or both may be occluded, while the cervical canal be- tween is partially or entirely patent. Atresia of the external os only, marks the slightest degree of this mal- development. The uterus above may be perfect in struct- ure or rudimentary. The vagina is normally developed, though occasionally the upper part of the canal may par- ticipate in the cervical atresia. Since obstruction is the essential accompaniment of absence or atrophy of the cervix, haematometra is the Fig 4338.-Schematic Diagram of an Infan- tile Uterus Unicornis Sinister, a, Cervix ; b, body ; c, apex of the uterus ; f, oviduct; g, ovary; h, lig. ovarii; i, round lig. ; k, parovarium. natural pathological sequence when menstruation occurs. Etiology.-In the more pro- nounced types of the deformity under discussion, and especially if other portions of the genital canal partici- pate in the existing mal-development, it is probable that there has been, at best, only an abortive attempt at cer- vical formation. But when the uterus, vagina, etc., are normal in structure and the cervix presents no very ag- gravated form of atresia, we must regard as the impor- tant etiological factor some nutritive disturbance origi- nating late in embryonal life, after differentiation of the genital canal has been effected by the appearance of the cervix. Physiology ; Symptoms.-If the ovaries and uterus are not arrested in development, menstruation will occur when puberty has been reached and haematometra ap- pears, accompanied at first with menstrual molimina, and later by almost continuous pain, by pressure-symptoms. Fig. 4337.-Haematometra with Atresia of External Os Uteri, a, Os exter- num ; b, os internum; c, accumula- tion of blood in the uterine cavity. (After Schroder.) Fig. 4339.-Uterus Unicornis Dexter. (After M. Duncan.) and by threatened rupture of the Fallopian tubes. If the uterus and ovaries are rudimentary, there will be no menstruation, and therefore no blood stasis. Sterility is an invariable accompaniment of any form of cervical atresia. Diagnosis.- Careful combined manipulation, performed as described in speaking of atrophy of the uterus, will reveal an absence or marked rudimentary condition of 465 Uterus. Uterus. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the cervix, while the failure to pass a sound or probe, or to find an opening in a neck apparently of normal struct- ure, will at once denote the existence of one of the less marked forms of cervical atresia. If hsematometra exists, fluctuation can be detected through the rectum, and perhaps through the ob structing membrane, if i1 be not excessively thick and resist- ant, as is likely to be the case when the upper part of the vagina is in- volved in the atre- sia. Treatment.- The plan of opera- tion suggested by Breisky, and de- scribed in detail in this Handbook under the head of " Vagina, Atresia of the," is espe- cially to be commended. This consists essentially in the puncture of the atresia at a point and in a direction to correspond with the usual seat of the external os uteri, a long-handled, lance-shaped knife guard- ed by a cannula being used. The original open- ing may be enlarged laterally after a portion of the fluid has been allowed to flow out, and the knife is then with- drawn. The wound is subsequently enlarged to any de- sired extent by dilat- ing forceps construct- ed for this purpose. The cannula may be then removed, and if it is not possible to cover the cut edges with mucous mem- brane, a plastic opera- tion of no little diffi- culty, a silver drain- age-tube is inserted and retained to pre- vent subsequent accu- mulation within the sac, and to admit of antiseptic irrigation. Great care should be exercised not to puncture the bladder, rectum, or perito- neal cavity, and although the operation should always be completed at one sit- ting, the retained fluid should be evac- uated with great deliberation. If the blood be too rapidly withdrawn, rupture of the tubes may ensue, a most unfortu- nate and dangerous accident. With adequate drainage, and if need be, antiseptic douches, septic infection from stagnation and decomposition of fluid need not be feared. Repeated dilatation of the artificial canal will be necessary to prevent con- traction and closure. In the simpler forms of atresia, similar, though less elaborate, procedures will suffice. An operation looking to the establish- ment of a passage between the vagina and uterus is jus- tifiable in some cases when the patient desires to become pregnant. Even a poorly developed uterus has been known to increase in size after such an attempt, aided perhaps by subsequent treatment. But if the womb is hopelessly deformed, or if the ovaries are implicated, no result will be achieved. IV. The One-horned Uterus : Uterus Unicornis : Uterus Unicornis sine ullo Rudimento Cornu Al- terius.-Anatomy.-When the uterus is one-horned the cervical is larger than the corporeal portion, and the lat- ter consists of a long, tapering, arched, or bow-shaped cone, situated laterally or lying obliquely in the pelvis, from the apex of which spring a Fallopian tube, a round ligament, and an ovarian ligament supporting an ovary. In the purest form of this anomaly no trace of the other horn, or of the tube, round ligament, ovarian liga- ment, ovary, or broad ligament of the corresponding side is to be found. Occasionally the one-horned uterus is solid. Although uterus unicornis may be the only rudimen- tary condition discoverable in a given case, yet the va- gina is often narrow, and in the more pronounced types of this anomaly one-half of the whole genito-urinary ap- paratus is occasionaily found to have suffered in its de- velopment. Etiology.-In uterus unicornis without a rudimentary second horn, it is probable that only one Mullerian duct has ever been formed. Physiology ; Symptoms.-Although the one-horned ute- rus differs in shape, size, and position from the normal uterus, yet when hollow it possesses such anatomical es- sentials as enable it to perform all the functions which pertain to that organ. Menstruation, conception, and pregnancy occur without hindrance, and even twins have been delivered from a one-horned womb. On account of somewhat deficient, muscular development, it might be surmised that rupture of the uterus would be readily in- duced during the throes of labor. Such is not usually the case, although, if the muscular structure of the organ be weakened and displaced by the growth of placental vessels, such an accident during parturition is not im- probable. The muscular hypertrophy accompanying the first pregnancy assists the uterus unicornis in the part it has to play in those occurring subse- quently. Diagnosis.- Uterus unicornis is easily rec- ognized on careful ex- amination, a sound being intro- duced into the uterus and one examining finger into the rectum. Even when impregnated its shape and oblique position may be pre- served ; but the normal organ is not uncommonly deflected to the side at this period, and the one- horned uterus may be so broad- ened by the physiological hyper- trophy of pregnancy as to lead to some confusion in diagno- sis. Treatment.-It is not unlikely that appropriate treatment will produce an enlargement and strengthening of the muscular structure of the one-horned ute- rus, and this is a very desirable end to be achieved when we con- sider the possible danger of rupt- ure during parturition. When rupture at this period is threat- ened, labor should be expedited by artificial means, if necessary, and at the same time the risk of post-partum haemorrhage should be held in mind and proper contraction of the organ se- cured. V. The One-horned Uterus with Atrophied Sec- ond Horn : Uterus Unicornis cum Cornu Rudimen- Fig. 4340.-Ruptured Uterus Unicor- nis. a, Left tube; b, left ovary ; c, broad ligament; d, rectum; h, ut. rudimentarius dexter; i, right ovary ; k, perforation, (After Mol- denhauer.) Fig. 4341.-Uterus Unicornis, with Atrophied Second Horn. (After Rokitansky.) 466 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Uterus. Uterus. tario : Uterus Unicornis Excavatus cum Rudimen- to cornu Alterius Solido s. Excavato.-Anatomy.- On the convex side of an obliquely inclined uterus uni- cornis there may be found a rudimentary second horn, which exhibits in different cases various degrees of im- perfect development. A solid muscular cord, or band, unconnected with the ovary above or the other horn be- low, is sometimes observed, but occasionally this is ex- and as the round ligament cannot be mapped out with any certainty, it will remain a matter of doubt whether the ovum has been implanted in the Fallopian tube or in the rudimentary horn. Treatment.-In this condition active interference is in- dicated only when there has been considerable blood stasis in the rudimentary horn and rupture or other dan- gers threaten, or when the horn offers a mechanical im- pediment to delivery, or is itself the seat of pregnancy. Accu- mulated blood may be evacuated by trocar puncture through the vaginal vault, although in some cases laparotomy and drainage, or entire removal of the sac, will be the more judicious procedure. The rudimentary cornu, which makes labor tedious or impos- sible, may be elevated above the parturient canal by vaginal manipulation combined with the assumption of the Sims or knee- chest position. Still, in some cases mutilating operations upon the foetus have been found necessary when the ovum has been implanted in the atrophic horn. Porro's operation may be performed with, as statistics show, fair chances of success. VI. The Two-horned Uterus : Uterus Bicornis.- Anatomy.-Next above the uterus unicornis with a rudi- mentary subsidiary cornu, is placed, in the scale of devel- opment, the uterus bicornis. Various degrees of this latter rudimentary condition are described. In the lowest and most imperfect forms there are two separate and distinct hollow uterine bodies, projecting laterally like horns, which unite below in a common cervix, deeply furrowed before and behind. Again, the union is more complete Fig. 4342.-Uterus Unicornis, with Atrophied Second Horn. (After Schroder.) panded at the upper extremity, is hollow, and commu- nicates with the tube alone, or with the better developed cornu below, or with both, although it may be closed at each extremity. Etiology.-In this condition both Mullerian ducts have appeared, but one has been more affected in its develop- ment than the other by causes, of a nature already de- scribed, operating early in embryonal existence. Physiology ; Symptoms.-The functions which a rudi- mentary cornu attached to a one-horned uterus is capable of performing depend, of course, upon the degree of its development. If it is hollow and its inferior extremity is patent, menstruation may occur, though not so early nor in so great quantity as from the more perfect horn. But if there is no opening below, a slowly developing haematometra will result, and perhaps a haema tosalpinx as well. When pregnancy occurs, it is usually in the more typically formed cornu, and utero- gestation is quite normal, and parturition also, except when, as sometimes hap- pens, the rudimentary horn offers a mechanical obstacle to its accom- plishment. It is quite possible, however, for the product of conception to be implanted in the rudimen- tary horn, especially if a com- munication exists between it and the vagina through the nor- mal cornu. When there is no such communication, a like re- sult may be accomplished by the processes known respective- ly as transmigratio ovuli externa and transmigratio semi- nis externa. When pregnancy does take place in the atrophic horn, this enlarges up to a certain point and then ruptures, usually between the second and fifth month of utero- gestation, death usually ensuing, although encapsulation of the foetus may occur and recovery take place. Still, pregnancy may go on to full term without interruption. The normal horn participates to a certain extent in the changes incident to pregnancy, and a decidual membrane forms within its cavity. Diagnosis.-The existence of a conical arched body, with a mass more or less like itself springing from its convex surface, will convince the examiner that he has to do with a one-horned uterus with a rudimentary sec- ond horn, although a pedunculated subperitoneal fibroid may closely resemble the atrophic cornu and be mistaken for it. When pregnancy occurs in the poorly developed horn the symptoms will all be those of extra-uterine foetation, Fig. 4343.-Pregnancy in a Rudimentary Uterine Horn. (After Jaensch.) A, Right well-developed horn ; c, vagina ; d, round ligament; e, tube ; f, ovary; B, left rudimentary horn ; d', round ligament ; c', tube; f, ovary; C, band connecting two horns; k, canal: D, placenta; s, fold between B and D; ch, piece of chorion with infarct and probable point of rupture. and a sulcus is found only on the external aspect of the fundus, indicating the point of coalescence of the two cornua, while the rest of the body and the cervix, though unusually broad, show no furrowing of their outer sur- faces. This condition has been variously termed uterus arcuatus, uterus introrsum arcuatus, and saddle-shaped uterus. When the fundus shows no furrow, but is flat-the next step in advance-the designations uterus 467 Uterus. Uterus. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. triangularis, uterus incudiformis, and uterus plani-fun- dalis have been employed; In all forms of the two- horned uterus one side of the organ is apt to be larger than the other, and the left horn, as in the normally de- veloped organ, lies a little farther forward than the right. A partition wall more or less complete may di- Etiology.-When coalescence of the middle portions of the Mullerian ducts is only partial, uterus bicornis will result, and the degree of de- formity will de- pend upon the extent of fu- sion. The rec- to-vesical liga- ment undoubtedly plays an important part in the genesis of this rudimentary condition. This liga- ment, as its name implies, stretches from the anterior surface of the rectum to the posterior sur- face of the bladder, and lies in the furrow on the fundus uteri. Its origin is somewhat doubtful. Winckel suggests, from a study of a case of his own, that its formation is due to an unfold- ing of the peritoneum before the upward-growing uterus. He examined the tissues of the ligament microscopically, but could find no muscular fibres. Physiology ; Symptoms.-The uterus bicornis may, in the performance of the functions pertaining to the nor- mal womb, act like two independent organs. Thus, while menstruation may occur simultaneously from the two cornua, it is not unusual to see them alternately per- forming this function, and a periodical flow may con- tinue to escape from one cavity after pregnancy has oc- curred in its fellox^. If one side is occluded (bilateral atresia has never been observed), hydrometra or hsemato- metra develops slowly, and here, as also with pyometra, rupture of the sac may take place and its contents be discharged into the vagina, into the better developed cornu, or into the abdominal cavity. Haematosalpinx is a frequent and early source of danger. A considerable number of pa- tients with two-horned uterus never conceive, but this is not due to the condition of the uterus, but rather to the fact that intercourse is car- ried on in the larger and occluded half of the accompanying divided vagina. Either half of a two- horned uterus may become gravid, the other horn participating in the subsequent hypertrophic and de- cidual changes. The foetus may lie largely in one cornu while the placenta is adherent to the inner surface of the other. Sometimes pregnancy occurs first in one and then in the other horn, and in twin pregnancies, which are not un- common, both ova may occupy the same or each dif- ferent cornua. The presentation varies largely with the grade of the rudi- mentary condition: in uterus bicornis septus and uterus bicornis unicollis, the vertex ; with a common uterine cavity, the breech; in uterus arcua- tus unicorporeus, transverse presen- tations are ' com- mon. During labor, contractions may occur simul- taneously in both horns of the uterus, or the empty horn may play an entirely passive part in the process of de- Fig. 4346.-Anvil-shaped Uterus. (After Oldham.) vide the cavity of the uterus bicornis. The entire womb may be thus sepa- rated into two parts (uterus bicornis septus), or the body is divided while the horns remain dis- tinct (uterus bicor- nis unicorporeus), or the body is double and the cer- vix single (uterus bicornis unicollis). Still in many cases no pronounced par- tition is discoverable, though bands of tissue may run from the anterior to the posterior uterine wall, or a prominent ridge on the interior of the uterus may show an attempt at division. With Uterus bicornis, although the vagina is often found divided, the remaining elements of the genital system are usually perfect in development. Sometimes, very curi- ous to say, the face, thorax, and pelvis are broadened, as if to correspond with Fig. 4344.-Uterus Bicomis. (After Hunke- moller.) wr, Urethra ; «, u, entrance to the urethra; vag and vagu, entrances to vagina. The anterior wall of both vaginae has been removed. Fig. 4345.-Uterus Bicornis. r, Rectum : ur, the only ureter; c, V, constrictor vaginae ; gl. B, glands of Bartholin ; cl, clitoris. (After Delle Chiaie.) the unnatural width of the uterus. When one-half of a two-horned uterus is conspicuously behind its fellow in development, it is not unusually occluded : this is more frequent on the right than on the left side, and the atresia may be seated in the cervix or at the external os uteri. Fig. 4347. - Hydrometra Lateralis. (After Breisky.) a. Patent horn ; b, occluded and distended horn. 468 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Uterus. Uterus. livery. In twin births contractions of the two horns alternate, and delivery from one may be accomplished rupture of a tubal blood-sac are to be feared. Puncture of the sac is best made at its most dependent part. Mul- ler observes that when the head during delivery is im- peded by the recto-vesical ligament, the correction of the obliquity of the pregnant horn, or placing the patient on the side corresponding to the nonpregnant half of the womb may suffice, but if not, podalic version and ex- traction should be attempted. Obstructing septa or bands may be pushed to one side or divided. VII. The Two-chambered Uterus : Uterus Bilo- cularis : Uterus Septus, Subseptus, or Uterus Septus Duplex.-Anatomy.-The twro-chambered ute- rus is an organ rather broader than normal, but of per- Fig. 4348.-Uterus Bilocularis Unicollis. (After Grauel.) a, Vagina; b, single os externum; c, septum ; dd, both loculi; e, fundus. much earlier than from the other. In- dependence of action between the two cornua is observed most characteristic' ally when independence of structure is most marked. The course of utero-gestation and of the puerperium in individuals with ute- rus bicornis is usually uneventful, but labor is apt to be tedious, difficult, or dangerous. The non-gravid horn, the recto-vesical ligament, or the septum dividing uterus or vagina, may oppose barriers to the exit of the child which are difficult to surmount. Death from exhaustion is apt to ensue, and rupture of the lower uterine segment has been observed. In nearly every case some operative interference is called for to insure safe and rapid delivery. Pla- centa previa is by no means uncommon, and post- partum haemorrhage is to be feared when the placenta is attached to the uterine septum. Diagnosis.-When, from great breadth of the ute- rus or the presence of a divided vagina, uterus bicor- nis is suspected, a correct diagnosis is often arrived at by the introduction of two sounds into the womb. When their points cannot be approximated low down in the uterine cavity a partition is usually present, and if after further introduction they diverge markedly toward the respective sides of the pelvis, they have probably en- tered the independent cornua of a two-horned uterus. feet outward form except that there is usually some dis- parity in size be- tween the two sides. A partition more or less perfect divides its cavity into two lateral portions. If this dividing wall extends from the fundus downward only for a short dis- tance into the body of the womb, we have the sub-variety of uterus bilocularis known as uterus bilocularis unicor- poreus or uterus sub-septus unicor- poreus ; if to the level of the internal os, the designation uterus bilocularis unicollis, or uterus subseptus unicollis is employed ; if to the external os, uterus bilocularis sep- tus sive compietus ; when the partition extends only so far into the cervical canal as that there is but one exter- nal opening (os) common to both chambers, the condition is termed uterus subseptus uni- foris. The name uterus biforis supra simplex indicates that a septum is situated only in the neighborhood of the external os and that the cavity above is single. Occasionally ihe uterine partition is continuous with a septum dividing the vagina in- to two lateral chambers. As in other varieties of duplex uterus, the dividing wall is not always perfect in its structure, but may contain one or more perforations. Atresia of one chamber has been observed but rarely. Etiology.-As would be supposed, this malformation is referable to the same period of intra-uterine life as uterus bicornis, or perhaps, better, to a slightly later time in the same period. The causes of the two anoma- lies are the same. The fusion of the Mullerian ducts has been complete, but the partition wall has only par- tially disappeared, or else persists throughout. Physiology ; Symptoms.-The two-chambered uterus, in so far as menstruation, conception, pregnancy, and de- livery are concerned, in no way differs from the two- horned uterus. Diagnosis.-On bimanual examination the uterus is found to consist of a single, somewhat broadened body, Fig. 4350.-Pregnant Uterus Bilocularis. (After Cru- veilhier.) a, Right horn ; ft, left horn ; c, external os; d, vagina ; e, tubes; /, ovaries. Diagnosis is facilitated also by the various combined methods of examination, and is especially easy when, after labor, the finger can be introduced through the dilated cervical canal. Treatment. - The same rules governing the opera- tion for the evacuation of fluid retained in the rudi- mentary cornu attached to a one-horned uterus, apply when a like result has fol- lowed unilateral atresia of a two-horned uterus, and the same complications originating in imperfect drainage and Fig. 4349. - Uterus Bilocularis. (After Liepmann.) 469 Uterus. Uterus. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. VIII. The Double Uterus : Uterus Didelphys; Uterus Duplex Separates : Uterus Diductus.-Anatomy.-In non-via- ble monsters, and occasionally in subjects capable of life, two uteri are sometimes while two sounds introduced into its interior are prevented from touching by the dividing wall. With all the facil- ities at our com- mand it is safe to say that, in the living subject, it is not possible to differentiate the two-chambered uterus from the least rudimentary forms of the two-horned organ. Treatment.-During labor, as in the uterus bicornis, the Fig. 4353.-Uterus Didelphys. (After Meckel.) a, In- verted bladder; b. small intestine opening out into a broad pocket; c, opening of this pocket forward; d, caecum ; d', rest of small intestine ending blindly ; e, vermiform appendix; f, right vagina and uterus opened : g. left vagina and uterus; A, openings of the vaginae into the bladder ; i, both kidneys; k, openings of both ureters in the bladder. found quite distinct and independent of each other in all their parts, and separated, some- times widely, by the recto-vesical ligament, s removed. urachus, bladder, and rectum. Each uterus is of a cylindrical or conical shape, is con- tinuous above with a Fallopian tube, and terminates be- low in a cervix. The presence of other grave anomalous conditions shows that quite a severe blow has been struck Fig. 4351.-The Same, Front View. Anterior walls removed. Fig. 4352.-Puerperal Uterus Bilocularis. (After Spilth.) a, Right loc- ulus which contained the ovum ; b. left, empty loculus ; c, sound ; d, right vagina ; e, left vagina ; f, partition wall of the uterus; g, septum of vagina. septum may interfere with the process of expulsion, and manual or instrumental assistance is occasionally re- quired. Fig. 4354.-Alleged Uterus Bicornis. (After Eisenmann.) a. Double vaginal inlet with double hymen ; 6, meatus urinarius ; c, clitoris ; d. urethra; ee, vaginae ; //, orificia uteri: gg, cervices; hh, bodies and horns of the uterus; it, ovaries; kk, oviducts; ll, round ligaments ; mm, broad ligaments. 470 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Uterus, Uterus. Etiology.-Before the eighth week of embryonal life, when as yet there has been no approximation or fusion of the Mullerian ducts, certain of the abdominal or pel- vic organs, among which are the bladder and intestine. Fig. 4357.-Uterus Bicbrnis with Pronounced Recto-vesical Ligament. (After Schatz.) e, Vagina with a septum; c.d, right horn: c.«, left horn ; i, piece of intestine lying between the horns ; lig, ligament rec- to-vesicale. force their way between the ducts and prevent their union. The recto-vesical ligament is also, no doubt, an important etiological factor. As a result of this interpo- sition the formation of a single uterine body is ren- dered impossible. Physiology ; Symptoms.- In double uterus the men- strual discharge does not seem to alternate between (luring the progress of devel- opment. Thus the cervical portions may end in the blad- der, rectum, or cloaca, or in the respective halves of a sep- tate vagina, which themselves terminate in these cavities. The uteri also may be solid throughout or a limited atresia of either organ may be present. Fig. 4355.-Uterus Didelphys. (After Heitzmann.) Fig. 4358.-Double Uterus with Ligamentum Recto-vesicale. (After Cassan.) ut.d, Right uterus ; ut.», left uterus ; ov, ovaries; c, cysts; lig.r.v, ligament recto-vesicale. the two cavities. Either may be occluded, and either or- gan or both simultaneously may become gravid. Diagnosis.-In the recognition of the rudimentary con- dition under discussion, it has been truly said that the pres- ence of two vaginal portions are of the utmost diagnostic value ; for since the tubes which coalesce to form the mid- dle portion of the genital tract unite from below upward, two cervices predicate two independent uterine bodies. If a sound is introduced into each uterine cavity, a fin- ger inserted in the rectum can be pressed forward in a straight line without coming in contact with either uterus. Fig. 4356.-Completely Separated Uteri and Vaginae with Ectopia Vesi- cae. (After Frankel.) ut.d, Right uterus and vagina ; ut.sin, left uterus, vagina laid open and external os apparent; il, a piece of small intestine ; r, occluded rectum lying between genital passages ; a, sin- gle umbilical artery ; v, umbilical vein ; u, left ureter. 471 Uterus. Uterus. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Treatment.-Retained menstrual blood is to be evacu- ated, and any obstacle offered to delivery is to be over- come by methods which have already been described. IX. Faulty or Deficient Development of the Uterus : Hypoplasia Uteri.-Anatomy.-Under this head are grouped a large number of associated condi- same relative proportion to each other as in the per- fectly developed uterus, but the whole organ perhaps is still deficient in size and possesses walls of abnormal thin- ness, while the plicae palmatae pass well up into the cavity of the corpus (uterus infantilis). All these forms are closely allied with one another, and with the least pro- nounced types of congenital malformation on the one hand and the normal adult uterus on the other. The term hypoplasia uteri may be used to include them all. As a rule, some of the remaining elements of the genital system show slight errors in develop- ment, and the ovaries are not infrequently ru- dimentary, or are some- times entirely absent. The heart and the rest of the vascular apparatus may likewise be unde- veloped. Etiology.-Hypoplasia uteri cannot with justice be called a purely con- genital condition. It is true that during the final months of embryonal life injurious influences, such as constricting pe- ritoneal adhesions, may prevent a uterus almost completely formed from attaining anatomical per- fection. But unhealthy systemic states (associated with disease of the vascular or nervous system) during infancy or childhood, and lack of ovarian stimulation when these glands are absent or rudimentary, may bring about a like result. Physiology ; Symptoms.-It is the condition of the ovar- ies rather than that of the uterus which determines largely the nature and degree of the disturbances which accom- pany hypoplasia uteri. Menstruation may not appear at all, or may be scanty, irregular, and painful; and preg- nancy, when it takes place, is not unlikely to end in abortion. Diagnosis.-If, upon examination, the uterus is found to be less than two inches in length ; if the cervix is larger than the body ; and if the uterine walls are thin and membranous, even with a cavity which measures a Fig. 4359.-Uterus Didelphys with Haematometra Lateralis. (After Staude.) Fig. 4361.-Foetal Uterus, Natural Size. (After Kussmaul.) tions, in all of which the uterus is fairly well developed, but has not quite reached the type of structure usually found in adults. Thus it may retain in later life the characteristics of the organ as found at the time of birth (uterus foetalis), when the cervix is large and the body small, the whole possessing the shape of an anvil, while often an extreme degree of cervico-corporeal anteflexion exists. Again, it may be developed yet a little further, and though still unnaturally small, with thin walls, the body and cervix are of equal size, or the former is some- little over two inches, the condition is one of hypoplasia ; though we should be careful to exclude uterus uni- cornis before express- ing a final opinion. Prognosis. - In many cases a hypo- plastic uterus will of itself, or in conse- quence of appropriate treatment, or of preg- nancy, take on further growth, and ultimately attain normal proportions. Treatment.-When the general condition is good ; when the ovaries are present and are not excessively atrophic, and when the uterus is not too small, much can be done for the relief of amenorrhoea, or dysmenor- rhoea with scanty menstruation, by the employment of the well-known local uterine irritants, and if these fail and suffering is excessive, castration in suitable cases should be resorted to. Fig. 4362.-Primary Atro- phy of the Uterus. (After Virchow.) Fig. 4360.-Uterus Didelphys with Haematometra Lateralis. (After Staude.) what larger than the latter (uterus pubescens; congen- ital atrophy or hypoplasia of the uterus). The walls are occasionally excessively thin and membranous (uterus membranaceus). The body and cervix may exhibit the 472 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Uterus. Uterus. X. Slighter Developmental Anomalies of the Uterus.-1. Obliquity of the Uterus; Obliquitas Uteri quoad Formam.-From deficient development of one Mullerian duct, and from the traction exerted by a broad ligament shortened by foetal inflammation, one side of uterus may either open into the cloaca, or have faulty communications with different portions of the urinary system, or with the rectum. A case is on record in which one side of a uterus bipartitus opened upon the ex- ternal surface of the body. 6. Premature Uterine Development.-Along with the breasts and the organs peculiar to the female, the uterus is occasionally found pre- cociously developed, and menstruation occurs pre- maturely. 7. Hernia Uteri.-The uterus, along with a pro- lapsed ovary, has been known to descend into a congenital inguinal her- nial sac, and to become pregnant in this peculiar situation, Caesarean section being thereby necessitated. Literature. Muller: Entwicklungsfehler des Uterus, Deutsche Chirurgie (Billroth and Luecke), 55, 194. Stuttgart, 1885. Winckel: Diseases of Women, 215. Philadelphia, 1887. Hart and Barbour : Manual of Gynaecology, 243. Edinburgh, 1886. Garrigues: Congenital Malformations of the Uterus. A system of gynaecology by American authors. 8vo. Philadelphia, 1887. George Woodruff Johnston. UTERUS, CERVIX OF, DISEASES AND INJU RIES OF. Diseases of the Cervix Uteri. Atrophy of the Cervix.-True atrophy of the cervix as a disease of early life is rare. Super-involution of the cervix, as an accompaniment of super-involution of the uterus following child-birth, is occasionally seen, being then apparently the early taking on of normal senile atrophy. In none of these cases have histological examinations been made, but it is probable that there is simply de- crease in the fibro-muscular elements. The symptoms are entirely negative. Treatment should be directed to the restoration of the normal size of the uterus. The employment of the mild galvanic current is useful, the positive pole resting in the cervix, the negative being a broad abdominal pad placed just above the pubes. The current should be barely percept- ible to the patient; it should be continued for fifteen min- utes, and repeated every three or four days. The faradic current may also be employed in a similar manner for a shorter time. Stimulating applications, iodine, the pas- sage of a sound, and even the wearing of an intra-uterine stem pessary, may be practised. Senile Atrophy of the Cervix.-Coincident with the meno- pause, a retrograde change should take place throughout the whole reproductive tract. The uterus, as a whole, becomes much smaller. There is a decided change in the shape and character of the cervix, the vaginal portion loses its full, round contour, and becomes more sharply conical, reverting in this to the infantile type. It diminishes materially in size, often being felt no larger than a small marble. With the disappearance of its muscular structure it loses its distinct form, so that it often is with difficulty distinguished from the sur- rounding vaginal walls. There being narrowing of the vagina and obliteration of the anterior and posterior culs- de-sac from the same cause, the cervix is frequently found marking the upper termination of a narrowing- tube-a position which under ordinary circumstances is of no importance, but which, in those rare conditions which require the adjustment of a pessary, becomes a matter of serious consequence. The membrane covering the external, that is the vaginal, portion of the cervix shares in the changes of the rest of the vaginal lining mem- brane, losing its uniform, clear, pinkish coloration, and becoming pale and anaemic. The rugae are smoothed out. At other times the membrane loses its epithelium, and then ensues an erosion followed by adhesive inflamma- tion which joins the cervix to the adjacent vaginal walls. Not infrequently,close inspection shows this membrane, although pale, to be studded with minute red dots, and presenting a glazed, dry look. Within the cavity of the Fig. 4363.-Obliquity of the Uterus. (After Tiedemann.) the uterus may be somewhat smaller than the other, and the organ is thus made to occupy an oblique position in the pelvis. (Fig. 4363.) Dysmenorrhoea and sterility usually accompany this condition. 2. Congenital Ante-, Retro-, and Latero-positions of the Uterus.-The uterus, although normally formed, may be situated too near the ante- rior, posterior, or lateral wall of the pelvis. If dis- placed laterally, it is usu- ally toward the left side. Contraction of one or the other broad ligament, and unusual size of neighboring organs, may bring about this result. 3. The Double - mouthed Uterus: Uterus Biforis.- An antero-posterior parti- tion may divide the exter- nal os into two lateral halves, the cervix and uterus being otherwise normal in every particular. As in other forms of septate uterus, of which this represents the least pro- nounced type, the dividing band may offer an obstacle to the passage of the presenting foetal ex- tremity, and may, when ruptured, either cause consid- erable haemorrhage or form a starting- point for septic in- fection. If the sep- tum during labor cannot be pushed aside, it can with safety be ligated in two portions and di- vided. 4. Abnormal Pli- cation of the Cervical Cavity.-In this con- dition a fold of tis- sue, not unlike a sec- ond portio vaginalis, projects into the cer- vical canal, causing haemorrhages occa- sionally, and leading also to tedious labor, incision or ablation is sometimes indicated. 5. Abnormal Communications with the Uterus.-The Fig. 4364.-Double-mouthed Uterus. (After Heitzmann.) Fig. 4365.-Abnormal Plication in the Cervi- cal Cavity. (After P. Muller.) a, Os ex- ternum ; b, Os internum ; c, d, abnormal fold ; e, f, cervical cavity. 473 Uterus. Uterus. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. cervix corresponding changes are going on. The ridges marking the arbor vitae so plainly during menstrual life are obliterated ; the glands cease their secretion and undergo atrophy ; the ciliated epithelium disappears ; the canal becomes a smooth-walled tube. Frequently the canal of the cervix is entirely obliterated in consequence of these changes, but this never proves the source of any danger, because senile atrophy and functional changes have already destroyed the secreting surface above, and, in consequence, there is no retention of uterine dis- charge. In a large proportion of the cases in which this condition (stenosis of the cervix) takes place during the early years following the menopause, there has been a history of antecedent uterine disease, usually of chronic endometritis, either alone or as a complication of other disorders. Senile atrophy of the cervix, expressing as it does the complete cessation of the reproductive func- tion, calls for no treatment. A condition simulating atrophy of the cervix may arise from softening of its muscular structure, so that on digi- tal examination its contour cannot be made out. In place of the firm mass of cervical tissue, only a small, soft knob is detected. If the bivalve, or any speculum which pro- duces its field of view by stretching the vaginal w alls, be employed, the os externum will appear as a depressed opening in the anterior wall; but, by the use of the Sims speculum, the contour of the cervix can readily be brought out. This condition is always associated with great gen- eral debility ; usually, also, with subinvolution of the vagina and lack of muscular strength in the whole uterus, as an accompaniment. Its importance lies only in the evi- dence which it furnishes of decided debility and, incident- ally, in the difficulty which it may cause in the adjust- ment of a support. The treatment should be general and local, consisting of strong tonics, expecially nux vomica, iron, diet, and exercise; locally of hot douches, and the application of Churchill's tincture of iodine, tannin and glycerine, or other astringents. Hypertrophy of the Cervix.-This condition is found most often as a result or complication of other uterine pecially in the vicinity of the os externum, which may give rise to troublesome haemorrhage if the parts happen to he injured. This condition is more common than is generally believed. It is frequently met with in sterile women, even unassociated with any endo-cervical catarrh. In such cases it is to be regarded"as a result rather than as a cause of the sterility. The glandular form of hypertrophy, due to the forma- tion of retention-cysts from the glands normally situated in the vicinity of the os externum, and to the exces- sive development of new glandular structures, is a com- plication of chronic cervical endometritis, and is not met with except as a complication of this latter condition. Its most typical appearances are associated with lacer- ated cervix. The surface of the cervix feels as though studded with small shot, but frequently, as the glands lie deeply imbedded, the whole surface of the cervix is uniformly smooth. The contents of these retention- cysts may be a clear or opaque fluid, or, in very chronic cases, solid. The retention-cysts vary in their size, being sometimes microscopical, at other times as large as a pea or even much larger. (For a fuller description of these retention-cysts and of their pathology see the section on Chronic Cervical Endometritis.) Hypertrophy of the in- fra-vaginal portion (Fig. 4366) may also assume a shape which gives rise to difficulty in diagnosis, simulating as it does prolapsus uteri; the length of the infra-vaginal portion increasing until the os externum protrudes from the vulva when the patient assumes the erect posture. This condition may or may not be associated with gen- eral hypertrophy of the cervix. It is not common for this form of hypertrophy to assume the cirrhotic condi- tion ; however, it may do so, the vascular elements atro- phying to such a degree that an operation upon it is almost bloodless, the tissue cutting like a piece of cheese. It is rarely found before middle life, is always associated w ith sterility, and is a frequent cause of dyspareunia. Hypertrophic Elongation of the Cervix.-The cervix may be affected by hypertrophic elongation either in the supra- or infra-vaginal portions. The part of the cer- vix lying above the vagina is more frequently the seat of this elongation, which is decidedly distinct from simple hypertrophy. It is almost never found in virgins or nulliparae. Its cause is either general or local : general, where there is constitutional dis- ease, tuberculosis, general debility, and wasting dis- ease ; local, where there is a lacerated perineum and subinvolution of the vagina, with accompany- ing cystocele and recto- cele, the uterus being fixed in the pelvis either by a backward displacement with adhesions, or by a decided anteflexion, so that its descent is prevent- ed. The method of pro- duction is purely mechanical. Being unsupported from below and dragged upon by the heavy vaginal walls, the relaxed and softened uterine tissue is drawn down until frequently the infra-vaginal portion of the cervix lies without the vulva. Except in extreme cases, some little care is required to establish a diagnosis ; because, as the patient lies upon her back for the examination, the elon- gated portion returns readily to its normal length. If, from the clinical symptoms, the presence of this condi- tion is suspected, examination should always be first made with the patient standing (Fig. 4367), when both the anterior and posterior vaginal culs-de-sac will be found much nearer the vulva than in their normal posi- tion. The infra-vaginal portion of the cervix is of nor- mal size, and firm pressure always will detect the supra- Fig. 4367.-Hypertrophy of Supra- vaginal Portion of Cervix, showing obliteration of vaginal fornicesand descent of vaginal walls. (Schroeder.) Fig. 4366.-Hypertrophied Cervix, protruding through vulva. (Schroeder.) disease. It affects both the supra- and infra-vaginal por- tions. As an uncomplicated condition it is confined to the infra-vaginal portion alone. Its causation as a dis- tinct disease is through circulatory disturbance, result- ing in an increase of the normal fibrous and muscular elements of the parts, later undergoing regular retro- grade changes to connective-tissue formation, exactly as in hypertrophic conditions elsewhere. On section, this formation shows a hard, firm surface, uniformly dense, and in the later stages cirrhotic. In the earlier stages there is a rich vascular increase, and frequently a decided varicose condition of the superficial blood-vessels, es- 474 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Uterus. Uterus. vaginal portion, round and slim, extending to the uterine body. Rectal examination shows this condition even more distinctly. Emmet and some other writers decline to recognize this condition as a distinct hypertrophy, or as being other than a mere stretching of the relaxed and softened cervical tissues. Its existence, however, as so distinct a pathological condition renders it worthy of separate consideration. Hypertrophic Elongation of the Infra-vaginal Portion of the Cervix differs (Fig. 4368) from the preceding only in that the seat of the disease is that portion of the cervix which lies below its junc tion with the vagina walls. The cervix is not increased in size, is per fectly smooth, and the vaginal vault is at its nor mal level. The symptoms of this condition are few - dyspareunia, occasion ally a sensation of weight, and sometimes difficulty in locomotion, and steril ity. Usually, however, the discovery of a small hard tumor just within oi outside the vulva, by the patient herself, is the only complaint. The various forms of hypertrophy and hypertrophic elongation are to be differentiated, because of the difference required in their treat- ment. Simple hypertrophy of the infra-vaginal cervix is recognized by its uniform enlargement, its smooth surface, and, in its early condition, softness of the tissues and varicose veins radiating about the os externum ; the uterus preserving its normal depth. The symptoms are usually trifling : free menstrual flow, dragging sensation, pressure against the rectum, often inducing haemorrhoids, and always sterility; in the later stages, when connec- tive-tissue formation is well advanced, various reflex nervous, especially gastric, disturbances are produced ; scanty menstruation and, rarely, endocervicitis. Treatment.-In the early stages the application of al- teratives, especially painting with strong tincture of iodine, the daily use of the glycerine tampon and tan- nate of glycerine, and the large hot douche with the ad- dition of astringents. In some cases which prove in- tractable to these milder measures, great advantage will be found in the free division of the varicose plexus ; but it should always be borne in mind that a very consider- able haemorrhage may result from this, and the patient should be watched and, if neqessary, the bleeding points touched with nitrate of silver or subsulphate of iron, or it may be necessary to firmly tampon the vagina with styptic cotton. The application of a single leech at in- tervals of a w'eek will often effect a decided change. General treatment should not be neglected ; wine of American ash, fluid extract of hydrastis canadensis, general tonics, cod-liver oil, iron, arsenic, nux vomica, and such special tonics as may be indicated, exercise, and good living. In the later stages, with the increased con- nective-tissue growth, little can be accomplished except by decided surgical measures. The simplest is the ex- cision of a large wedge-shaped piece on each side, ex- actly as in the operation for the repair of lacerated cervix, extending well up to the lateral fornices, and then bring- ing together these edges with catgut or silver wire. (For a more complete description of the operation see the section on Lacerated Cervix.) The incision should be with a knife rather than with scissors, and the ■wedge is to be removed in a single piece to secure as little cicatrix as possible. The after-treatment should be as for lacerated cervix. Mul- tiple punctures by the galvano-cautery will sometimes effect decided diminution, but are to be condemned from the excess of cicatricial tissue thus caused. If this meth- od be used the cervix may be made insensible by the ap- plication of a twenty per cent, solution of cocaine, and the needle inserted in three or four places at each sitting. The operation should not be repeated more often than once a month, in order to allow time for such absorption as may take place. Hypertrophy, due to the excessive glandular formation of retention-cysts, is always limited to the lower part of the infra-vaginal portion and, as stated before, is de- pendent upon chronic cervical endometritis. Its symp- toms are leucorrhcea, dragging pain in the back, sterility, and various reflex neuroses. Vaginal examination is al- ways required for certain diagnosis. Treatment.-As this condition is dependent upon pre- existing cervical catarrh, its treatment is but supplement- ary to that of the endo-cervical inflammation. The cysts that are visible should be punctured, their contents evac- uated, and the interior touched with strong tincture of iodine or with a sharp crayon of nitrate of silver. With the destruction of the superficial cysts others,which have been lying deeper, will approach the surface and in their turn will require treatment. The use of the glycer- ine tampon and large hot douche must be perseveringly continued. If this treatment fails to produce a cure there remains the surgical means by ablation of the dis- eased portions. When not a complication of lacerated cervix, the simplest operation is to dissect with knife and scissors the healthy mucous membrane around the entire circumference of the cervix, separating it from the underlying tissues. This dissection may be carried to the height of from three-fourths of an inch to an inch. The denuded portion should be cleanly amputated, and should the cut surface show any cysts, which almost never ex- tend so high, the dissection must be carried still farther up the cervix. A spear-pointed needle, a little curved at the end, is then entered at the cervical canal, passed through the stump, and brought out through the mucous membrane. This is best done at each lateral aspect of the cervix. This brings the mucous membrane and the lining membrane of the canal together, preventing subse- quent stenosis from cicatrization. Whatever portion of the mucous membrane is redundant is now removed, and the edges are brought together with superficial sutures as far as the median line upon each side. A small plug of iodoform gauze is inserted into the canal to insure pat- ency, and a firm vaginal tamponade of iodoform gauze applied, thus holding the raw edges of the mucous mem- brane and the stump in close apposition until union takes place. The sutures may be either catgut or silver wire -preferably the latter, as admitting of more exact coap- tation and compression. The vaginal tampon may be removed in three days and douches given. It is well, however, to replace the cervical plug, keeping the canal open by means of it for at least a week. The patient should be treated as after any gynaecological operation. Treatment of hypertrophic elongation of the infra- vaginal portion.-No gen- eral measures are indicated, the affection being entirely local. Mechanical meas- ures by which the axis of the cervix can be so changed that it no longer corresponds to the axis of the vaginal canal, are to be first tried. For this the ordinary forms of intra-vaginal pessaries are useless, as the cervix pushes itself downward between the lateral bars unhindered. With Fowler's pessary (Fig. 4369) it may sometimes be retained. The daily in- troduction of a tampon of cotton as large as possible, sprinkled with iodoform, often works well in a mild case. But all intra-vaginal measures are difficult of execution, because the canal has usually taken on the changed form of senile atrophy. Of external supports the only one that offers a fair prospect of relief is that in which the intra-vaginal portion is a deep cup (Fig. 4370) on an in- flexible stem, with perineal bands attached to a belt at the waist. This must be adjusted with the patient lying down, and the cervix accurately received into the cup. Fig. 4368.-Hypertrophy of Infra-vagi- nal Portion of Cervix, showing vagi- nal fornices in normal position and no . descent of vaginal walls. (Schroeder.) Fig. 4369.-Fowler's Pessary. 475 Uterus. Uterus. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. There is danger in the use of this pessary, and the patient should be carefully and constantly kept under observa- tion. The occurrence of a vesico-vaginal fistula from its use is not unknown. The intra uterine stem pessary at times may be suc- cessfully employed. Failing to retain the cervix in place by the above measures, resort should be had to amputation of the elongated portion. The amputation may be performed with either the ecraseur, the galvano-cautery, or the knife. The two former are un- safe, because of the liability that the loop will include a por- tion of the bladder or of the rectum, or that the peritoneum itself may be opened. By the knife several methods are open for choice. The simplest is known as the circular method (Fig. 4371). In this there is no dissection of the mucous membrane, but the cervix is simply amputated at the level desired ; the stitches passed across the face of the same bring to- gether the edges of the mucous membrane, and leave the canal open. With this ampu- tation there is greater liability of cicatrization and contraction of the external opening than with the other methods. In Hegar's method (Fig. 4372) the edges of the mucous membrane of the vagina and of the membrane lining the cervical canal are brought together, keeping the opening pat- ent. Another method (Fig. 4373) is to cut out a wedge-shaped piece from each side of the cervix, first splitting it into anterior and pos- terior lips. The edges of each of these wedge-shaped incisions are then brought together. Other and more complicated methods of am- putation may be resorted to in cer- tain cases, but the foregoing are the simplest and perhaps the best. Hypertrophic elongation of the supra-vaginal portion of the cervix may occur at any age, but more usually near the time of the climacteric. The diagnosis is indicated by the position of the vaginal vault, and also by the greatly increased depth of the uterus, which may meas- ure six or seven inches when the patient is standing, but which is reduced to three or three and a half inches when the recumbent position is assumed. This form of prolapse is, with rare exceptions, accompanied by ves- ical and rectal dis- turbances, owing to the association of the cystocele and recto- cele, by dragging pains in the back and loins, and by endocervicitis from the mechanical dis- turbance of the cir- culation, but not usually by any functional neuroses. Treatment.-As there are associated here, not alone ab- sence of retentive power, but the directly favoring cause of the weighty prolapsed vaginal walls, there is a two- fold force to be overcome. Should the fundus, as is usual, be retrollexed and adherent, efforts should be made to replace it by packing or other available means, that the posterior vaginal cul-de-sac may be freed for the reception of the upper bar of a pes- sary. The form of pessary applicable is best a Hodge or a simple cradle- shaped pessary (Fig. 4374). The various modifications of the Hodge pessary are unsuitable if the lower end is at all wedge-shaped, as the sup- port will not remain in place. When the uterus inclines forward, the op- portunity afforded for the adjust- ment of an internal support is much greater. No inconsiderable skill is required to satisfy all the conditions of a support which shall keep the vaginal walls in their proper position and yet not stretch them injudi- ciously. Fowler's pessary (Fig. 4369) has fulfilled the requirements in not a few of these cases, and occasionally the Gehrung is useful (Fig. 4375). By combining with this internal vaginal support the use of astringent injections and copious hot douches, complete involution of the cervix is sometimes induced, especially if the patient fortunately becomes pregnant during the treatment. The use of the combined intra- vaginal cup or stem pessary, with its perineal bands and abdominal support (Fig. 4370), will perhaps, in the hands of the general practitioner, be more frequently successful than intra-vaginal pessaries alone, but it should not be resorted to until after a thorough trial of these latter. The Thomas modification of the Cutter pessary is the best. Cups, especially those of soft rubber, are least de- sirable. If employed, the patient should be instructed in their use and thoroughly taught the importance of keeping them clean. Ulceration, of the Cervix.- Simple idiopathic ulceration of the cervix does not occur. Ulceration is found second- ary to injuries or to malig- nant or constitutional dis- eases. " Ulceration of the cervix " is one of the most abused and misapplied terms in use, there being classed under this heading, by general practitioners, all diseases in which there is an alteration in the appearance of the normal mucous membrane of the cervix or of the os extAnum. Syphilitic Ulceration.-The primary lesion of syphilis is not uncommonly met with upon this site. Its appear- ance closely resembles that of the sore occurring upon the tongue or the inside of the mouth. The edges are usually oede- matous, rather than sharply cut ; indura- tion is diffuse. There is a tendency to as- sume a phagedenic form. As soon as di- agnosis is made, the constitutional treat- ment should be at once begun, as well as local treatment by iodoform carried directly to the sore upon dry cotton. The dressing should be daily changed, and vaginal irrigation should be made with a solution of corrosive sublimate, one to three thou- sand. Perfect cleanliness is, of course, important. Chancroids.-Less often is the cervix the site of this Fig. 4370.-Cup Pessary, with Inflexible Stem and Bands for Attachment to Waist Belt. Fig. 4373.-Illustrating Removal of Wedge- shaped Piece from each Lip of the Cervix. A stitch is passed through the posterior portion to show the manner of approxima- tion of the edges. Fig. 4371.-Circular Am- putation of Cervix. Stitches passing across the cut surface to draw into apposition the mu- cous membrane of the opposite edges. Fig. 4374.-Cradle-shaped Pessary. Fig. 4372.-Illustrating Method of Passing Stitches to Join the Cervical and Vaginal Mucous Membranes. When twisted these sutures bring the edges in contact, leaving no denuded surface to heal by cicatriza- tion. Fig. 4375.-Gehrung Pessary. 476 Uterus. U terns. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ulceration. Even when the vulva is thickly studded with ulcers the cervix usually escapes. Occurring in this situation, however, it merits the strictest attention, lest the resulting cicatrix cause cervical stenosis. The ulceration is usually deep, irregu- lar in outline, with a tendency to extend. Induration from inflam- matory exudation often masks its true character; but, as it almost never exists singly in this location, diagnosis is aided. Treatment is important, in order that further opportunity for auto infection be stopped. Cauterization of the sore with nitric acid is the readiest method of accomplishing this. The vagina should be thoroughly cleaned with a corrosive- sublimate solution (1 to 3,000); then the cervix should be exposed and protected by cotton covered with bicarbo- nate of soda. The nitric acid may then be freely applied without fear of injuring the vagina. A tampon of cotton covered with iodoform is then to be applied to the cau- terized surface. Vaginal douches of a solution of corrosive sublimate (1 to 3,000) should be employed daily, and an iodoform tampon ap- plied through the speculum. Injuries of the Cervix Uteri. Abrasions of the Cervix.-Owing to its position the cervix is subject- ed to injuries from but few sources. Injuries from intravaginal pessa- ries rarely amount to more than abrasion of the mucous membrane, provided the pessary has received proper attention. The injuries arising from the various forms of combined external and internal pessaries, especially those having a cup-shaped attachment to receive the cervix, are, on the other hand, often severe, as usually they are adjusted without proper measurement, and worn without medical supervision. The whole anterior surface of the cervix may be dissected from the bladder, vesico-cervical fistulae resulting; and if the cer- vix be lacerated, not infrequent- ly a sloughing of one or the other of the lips results. Inju- ries from caustics are rarely met with to-day. The free use of caustics which formerly pre- vailed was the frequent source of cicatricial deformities, caus- ing at times even complete de- struction of the cervix. Treatment. - For the minor and usual forms of injuries, cleanliness and the removal of the exciting cause are sufficient to effect a cure. If the abrasion has increased until there is associated with it the formation of exuberant granulations, applica- tions of nitrate of silver, glycerine and tannin, boracic acid, iodoform, or any astringents, will heal them rap- idly. The dressing should be kept between the abrad- ed surfaces, when the injury involves not only the cervix but the vaginal walls, to prevent the formation of cicatricial bands between the two which may obliterate the fornices of the vagina. Deep and fistulous ulcerations require treatment ac- cording to their site. Acquired Stenosis of theCervix.-The practice of former years was the free application of caustics for nearly all gynaecological disorders. Under this treat- ment acquired stenosis of the cervix was a common re- sult, but is now seldom found arising from this cause. The unskilful closure of a lacerated cervix, or high am- putation of the cervix for malignant disease, is respon- sible for a certain number of cases. The symptoms are not, as a rule, definite, depending upon the degree of stenosis present. From the partial retention of the en- dometrial secretion there may arise leucorrhoea, dysmen- orrhoea, and sterility. Diagnosis is readily made by the finger and the speculum. Stenosis may be limited to the os externum alone or involve the whole canal. Ste- nosis of the os externum and of the canal are commonly caused by injudicious cauterization for endometrial dis- orders. Should the canal be entirely obliterated, the symptoms are decidedly marked. Stenosis of the os in- ternum is rarely met with except as the result of the malformation of the uterus, or of the presence of foreign growths. Temporary stenosis of the os internum is often induced by in- strumental manipulation ; it is merely a muscular spasm and yields to firm but gentle pressure with the probe. When the os externum alone is ste- nosed (Fig. 4376), it is usually suffi- cient to divide the opening bilaterally with knife or scissors, and insure the patency of the canal by the subse- quent introduction of a full-sized sound. If this simple procedure does not maintain a free opening at the os the removal of four flaps (Figs. 4377 and 4378), as suggested by Fritsch, may be practised. Should the extremity of the cervix be greatly hypertrophied and shaped like a mush- room, the excision of a wedge-shaped section from its entire circumference offers the best results. After the performance of any of these operations (Figs. 4379 and 4380), the patient should report at intervals during the next twelve months for introduction of the dilator. Treatment of stenosis of the cervical canal and os in- ternum.-Treatment is best considered under three heads: Gradual dilatation, divulsion, and discission. Gradual dilatation may with safety be performed at the office, and the patient not de- barred from her regular occu- pation. This form of treatment is best adapted to slight strict- ures of the os internum only. A series of hard-rubber plugs, graded to a regular scale, which for convenience of reference is best that of the French scale of sounds, is employed. Hard rub- ber is preferable to steel, because the shape can be altered to suit every case, and because they can be cleaned with corrosive subli- mate (Fig. 4381). In size the dilators should range from three to ten millimetres in diameter. There are many forms of dilators upon the market, all of which possess some one special point of excellence, but the objection to them all is that their gradation is entirely an arbitrary one, and hence there is no opportunity for exact meas- urements. The operation is performed wfith the patient in the left lateral or Sims position. The general rules as to securing perfect asepsis of the vagina, swabbing with corrosive sublimate, one to three thousand, and complete disinfection of the cervical canal by the clean- ing out of the mucus, should be observed. The cervix should then be caught and held firmly by a tenaculum Fig. 4376.-Stenosis of Os Externum. Fig. 4319.-Stenosis of External Os. with Thick, Broad Vaginal Portion, c, Os uteri. (Fritsch.) Fig. 4377.-ac, Four inci- sions carried from the os, c, toward the out- side; b, the four trian- gles removed. (Fritsch.) Fig. 4380.-Conical Excision of the Vaginal Portion. g,h,i, Wedges excised: d.d, portions removed; c,e, bi- lateral discission to facili- tate the excision of the wedges. (Fritsch.) Fig. 4378.-Section of Cervix showing Stenosis of Os Ex- ternum cured by Removal of the Four Triangular Flaps. Fig. 4381.-Hard-rubber Cervical Dilator. with the point just inside the os externum. Drawing the cervix down slightly toward the vulva straightens the axis of the canal, bringing it in a more favorable po- sition for manipulation. The largest-sized dilator that can be passed is well oiled and carried steadily up to the os internum, and firm pressure maintained until the muscular spasm is forced to yield and the dilator slips 477 Uterus. Uterus. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. through. Allow this to remain in place a few minutes and the grasp of the os will be found relaxed ; the next size is then passed, and further dilatation is to be carried up to the point at which a little blood appears. Then, by an applicator armed with cotton, iodine is applied freely to the whole cervical canal. A glycerine tampon with iodoform is placed against the cervix. The treat- ment should not be repeated oftener than once a week, in order that the superficial abrasions may have time for healing and danger of sepsis be avoided. With careful attention to all the details of cleanliness, permanently unfortunate results rarely follow this treatment. It is not uncommon that a severe attack of uterine colic en- sues, or that the patient suffers a slight collapse. The treatment by gradual dilatation, however, does not result in a permanent cure unless, after the opening of the canal, pregnancy follows. Divulsion.-Rapid, forcible bursting open of the ste- nosed canal should be ranked as an operation. It has been practised by means of tents and various dilators for many years. The use of sponge, laminaria, tupelo, slip- pery elm, anil other forms of tents, is usually considered under the head of dilatation, but wrongly ; they do not dilate the mucous membrane, they tear it, and, laying bare the freely absorbent tissues below, expose the patient to the danger of sepsis. Their employment should be limited to carefully selected cases. Divulsion by tents or by sounds was abandoned, when gymecologists fol- lowed the leadership of Sims and Simp- son, almost entirely for a time, and knife and scissors occupied their place, but now divulsion is once more regaining its former standing as a safe operation. Tents are now superseded by mechanical dilators. Goodell's has the theoretical advantage that the blades are kept paral- lel, but their practical employment shows that there is much less dilatation at the ends than near the shank. Schultze's dilator (Fig. 4382) is more simple, more easily kept clean, and quite as efficacious. Anaesthesia is necessary to the operation by divulsion. Sims' position is advisa- ble. The cervix should be steadied with a stout vulsellum forceps and the dila- tor introduced into the cervical canal. Dilatation should be slow. The amount of cicatricial tissue present will deter- mine the rapidity ; twenty to forty min- utes is the average time. The separation of the blades of from If to If inch will insure a permanently patent canal. Too rapid separation of the blades will rupture the cer- vix instead of dilating it, the rupture possibly extend- ing into the venous plexus surrounding the cervix, and troublesome haemorrhage will ensue, requiring decided surgical measures to check it. After the dilatation the cervix should be sponged out with iodine. As regards the subsequent use of a plug to keep the canal open, there is variance of opinion between opera- tors of almost equal authority. Undoubtedly, the use of a hard-rubber or glass plug (Fig. 4383) does prevent the heal- ing of the ruptured mu- cous membrane and, consequently, exposes the patient to further danger of sepsis. If used, it should be re- moved daily, the canal swabbed out with antiseptics and iodine, and iodoform freely dusted into the vagina. If this be not done, the os should be covered with a tampon of cotton sprinkled with iodoform, which is removed in twelve hours and an antiseptic douche given. The patient should be kept in bed a fortnight, and at the next menstrual period should avoid exposure of any kind. Discission of the cervix.-For the relief of stenosis Simpson advised incision of the cervix. His instrument is the representative of a large class, varying in number and forms of blades (Fig. 4384), which are introduced with the cutting edges concealed. The blade being freed by pressure upon a spring or by the turning of a screw, the instrument as it is with- drawn cuts the tissues freely. With this form the incision is made bilaterally, not antero-posteriorly. A better instrument, because capable of more exact guidance, has been suggested by Dr. Emmet: a knife which can be placed at any angle in a ball socket. The operation, in its details, should be performed as described above for divulsion. The incised cer- vix should admit with ease a sound 5 mm. in diameter. The plug should always be inserted, or the cleanly cut edges will at once unite. It may be necessary to secure a certain amount of dilatation previously by tent or sound, in order to introduce the knife. After- treatment is to be conducted on the same rules as those followed after divul- sion. The danger of incision is dispro- portionate to its advantage. It is im- possible to know the depth to which the knife penetrates, there is always a possibility of wounding the large blood- vessels, and there is greatly increased risk of sepsis. The cicatricial contrac- tion in many cases very rapidly reduces the calibre of the canal to its former size. Injuries from Parturition.-The one lesion from this cause in which there arises necessity for interference is laceration of the cervix, either simple or complicated by extension of the tear into the vaginal walls or adjacent viscera. It is to Dr. Emmet, of New York, that the pro- fession is indebted for the recognition of this condition in all its full physical and physiological significance, and for instituting its proper treatment. Among parous women the percentage of those presenting this lesion is, according to Dr. Emmet, 32.8 ; according to Dr. Munde, 30 per cent. Other writers vary the limit decidedly, but this is undoubtedly a fair statement. The poor are more frequently the sufferers from this cause than the rich ; in part, because of the more rapid delivery and the practice of manual dilatation of the os to which the accoucheurs of the former class too frequently resort; in part, because a succession of rapid pregnancies prevents the proper in- volution and hinders the reunion of the torn cervix. The etiology of the condition is not precisely known ; the size of the foetus does not determine it. It may fol- low abortion in the early months, while, on the other hand, the severest instrumental interference may leave the cervix untouched. In a general way it may be stated that the application of high forceps, manual stretching of the os, carelessness in allowing prolapse and strangu- lation of the anterior lip of the cervix in advance of the descending head, are perhaps as potent factors as any. The recognition of a laceration at the immediate time of its occurrence is not easy. It may be suspected when there is free haemorrhage and the uterus at the same time is felt to be firmly contracted. Examination then may show a rent extending well out into the tissues at the side ; perhaps even into the broad ligament. The results of lacerated cervix are twofold : the imme- diate and direct, the secondary and reflex. The imme- diate are haemorrhage at the time of delivery, which is of rare occurrence, impairment of the normal process of involution, and exposure of the patient to increased risk of sepsis. Should, however, as in no inconsiderable percentage of cases, immediate union follow and these dangers be avoided, the immediate influence of the lac- eration is practically negative. Fig. 4384. - Simp- son's Metrotome. Fig. 4382.- Schultze's Dilator. Fig. 4383.-Plug for keeping open Cervi- cal Canal after Dilatation. 478 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Uterus. Uterus. Secondary Results.-Whenever the laceration fails of prompt union a series of physical changes may ensue. These are classed under the general head of subinvolu- tion of the uterus, endometritis, and endocervicitis. The symptoms, both physical and reflex, are not to be dis- tinguished from those which are present when these le- sions arise from other sources. In addition, there are certain reflex nervous disturbances which are attribu- table to irritation of the terminal nerve-fibres at the seat of the laceration itself. The enumeration of all these would be unprof- itable. The journals of the day are replete with isolated cases of the cure of asthma, migraine, epilepsy, and kindred disorders, by the removal of the cicatricial wedge from the angle of the lacer- ated cervix, or the re- pair of a simple lacera- tion. While some of these functional ner- vous disturbances may have their origin here, and be readily suscep- tible of physical im- provement by an op- eration, the majority owe their cure to the impression made on the nerve-centres by the performance of an operation, and would receive equal benefit by other treatment. Following the announcements by Dr. Em- met of the facility of distinguishing this lesion, its im- portant bearing upon many hitherto intractable condi- tions of uterine diseases, and the advantages that come from its proper treatment, it was natural it should have been over-rated as a causative agent in gynaecological disorders. A reaction has now set in, and from being overdone the operation of repair is in danger of falling into undeserved disrepute. A middle conservative course is the one to be adopted in regard to this condition. The laceration of the cervix per se is not an evil. If there is merely a slitting up of the cervical tissue, unac- companied by secondary changes, it is of no more path- ological importance than the very slight fissures that may be seen about the os of any parous uterus ; nor, on the other hand, is the tear, however slight, to be disre- garded when the secondary changes above mentioned (For fuller description of the symptoms of the secondary changes-subinvolution, or endometritis-that may fol- low lacerated cervix, the reader is referred to the special articles on those subjects.) Pathology.-Lacerations of the cervix are single (Fig. 4385), bilateral (Fig. 4386), stellate or multiple (Fig. 4387). The usual form is bilateral; that is, on both right and left aspects of the cervix. The two fissures are usu- ally of unequal depth. Of single lacerations, that of the left side is the more common, then follows that of the right side, those of the posterior and anterior aspects of the cervix least frequently. The laceration, as a rule, takes place in the first labor ; but the cervix may then escape, to be torn subsequently, so that especial care must be taken to avoid the unjust criticisms that the patient is very apt to bestow on her first accoucheur. The influ- ence of a cervical laceration in inducing subinvolution seems to be due rather to the local sepsis, for which the torn surfaces present a favorable field, than to the mere presence of a tear. It is in its secondary results, by the induction of endometrial inflammation with its second- ary lesions, that the importance of the cervical laceration is manifested. When the patient is allowed upon her feet the weighty uterus sags, and, the cervix resting against the posterior vaginal wall, there naturally ensues a certain amount of separation of the ununited edges of the rupture ; also, if the laceration be deep the tension of the vagi- nal walls tends still further to evert it. In consequence of this, there is exposure of the mucous membrane of the canal to friction and external injuries, and thus glandular in- flammation is set up, which results in hy- pertrophy and in- creased eversion. (The appearance and re- sults of this glandular hyperplasia and cell- proliferation are de- scribed in the section on Endocervicitis.) Another source of the disorders aris- ing later, especially the reflex symptoms with nervous dis- turbance, is to be found in the firm cicatrix formed in the angle of the lacerated lips. Here the nerve-filaments are caught and irritated by the contracting tissues, exactly as in cicatricial formations elsewhere. To this many of the sympathetic disturbances are attributable. In the bilateral laceration the ensuing hypertrophy often takes a peculiar form. The posterior lip, as it everts, is crowded against the posterior wall of the vagina and forms a thickened, rounded mass. The anterior, growing in the direction of the least pressure, may stretch out in a thin tongue-shaped form until it even reaches the vulva. In another form, in which the glandu- lar inflammation proceeds to such an extent that the everted hyperplastic lips become strangulated at the line marking the limits of the tear, the cervix, presented to view through a speculum, shows little indication of a bilateral rupture, but resembles rather malignant disease. The relation between the axes of the uterus and of the vaginal canal de- termines to a considerable extent the amount of eversion ; when these coincide, as is possible with a slight degree of retroversion, the torn halves are kept in apposition by the anterior and posterior vaginal walls, and the mucous membrane of the canal, being subjected to no external violence whatever, pre- serves its normal healthy state. The disturbance of the parallelism of these planes, as by replacing the uterus, may so alter this condition that in a few days a decided endocervicitis results. It remains to state but one other remote result of the lacerated cervix : its influence in the production of epi- Fig. 4385.-Right Unilateral Laceration of Cervix. (Mund6.) Fig. 4387.-Stellate Laceration. (Mund6.) Fig. 4386.-Bilateral Laceration of Cervix. The two tenacula show the direction of approximation of the everted lips. (Mundd.) are present. In other words, no general rules can safely be formulated as to the necessity of an operation, each individual case demanding separate study ; but it may be stated that a laceration, of whatever magnitude or shape, occurring in a uterus of normal depth and size, unaccompanied by ectropion or endometrial inflamma- tion, is not responsible for the gynaecological symptoms that may be present, nor would its repair cure them. 479 Uterus. Uterus. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. thelioma of this part. It is a fact that epithelial disease is almost never found in virgins, and in an extremely small number of married, but sterile, women. The exact number of cases in which epithelioma results cannot be known, but it is a small fraction of one per cent. This, then, is a consideration to which due weight must be giv- en in deciding upon the advisability of an operation in an otherwise doubtful case. Even though the subjective symptoms be few, if the character and position of the laceration be such as to promise a continual irritation of the mucous membrane of the canal, the operation may conscientiously be advised as a prophylactic measure. It is but fair to state, however, that certain writers deny entirely the influence of a laceration in producing malig- nant disease, basing their views upon the difference in the epithelium present in the two cases; that covering the erosion after a simple laceration being cylindrical epithe- lium derived directly from the normal glandular epithe- lium, while the epithelium of malignant disease is true pavement epithelium. The weight of evidence, regard- ing the matter from a clinical stand-point, preponderates in favor of the former view. Symptoms.-As stated above, the symptoms, apart from immediate haemorrhage at the time of occurrence, are secondary to the changes induced by endometrial inflam- mation, or due to the irritation of the terminal nerve- fibres by resulting cicatrization. Leucorrhoea is a promi- nent one. Sterility cannot be considered a symptom of lacerated cervix. Diagnosis.-Laceration of the cervix is to be distin- guished from ectropion of the canal due to endocervi- citis, from malignant disease of the cervix, and from true ulceration with loss of substance. By the touch it is usually possible to detect the angles of the laceration, but for certain diagnosis the speculum is required. Cylin- drical and bivalve specula, by the tension they exert on the vaginal walls, still further evert the edges of the lacer- ation and increase the ectropion, thus flattening out the angles of the rent and giving an erroneous impression as to its depth. In all doubtful cases the Sims speculum and position should be employed. As the vagina dilates, the lacerated cervix appears in view with the edges more or less separated. By a tenaculum fastened firmly into the edge of each lip of the tear these are brought together and the eversion is entirely rolled in. This cannot be done when the raw-looking cervix is due to any other condi- tion. It will occasionally happen that there will be too great hyperplasia of the papillary form to permit this re- inversion. The cervix in this case, too, usually bleeds easily and its appearance is highly suggestive of epithe- lial disease. The microscope here is necessary for diag- nosis, revealing, by the presence of cellular elements, the true character of the growth. Treatment.-Immediate repair of the laceration at the time of its occurrence should be undertaken only when there is haemorrhage which ordinary measures fail to control. A primary operation in all cases would subject patients to an unjustifiable amount of operative interfer- ence ; also, it is no easy matter to determine the extent of a laceration or to secure proper coaptation of its edges at the conclusion of labor. Secondary treatment.-Every puerperal woman should be thoroughly examined at the end of her lying-in period of a month or six weeks. If a laceration be.then found, the appearance which this presents and the condition of the uterus, other conditions being disregarded, determine the question of immediate repair or further delay. If the uterus be well involuted, the edges of the laceration showing little or no tendency to eversion or erosion, and if the uterine discharge be healthy, it is well to wait until the patient has fully regained her strength, especially if the child is nursing. She should be examined at inter- vals of a few weeks to note any changes that might call for interference. If, however, these favorable con- ditions are not present, if there is endometrial inflam- mation, erosion, or subinvolution, repair of the cervix should not be delayed. The treatment of the lesion in its more chronic form is best considered under two heads. Palliative treatment.-Should the patient refuse opera- tive treatment, much may be done to alleviate the second- ary conditions of subinvolution and endometritis. The passive hyperaemia may be reduced by a large hot douche, with or without the addition of an astringent, such as alum or borax, employed once or twice daily ; by the bi-weekly puncture of cysts as they appear upon the surface ; and by a free application of Churchill's tincture of iodine, fol- lowed by a tampon well soaked in glycerine, glycerite of tannin, or boro-glyceride. If the uterus be displaced, the employment of a suitable pessary is indicated. The endometritis may also be treated by its proper method, as indicated under article Endometritis (Vol. VII., p. 481.) Under this depletory treatment the hypertrophy and hyperplasia of the cervix can be reduced, except in most Fig. 4388.-Tenaculum for Approximating Edges. obstinate cases, in a few weeks or months, and the eroded cervix will become thinly covered with normal epithe- lium. This condition of improvement is, however, in a majority of cases, not permanent, and treatment will need to be resumed after a few months. When once the lips of the cervix are so reduced in size that they can be brought into apposition, a Fowler pessary (see Fig. 4369) will retain them and materially decrease the tendency to relapse. It is never safe to hold out the prospect of a cure by palliative treatment alone. Radical treatment.-The operation known as Emmet's operation for repair of lacerated cervix, or trachelor- rhaphy, consists in denuding the surface of the rent except just along the median line, which represents the canal of the cervix, removing the cicatricial wedge formed in the angles of the tear as an attempt at union, and by means of stitches bringing these everted parts together in such a manner as to restore the normal shape and integrity of the cervix. The operation varies in the ease of its per- formance as do plastic operations elsewhere. Method of operation.-In those lacerations in which there is a considerable amount of erosion and eversion, one or two months' preparatory treatment by the puncture of cysts, the use of hot douches, and the various depletory measures indicated above, in the section on Palliative Treatment, will reduce the hyperplasia so that adjust- ment of the parts is facilitated and union rendered more cer- tain. Before operating the ab- sence of any subacute inflamma- tory process in the pelvis must be determined. The operation is best performed with the Sims position and speculum, as other specula disturb the normal posi- tion of the parts. The rectum should have been thoroughly evacuated the day preceding and cleaned by enema just before the operation. The bladder, also, should be empty. The vagina should be made thoroughly asep- tic by swabbing with a solution of corrosive sublimate of the strength of 1 to 3,000, or by a sublimate douche of the same strength. The edges of the laceration should be approximated by rolling them in by a tenaculum (Fig. 4388) fastened in either lip, to determine the limits of the tear. If there be much hyperplasia this manoeuvre can- not be readily accomplished. Upon spreading the lips, usually the remains of the arbor vitae can be traced, afford- ing a guide to the amount of tissue to be left to form the new cervical canal. If the mucous membrane of the canal below the angles of the laceration has been entirely destroyed by the inflammatory process, then a strip of the newly formed tissue, which would form a continua- Fig. 4389.-Illustrating Shape of Denuded Surfaces in Op- eration for Bilateral Lacera- tion of the Cervix, a, b, b, Portion denuded. The por- tion between the dotted lines represents the undenuded surfaces which are to form the new canal. 480 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. uterus. Uterus. tion from the mucous membrane above to the edges of the laceration, must be marked out to be left undenuded (Fig. 4389). The instruments needed are two tenacula, a pair of scissors slightly curved on the flat, a long-han- dled knife, a small-toothed forceps, a Sims speculum, sponge holders, one or two pairs of artery forceps, silver- an inch from the edge of the cut, passing through the cervical tissue and emerging on the internal surface of the cervix, just inside the edge of the undenuded strip that is to form the new canal. A new grasp should be taken of the needle, and entering it just at the corre- sponding point of the canal on the posterior lip, it should emerge opposite the point of its first entrance. If the needle is threaded with a double thread as a guide, the wire is bent over this and drawn through into its proper place. The needle may be directly threaded with wire, but there is great lia- bility of getting this kinked, and the use of a guide is advisable. The other stitches are passed in the same manner, and finally those of the lower laceration (Figs. 4390 and 4391). All the stitches are passed be- fore any are tightened. The twisting should begin with the lowest stitch, that is, the stitch nearest the angle of the laceration. Holding the tenaculum firmly against the stitch at its point of emergence, the wire is drawn sharply toward the middle line, making a "shoulder," so that, in twisting, the tissues are not pinched together. The wire shield is then slipped down firmly against the cervix and the wires evenly twisted, until their separa- tion disappears from sight over the edge of the shield. The stitch thus secured is not so tight as to cut, nor so loose as to permit separation of the edges (Fig. 4392). The shot is clamped over the short cut ends, protecting the vagina. Stitches are removed on the eighth day. As a rule, the bowels are not moved for a week or ten days. The patient should be kept in bed two weeks. Thorough antiseptic precautions should be employed. A cervix which has once been torn and repaired does not, necessarily, offer an obstacle to subsequent pregnancies, nor is it usual for the rupture to reoccur. Charles P. Strong. UTERUS : ENDOMETRITIS. Acute endometritis is found affecting the fundus only, or affecting both fundus and cervix. Regarding the etiology of this condition, it is uniformly agreed that it is not found before the age of puberty. It is infrequently met with, except as a di- rect result of inflammation during the puerperal state, or from the extension of gonorrhoeal or some septic form of vaginitis. It may follow exposure to cold, excessive venery, or imprudence at the menstrual period, and is a rare complication of acute exanthemata. It lias been observed in cholera. Injudicious and unclean intra- uterine instrumentation by sounds, tents, curettes, etc., bears the responsibility of many cases. It is essentially an affection of bacterial origin, and hence is rarely found uncomplicated with inflammatory trouble of the deeper tissues, or metritis. In the puerperal form it is usually diphtheritic. The disease is rarely to be found limited distinctly to either the corporeal or the cervical portion of the uterus alone. Pathology.-Opportunity for studying the disease, ex- cept in the diphtheritic form of the puerperal state, is rare ; but enough has been learned to show that it is es- sentially a catarrhal condition, with increase in size and number of blood-vessels, infiltration of the tissues, and associated with a free discharge of serum and white cor- puscles, often of the red corpuscles as well. About the swollen, soft, everted os externum, red spots of severe catarrhal inflammation are seen. The inflammatory changes are more marked in the corporeal than in the Fig. 4390.-Illustrating Manner in which the Stitches are Passed. The numerals show the order of the stitches; the line a, b, c, d, shows the course of a single stitch, the dotted portion indicating its position, buried in the cervical tissue. Fig. 4392.-The Denuded Surfaces of the Laceration held in Apposition by the Twisting of the Stitches as Passed in Figs. 4390 and 4391. plated wire or catgut, spear-pointed, round, curved need- les and needle forceps, a wire twister and shield, and perforated shot. The addition of right and left curved scissors and Emmet's uterotome often facilitates the op- eration. The extent of the cervix to be denuded is marked out by a superficial incision. With a bistoury a clean cut is then made well down into the angle on the poste- rior lip, and repeated on the anterior lip, so that the wedge of tissue may be taken out in one piece, if possi- ble, thus securing more certain removal of the cicatricial plug which occupies the angle of the laceration. To completely free this angle is a most important detail. If the injury is bilateral the other side is similarly treated. The amount of tissue thus removed must vary in each case ac- cording to the amount of hyperplasia pres- ent. The common error is to remove too little ; thus, when the parts are brought to- gether there is tension at some point, usually at the angle, and union does not take place. Any undue amount of tissue not removed by the first denudation may be taken off by knife or scissors until the raw surfaces lie easily in contact, with a strip of undenuded membrane extending down the centre of each. The use of a uterine tourniquet is un- necessary and unadvisable. The stitches may be of silk, catgut, or silver-plated wire ; but silk, for all vaginal stitches, is unclean and not to be recommended ; catgut does not admit of as exact apposition of the parts without undue tension as does wire, also the knots may slip or a portion may be absorbed too soon. Wire is therefore the preferable material. The insertion of the stitches is the second important step in the operation. The upper lacer- ation is usually selected for the first stitches, that the field of operation may be as little obscured by blood as possible. The first stitch should be entered just on a level with the angle of the laceration, about an eighth of Fig. 4391.-The Lips of the Laceration Ap- proximated by the Stitches as Passed in Fig. 4390, before Twisting. 481 Uterus. Uterus. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. cervical portion. The intensity of the inflammatory ac- tion may be such as to entirely divest the uterine canal of its epithelial lining. Symptoms.-Should the disease not arise from the in- troduction of septic material, the symptoms may be so little pronounced as to be overlooked, unless at or near the menstrual epoch, when amenorrhoea is usually pres- ent. It being, however, usually a germ disease, the cus- tomary constitutional evidences of infection are com- monly observed-chills, headache, pain in the pelvis, sensation of weight and fulness, and reflex phenomena, through the sympathetic system, of gastric or intestinal disturbance ; leucorrhcea, profuse, thin and watery, but later purulent, is also present. The local examination reveals an irri- tated and inflamed mucous membrane, with sensitiveness of the uterus to press- ure ; the os gaping and filled with a co- pious sanguinolent, or entirely purulent, discharge ; the cervix softened to the touch as in pregnancy ; and the uterus lying lower in the pelvis than normal. Diagnosis.-The error that may arise in diagnosis is the confounding this condition with other and more severe forms of pelvic inflammation-salpin- gitis, peritonitis, or parametritis. A lesser degree of constitutional disturb- ance, the mobility of the uterus, the location of abdominal tenderness in the median line, the presence of purulent uterine discharge, and amenorrhoea, are distinctive of endometritis. The em- ployment of the speculum enables one to distinguish the diagnosis from simple vaginitis, showing the origin of the catarrhal discharge to be in the uterus. In cases in which the endometritis is secondary to an already existing vagi- nitis, the vagina should be thoroughly cleansed of all discharge, a clean tam- pon carefully adjusted over the os ex- ternum, and the patient kept perfectly quiet for several hours. The tampon, removed through the speculum, shows, by the presence of the purulent dis- charge upon its outer surface, whether the epithelial lining of the uterus shares in the inflammation or not. Metritis is always associated to a varying extent with endometritis. Prognosis.-The disease is important from its sequelae. A knowledge of the etiology of each case is essential. Even the rare mild, non-septic forms require a guarded prognosis because of the complications which they induce-sal- pingitis, metritis, and, later, peritonitis. Treatment.-This should be based upon the knowledge obtainable as to the origin of the disease. Simple and uncomplicated cases require rest in bed and hot compresses for the abdomen, light liquid diet, mild saline laxatives, suppositories of hyoscyamus and belladonna, and perhaps morphine in sufficient amount to allay pain ; also large hot douches, four to six quarts, at a temperature of 110° to 115° F., or hot sitz-baths for ten minutes daily. Usually these mea- sures effect a rapid cure. The septic forms demand more vigorous treatment. Intra uterine medication is essential. The vagina should be thoroughly cleansed twice or of tener daily, by large hot injections of corrosive sublimate, in a solution of 1 to 8,000, followed by pure hot water (to pre- vent mercurial poisoning). The cervix should be exposed through the speculum, the uterine canal should be thor- oughly cleansed by the cotton applicator (Figs. 4393 and 4394), and another applicator, similarly armed but soaked in a solution of corrosive sublimate, 1 to 500, should be passed to the fundus very gently and allowed to remain a few minutes. Immediately upon its w ith- drawal a gelatine pencil containing five grains of iodo- form should be inserted, and a glycerine dressing applied over the os. The more severe the sepsis, the more neces- sary the frequent repetition of this treatment. Opium and belladonna suppositories, poultices and hot com- presses, and the constitutional treatment indicated above should be carried out, except in the case of diphtheritic Fig. 4394.-Applicator wrapped with Cotton for Removing Uterine Dis- charges and Conveying Medications. inflammation, when the general measures are to be stim- ulating rather than depleting. Chronic Endometritis.-Etiology -Chronic endometri- tis is rarely found as a result of simple acute endometri- tis, unless it be considered that many cases of simple -that is, non-specific-acute endometritis have an un- recognized existence. It is a common sequence of the acute septic form. Constitutional diseases have a de- cided influence in its causation ; among these causes are tuberculosis, aneemia, general debility, and faulty hy- giene. The direct local causes are many-injuries from the use of sounds, tents, and intra-uterine medications ; passive congestion from displacement or from peri-uter- ine inflammations which interfere with the normal circulation; exces- sive venery ; pro- longed or frequent erotic excitement ; imprudence at the menstrual periods ; foreign bodies within the cavity of the uterus, espe- cially intra-uterine stems ; improper attendance during parturition, or the lying-in period ; deformities of the canal with stenosis ; neglected lesions following child- birth. Pathology.-As contrasted with the acute form of en- dometrial inflammation, there is found a distinct chronic endometritis affecting either the corporeal or the cervical portions of the uterus alone, as well as a general chronic endometritis. That of the cervical portion is the most common, there being rarely uterine disease of any kind of which this is not an accompaniment. Next in the order of frequency is to be placed general chronic en- Fig. 4395.-Cross Section of a Granulation in a Case of Endometritis. 1, Stroma ; 2, glands. (De Sin6ty.) Fig. 4393. - Hard- rubber Applicator. Fig. 4396.-Vascular Type of Endometritis, or "Endometritis Fungosa." (Olshausen.) dometritis and, finally, that form which is limited strict- ly to the body, or corporeal endometritis. This vari- ance in the seat of the disease is due to the distinct characteristics of the two kinds of mucous membrane lining the separate portions of the canal, the cervical and the corporeal. Chronic Corporeal Endometritis.-Hypertrophy of the 482 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Uterus. Uterus. mucous membrane is a result of this chronic corporeal endometritis, manifested, however, in three different ways. The most common is simple glandular hyper- trophy (Fig 4395), resulting in an uneven papillary sur- face, not easily bleeding. The hypertrophy is uniform, not in projecting masses ; the general symptom is leucor- rhoea. The second form is characterized by dilatation and hypertrophy of vessels rather than glands, and the corresponding symptom of haemorrhage rather than pur- ulent discharge (Fig. 4396). The surface is studded with fungoid growths which vary greatly in size, some being mi- croscopical, others as large as a placental tuft. The entire cavity of the body may be filled and dilated by these soft, spongy growths, which upon their ex- ternal surface are smooth. Upon r e - moval they rapidly lose their original size and shape, shrinking into insignificant mass- es of collapsed blood- vessels and connective tissue. Olshausen, who especially has de- scribed this form of hypertrophy, named it " endometri- tis fungosa." Of all the types this is the most responsive to treatment, and the only one which affects directly the patient's health, i.e., by haemorrhage, irrespective of the secondary changes that are induced. The cervical portion of the uterus is never the seat of this type of the disease. The third type, which is rarely met with, is described by De SinSty (Figs. 4397 and 4398). In this form of inflammation the mucous membrane contains neither dilated glands nor blood-vessels, but there is a formation of new connective-tissue cells, the vegetations being specially constituted of embryonic tissue. He con- siders it analogous to true inflammatory tissue which forms on the open surface of wounds. It may be ques- tioned if this be not rather a stage in the retrograde change of types one and two toward their final result, viz., the obliteration of the true glandular and vascular elements of the endometrium, and the replacement of of pregnancy, pains in the breasts, darkening of the areola, and nausea. The leucorrhoea, at first viscid but clear, changing in the later stages to yellow and creamy, may become so profuse as to require a protection for the linen. With the predominance of the glandular inflam- mation there is rarely bleeding, but occasionally bloody streaks occur in the discharge It may, in slight cases, be unnoticed except for a few days preceding and fol- lowing menstruation ; hence, in cases of doubt, the im- portance of examination near this period. From its acrid character, it may induce severe vaginitis or vulvi- tis, with resulting eczema. Menorrhagia is the symptom which, next to leucor- rhoea, is constant and distinct. Its onset is usually grad- ual and unnoticed by the patient, until so well established as to induce anaemia or prostration from the haemorrhage. Beginning with menorrhagia, especially in the fungoid type of the disease, the symptoms pass on into metror- rhagia. The metrorrhagia may be so persistent and free as to reduce the patient to a state of chlorosis and call for the greatest care in treatment, lest the additional shock prove fatal. The most marked cases of metror- rhagia due to this cause are often met with in young girls during the first years of their menstrual life, and in women at the period of the climacteric. Sterility is not to be reckoned upon as invariably the accompani- ment of this disease, of which the importance in this regard seems probably exaggerated ; else, few multip- arse being free from it, the fertility of women-especially of the lower classes, by whom treatment is neglected- would be greatly lessened. Abortion.-No cause of abortion is more prominent. The engrafting of the decidua upon the diseased mucous membrane subjects it to irregular and defective nutri- tion, with the result that its exfoliation usually precedes the formation of the placenta. Abortion arising from chronic endometritis has, usually, as a prominent symp- tom, frequent bloody discharges, not amounting, how- ever, to decided haemorrhages. The general symptoms arise in part from the direct physical changes in the size and structure of the uterus, in part from the enforced debility due to these changes. There is nothing pathognomonic about them. Their im- portance is rather in prognosis as to the results to be ex- pected from treatment than in diagnosis. The patient who has long suffered from chronic endometritis will present an array of general symptoms of debility that is endless in its variety, and clearly shows functional dis- turbance of all organs. Physical signs.-Varied and distinct as the rational signs may be, it is by digital and specular examination only that diagnosis is to be made. The uterine body is en- larged, and in an uncomplicated case rarely tender, except on very firm pressure. Its outline is not distinct. It feels soft and readily escapes from the examining touch, doubling on itself and slipping away. Should displace- ment exist, it is difficult to replace it bimanually, even though there be no adhesions, because of the softening of the tissues, especially in the region of the os internum. The cervix is patulous, softened as in pregnancy, and is often not easily differentiated from the surrounding vagi- nal walls. The speculum shows a characteristic muco- purulent discharge escaping from the os, and the probe passes easily into the uterus to a depth greater than nor- mal, encountering irregularities of the mucous mem- brane. To the touch of the probe the fundus feels soft and velvety, in which case there usually follows decid- ed haemorrhage, or it is rough and nodulated, giving a grating sensation. Following the withdrawal of the probe there is usually a decided gush of bloody mucus and pus, showing that the cavity of the uterus is dilated and retains in part its secretion. The internal os is usually more tolerant of the probe, the fundus less so, than normal. Diagnosis.-Chronic endometritis, as a distinct disease, not as a complication, must be differentiated from new- growths, benign or malignant, growing within or upon the mucous membrane. The gross physical signs, as well as the rational, may be alike in all. Microscopical Fig. 4397.-Cross Section of a Granulation composed of Dilated Blood-vessels in a Case of Endometritis. 1, Vessels cut lon- gitudinally ; 2. vessels cut transversely ; 3, dilated vessels filled with blood-corpus- cles; 4, embryonic tissue. (De Sinety.) Fig. 4398.-Cross Section of a Granulation composed of Embryonic Ele- ments, from a Case of Endometritis. 1, Embryonic tissue; 2, part undergoing fatty degeneration. (De Sinety.) them by connective-tissue formation, exactly as follows chronic inflammatory changes elsewhere in the body. Occasionally retention-cysts, resulting from the oblitera- tion of the gland-ducts, are observed in this form. Symptoms.-The direct symptoms of this condition are four : Leucorrhcea, menorrhagia, sterility, and abor- tion. A train of symptoms arising from the results of the chronic endometritis, due either to reflex irritation or to secondary functional changes induced both in the uterine and other organs, are, neurasthenia, digestive and gastric disturbance, bearing-down pains in the pel- vis, sensation of weight and dragging in the back, dys- menorrhoea, and, not infrequently, the usual disturbances 483 Uterus. Uterus. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. examination of the endometrial discharge as it escapes from the os and is collected through the speculum is, in a negative way, of value as showing the pres- ence or absence of any characteristic cells of malignant growths, but the curette must be employed in all doubtful cases. The dull wire curette (Fig. 4399) of Thomas is most practicable at first examination, because its use is devoid of danger. The manipulation should be carefully performed through the speculum. The cervix is to be steadied by a tenaculum, the lower part of the canal freed from the discharge by the cotton applicator (see Fig. 4394) or the uterine syringe (Fig. 4400), and the curette carried directly to the fundus, pressed firmly against the mucous membrane, and drawn slowly out along the posterior surface of the uterus. This operation is to be repeated once or twice, and the mass of scrapings from the various parts of the uterine surface should be at once examined. These will show either one of the three forms of chronic inflammation of the mucous mem- brane as above figured, or the round cells of sarcoma, or the characteristic epithelial cells of carcinoma. The special products of con- ception, the retention of which may have caused the endometritis, are also easily recog- nizable by this means. Prognosis.-The endometritis could con- tinue indefinitely, except in the haemorrhagic cases, were it not for the secondary changes which are induced-metritis, salpingitis, peri tonitis, and kindred pelvic inflammations. Of itself it is not a fatal disease. As mentioned above, the fungoid variety is directly dangerous from haemor- rhage. The disease is almost never found unaccom- panied by complications ; therefore prognosis must be always guarded and made from a study of the complications present rather than from any definite knowledge of the disease itself. Gonorrhoeal endometritis and all forms of constitutional origin, i.e., syphilitic or tuber- cular, are especially resistant to treatment. Treatment.-A careful eliminative diagno- sis must be made of all complications present, whether these be the cause or the effect of the endometritis. With acute or subacute in- flammation surrounding the uterus, local in- terference must be limited to such measures as will be appropriate for the relief of these conditions. The large hot douche, followed by tampons soaked in glycerine or boro- glyceride packed around and against the cer- vix, should be employed daily ; and bi-weekly applications of iodine should be made to the vaginal vault and to the external surface of the cervix, unless the complicating inflamma- tion be so acute as to entirely preclude the use of the speculum. When the endometritis depends upon some general condition, e.g., syphilis or tuberculo- sis, the proper constitutional treatment for such disease should be at once instituted. Should there be found no complicating peri- or para-metritic inflammation, the question that must be answered in every case is the propriety of intra-uterine medication, and the form to be adopted. On both sides of this question authorities of equal weight are ar- rayed, the variance being due, in great part, to the different views held as to the pathology of the disease ; one class regarding it in the majority of cases merely as a passive congest- ion, hence not demanding direct treatment. This view, however, is not in accordance with the more recent histological researches, by which its character as a true inflammatory process is maintained. The first step should be to remove, by appropriate treat- ment, any existing complication, e.g., displacement, by which passive hyperaemia is kept up, and the inflamed mucous membrane should then be di- rectly treated. When the principal symp- tom is not haemorrhage, at once two courses are open : The employment of alteratives and caustics to the diseased surface by applicator and syringe, or the more heroic procedure of immediate cu- retting. To the general practitioner the first course will be more feasible and often successful. The cervix is exposed through a speculum, preferably Sims', the anterior lip caught by a tenaculum, drawing down and straightening the ute- rus, the exact curve of the uterine canal determined by passing the probe, and the plug of mucus sucked out of the canal by the uterine syringe, or wiped out by cotton-covered applicators. This is not easy, owing to its tenacious character. The free use of bicarbonate of soda or any alkali is an aid. The applicator, with its thin coating of absorbent cotton, is then bent to the exact curve of the probe, dipped in the agent employed, and rapidly passed to the fundus, allowed to remain about half a minute, withdrawn, and a glycerine tampon applied to the cervix over the os. It is important to thoroughly remove all the uterine secretions before introducing the remedial agent, which otherwise would not be brought in contact with the diseased surface. The application most frequently employed is Churchill's tincture of iodine, which, above all others, possesses the power of diffusing itself among the deeper-seated diseased glands. Iodized phenol (one part iodine, four parts carbolic acid) ranks next. Pyroligneous acid, which Schroeder recommends, also gives very good results. A solution of corrosive sublimate (1 to 500) has cured some very intractable cases. Pure carbolic acid is more powerful than iodine, but useful only when the disease is superficial, as its prop- erty of coagulating albumen prevents deep penetration. No more powerful caustics than these should be employed without protecting the cervical canal throughout its whole extent by one of the different forms of cervical specula in use, because of the danger of cervical stenosis from sloughing of its mucous membrane. There will usually be found no difficulty in in- troducing the cervical speculum through the os internum, which is characteristically dilated by the disease itself, but, should it not be sufficiently patent, a small laminaria tent should be introduced and allowed to remain a few hours; or, better, a series of hard- rubber dilators should be employed, and the whole operation completed at one sitting. The caustic employed is usually fuming nitric acid. Chromic acid was formerly a favorite application, and is now with some operators. Solid nitrate of sil- ver, fused on the probe, was for many years an almost universal remedy, but should never be employed, being uncertain and irregular in its effects, often produc- ing stenosis. The use of the so-called ap- plicator syringe (Figs. 4401 and 4402) has been brought prominently forward by Dr. MundS, of New York, to whose book I am indebted for this descrip- Fig. 4399.- Dull Wire Curette. Fig. 4401.-Appli- cator Syringe. (Mund6.) Fig. 4400.- Uterine Syringe. Fig. 4402. - Ap- plicator S y r - inge, wrapped with Cotton. (Mund6.) 484 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Uterus* Uterus. tion. The instrument in experienced hands is as safe as the applicator. In the applicator syringe the final two and a half inches of the uterine end of the tube are made very slender, and are perforated with small holes. The expansion of the tube at two and a half inches from the tip shows the limit of the normal canal. The cotton is wrapped moderately tightly about the point, and the piston is pushed very gently by turning it as a screw. The saturation of the cotton is shown by oozing of the fluid from the os, and as soon as this oozing occurs the syringe should be withdrawn. Dr. Munde states that, having employed this method many hundreds of times, he is convinced that it is a " most efficient, convenient, and safe method of making intra-uterine applications." Intra-uterine injections.-Their employment cannot be too strongly condemned. In the earlier days of gynae- cology medicinal agents of all kinds were indis- criminately injected into the uterine cavity, but to-day, as a routine measure of treatment, their employment cannot be justified. The most serious results are directly attributable to their use ; syncope, metritis, salpingitis, peritonitis, follow this procedure in a large percentage of cases, despite all theoretical arguments to the contrary. When we have at command so many other comparatively safe, and certainly more effectual, methods of treatment, the injection of fluids into the uterus is indefensible. The use of iodoform, carbolic acid, tannin, and other alteratives, in suppositories of gelatine or cocoa butter, is less objectionable than the intra-uter- ine injections, but they offer no advantage over the simple application of the same agents upon some form of applicator. Should they be used, special care must be taken that the internal os be perfectly patulous, so that the excess of fluid as they melt may escape readily from the ute- rus. They have the disadvantage of causing more intense suffering to the patient, and often uterine colic and syncope. Should they be employed, they should be inserted through the speculum. Whatever method of intra-uterine medication is decided upon, it must constantly be kept in mind that gentleness, cleanliness, and perfect attention to all details should mark each treatment, to avoid inducing a more serious condition than that already existing. It is true that many uteri become very tolerant of treat- ment, but it is equally true that this tolerance is variable, and harshness in the measures em- ployed may start some dormant pelvic inflam- mation into an acutely suppurative process, with serious results. Applications of iodine and the milder alteratives may be employed weekly; the stronger alteratives or caustics but once or twice a month. Should any general disturb- ances be produced, as faintness or syncope, it is wise not to give subsequent treatments at the office, but at the patient's home, and to re- quire absolute quiet for the next twenty-four hours. Applications made immediately after the menstrual period produce the most decided alterative effect. Curetting.-When the milder treatment suggested above has been faithfully practised for some months without marked improvement, or where menorrhagia or metrorrhagia is the urgent symptom, the curette should be employed. There are two general types of curette : The dull wire loop (see Fig. 4399) and the sharp (Fig. 4403). The latter has a cutting edge and a stiff shank. The curette forceps of Dr. Emmet is most useful when the disease exists in the form of villous projections. For the proper and thorough employment of the curette an- aesthesia is desirable, although in exceptional cases it may be dispensed with. The left lateral position and Sims' speculum should be used. The vagina should be rendered thoroughly aseptic by a solution of corrosive sublimate, 1 to 3,000, the uterine canal made thor- oughly patulous by the hard-rubber or expanding steel dilators, and the interior of the uterus swabbed out with the corrosive-sublimate solution. For removal of these growths I prefer a sharp curette, reserving the dull wire for diagnostic purposes, because the fungoid masses, if of any size, readily escape entanglement in the loop of the dull wire. The cervix being steadied by a tenaculum, but without exerting sufficient trac- tion to displace the uterus, the cuVette is passed to the fundus and drawn with firm, uniform pressure across it until it is felt that all the soft, spongy masses are re- moved and the muscular tissue is laid bare. A grating sensation is felt when this is accomplished. (The opera- tor can familiarize himself with this sensation by draw- ing the curette across the palm of the hand.) Particular attention should be given first to that part of the uterus near the opening of the Fallopian tubes which is the fa- vorite seat of the disease ; next, the posterior wall, then the anterior, and finally the cervical canal should be thoroughly cleansed of all diseased tissue. The cavity should be sponged clean with solution of corrosive sub- limate of the regular strength, and an applicator or small sponge well soaked with Churchill's tincture of iodine carried to the fundus. The iodine is in itself an anti- septic and, in addition, it stimulates contraction of the uterus, providing an additional safeguard against sepsis. The vagina should be thoroughly cleansed and a pad of cotton, wrung out in the corrosive-sublimate solution, placed against the vulva. The patient should be kept in bed for ten days at least, upon a light diet. With at- tention to these details curetting is deprived of its dan- gers ; viz., metritis, salpingitis, etc., which are attribu- table to sepsis. With the employment of the aseptic pad at the vulva, douches are not needed. The uterus should be free from any manipulative interference until after the next menstrual period, when intra uterine ap- plications of the iodine should be employed weekly for at least a month. Curetting often requires repetition, but this should not weigh against its employment. Apostoli, in a recent monograph, has brought into no- tice the employment of electricity as a means of curing the lesion, by destruction of the diseased mucous mem- brane. He employs a platinum probe introduced into the uterus and a broad abdominal electrode of fuller's earth. Cases in which the hajmorrhagic element is prominent are benefited by making the intra-uterine probe positive ; when this element is lacking, the negative pole is pre- ferred. The intensity of the current should be as strong as the patient can bear, and the time of the application from five to ten minutes. Apostoli claims that newr and easily cured cases require no more than three to five ap- plications, the more intractable from twenty to thirty. This method of treatment has not yet had the benefit of an extended application. Endometritis of gonorrhmal origin merits especial men- tion because of the serious complications that almost in- variably follow its occurrence. Noeggerath has demon- strated very clearly that many intractable cases of which the origin is obscure are due to infection by what he de- nominates " latent gonorrhoea " in the male. The treat- ment must be most vigorous. No time should be wasted in alterative applications, but a strong solution of corro- sive sublimate, one to five hundred, or of carbolic acid, one to twenty, should be thoroughly applied to the inte- rior of the uterine cavity, every two or three days. The vagina should be kept thoroughly clean and aseptic by daily douches, and if the gonorrhoeal inflammation is still present in this locality it should receive prompt and de- cided treatment. Chronic, Cervical Endometritis.-Pathology.-The dis- ease variously known as chronic cervical catarrh, endo- cervicitis, and chronic cervical endometritis, is an inflam- mation involving the glandular elements of the mucous membrane lining the cervical part of the uterine canal. The researches of Ruge and Veit and Fischel have, within a very recent period, overthrown the pathologi- cal views of former writers and established what seems to be, undoubtedly, a true deflnition of this condition. Their studies show that, as the result of glandular in- Fig. 4403. - Sharp Curette. 485 Uterus. Uterus. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. flammation within the cervical canal, there appear about the edge of the os externum reddened patches of irregular outline, the so-called erosions. These patches are cov- ered with cylindrical cells, which exist in a layer so thin that the hyperaemic vascular tissue below is clearly vis- ible ; hence the color of the patch is red. Ruge and Veit attribute these new cells to formation by irritative changes from the deeper layers of the rete Malpighi. sue beneath was exposed, there being also hypertrophy and projection of its villi. The discrepancy in these viewrs arose from the fact that all previous studies had been made upon post-mortem subjects, in which the deli- cate cylindrical epithelial covering had been macerated and lost; the later conclusions of Ruge and Veit and Fischel wrere based upon the study of tissues removed from the living subject. In consequence of the inflammation there is increase in the connective tissue of the cervix, which obstructs the gland-orifice so that retention-cysts are formed, the so-called ovula Nabothi, which not infrequently attain considerable size, and may even dissect well down upon the anterior surface of the vagina. As a rare occurrence, mention is made by Hart and Barbour of such a reten- tion-cyst complicating labor. In general the cysts are small, varying from the size of a pin-head to that of a large pea (Fig. 4406). Their contents may be clear, transparent mu- cus, or pus, or concre- tions. They may be few and isolated, or they may infiltrate the whole vaginal cervix so that, on section, it presents a honey-combed appear- ance. There is still some question as to the nor- mal existence of these glands in the tissues outside of the cervical canal, but the weight of authorities prepon- derates in favor of their being entirely new for- mations in that locality, from the proliferation of cells from the glands entirely within the canal ; which cells, working their way beneath the epithelial membrane, find lodgement in the connective tissue without. In addition to the formation of cysts, the increase of the glandular elements may lead to the formation of polypi projecting from the cervical canal, usually slim and soft, at times forming tumors of considerable size. The surface of these growths is always covered with a characteristic glandular epithelium. There is, as an accompaniment of the new glandular formation, a great increase of se- creting surface ; hence the leucorrhceal discharge. As in all chronic inflammations, there ensues increase in the connective tissue of the cervix leading directly to hyper- trophy. The pathological elements of chronic cervical endome- tritis are inflammation of the already existing glands in the cervical canal, formation of new glands in the tissues without the canal, hypertrophy of the connective tissue. Etiology.-Its origin as an idiopathic disease is rare. It exists as a complication of nearly every uterine dis- order. It follows almost invariably lesions of child- birth, lacerations, or subinvolution of the uterus, dis- placement, especially retroflexion and prolapse, and in- juries from tents, sounds, or other mechanical violence. It is a common accompaniment of puerperal endometritis, and is also readily induced by the spread of contagion from below upward, as from gonorrhoeal vaginitis. It depends less upon the condition of the bodily health than either general or chronic corporeal endometritis, except as these secondarily affect the uterus and induce passive congestion. Emmet and most of the modern writers re- gard laceration of the cervix as the direct cause, in parous women, through the mechanical effect of the friction of the exposed cervical mucous membrane against the vagi- nal walls. Stenosis of the os externum, by blocking up the uterine secretions, forms a dilated sac in the canal and favors the production of the disease (Fig 4407). Consti- tutional taints, scrofula, syphilis, and faulty hygienic conditions, are responsible for many cases. It is the ac- companiment of any disorder causing passive hyperaemia of the uterus, and is the frequent sequel of acute cervi- cal endometritis. Fig. 4404.-Follicular Erosions. On the left, normal papillae; on the right, adenoid proliferations; below, cross sections of glands. (Ruge and Veit.) Fischel and later observers are inclined to regard them as produced by excessive development of the cells nor- mally lining the glands within and just outside the cer- vical canal. These cells, proliferating, work their way beneath the normal epithelial covering of the vaginal por- tion of the cervix, which is thus displaced and destroyed. If, from any cause, abrasions about the os are already present, then this new glandular epithelium grows out and covers it at once with its characteristic cylindrical cells. At times, from the rapid growth of these cells through the open-mouthed glands, papillomatous appear- ances are produced. Whether the one or the other of these two explanations of the origin of the new cylindri- cal epithelium is correct-and the latter appears more in accordance with our knowledge of cell-production-the histological appearances are, without doubt, correctly described. What has heretofore been known as " ulcer- ation," or by some kindred term implying a destructive process, is really a new formation of tissues by cell-pro- liferation from the glan- dular portion of the cervical mucous mem- brane. The lesions which have furnished the material for these studies have borne for years names suggested by their macroscopical appearances-names of descriptive character only, viz. : Granular Erosions.- A raw-looking surface without gross appear- ances of elevation or depression, but which under the microscope shows a series of actual ridges and depressions, causing a rough look. Follicular Erosions (Fig. 4404).-During the process of epithelial formation and the production of new cells the free open ducts of the glands involved may be shut off, and thus are formed cysts ; some coming to the surface and bursting, some lying deeply embedded. Papillary Erosions (Fig. 4405).-The depressions are deeper, and often are the result of follicular erosions in which the gland-openings are freely exposed, and the ex- cessive cell-proliferation goes on through their dilated mouths. The above expresses briefly the result of the researches of Ruge and Veit. Old pathologists explained these changes by the theory that the normal epithelium was displaced and destroyed, and that the denuded tis- Fig. 4406.-Showing Ovula Nabothi, a, a, b, b, and Erosion, c, on the vagi- nal aspect of cervix. (Fritsch.) Fig. 4405.-Papillomatous Erosions. Depressions of the new glandular for- mations between which the masses of tissue resemble papillae. (Ruge and Veit.) 486 Uterus. Uterus. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Symptoms.-The personal habits of the patient influ- ence decidedly the symptoms for which relief is sought. If accustomed through early life to leucorrhceal dis- charge, a slight increase in this does not attract attention until the secondary results of the inflammation are made manifest ; these are, pain and bearing down in the pel- vis, reflex nervous disturbances, especially gastric, back- ache, inability to stand or walk, and malaise. The one primary symptom is usually leucorrhceal, the discharge of a thick, glairy, tenacious, white or yellowish, muco- purulent secretion, occasionally, though rarely, streaked with blood. This leucorrhoea is not usually of a strong irritative character, and rarely causes vaginitis or vulvitis, except when the elements of specific contagion are pres- ent. The symptoms secondary to the catarrhal dis- charge are, in addition to the reflex symptoms, pain; sterility, due to the destruction of the vitality of the sper- matozoa by the discharge, or to the blocking up of the cervical canal to such an extent as to render the passage into the uterus impassable to them ; irregular and pain- ful menstruation, from the nutritive changes in the uterus and adnexae. In case of anaemia and debility, it is ex- ceptional not to find chronic cervical endometritis, and the determination of the rela- tion of the two conditions, as to cause and effect, is not al- ways easily made. D i a gnosis.-Examination digitally and by the speculum is necessary to render the di- agnosis certain. If the disease is all within the canal the cer- vix may feel perfectly normal. When, however, there are fol- licular or granular patches about the os, the examining finger detects a softening of the cervical tissues in that vicinity, which may be so marked as to give the feeling of laceration with eversion ; also glandular hypertrophy, with the hard nodules of the retention-cysts, may be very evident to the touch. Pressure upon, or displacement of, the cervix rarely causes pain. The speculum shows in nullipara?, if the disease be entirely in the cervix, the normal os externum blocked with the extremely tenacious discharge, either white or yellowish ; or more commonly, an irregular and dilated os surrounded by the various pathological condi- tions above described. The introduction of the probe is usually painless. A little bleeding very commonly fol- lows. In cases of long standing, accompanied with con- siderable hypertrophy of the glands, the calibre of the cervical canal may be so diminished that the end of the probe becoming entangled in these hyperplastic growths its passage through the canal is attended with the utmost difficulty. Prognosis.-Prognosis is to be based upon the disorder of which this disease is a complication. Cure may be anticipated only in proportion to the improvement in the primary disease. Treatment.-The broad rule must be laid dowm, cure first the disease of which the cervical catarrh is a com- plication, whether this disease be general or local, and relieve the existing anaemia and gastric disturbances by suitable treatment. Nux vomica, arsenic, iron, and cod- liver oil are, above all others, the proper tonics. Out- door life, and avoidance of coitus, or of any exercise tending especially to induce pelvic hyperaemia, are nec- essary. When there is any special constitutional disease, appropriate remedies should be employed. In nearly every case some general treatment will be required. Local treatment.-It is rare that a case of chronic cer- vical endometritis will be cured simply by remedying its cause without further local treatment. The chronically inflamed glands must be attacked directly by alterative measures in mild cases, by destructive ones in severe. Alterative measures.-The simplest is to diminish the blood supply of the uterus. The means at our disposal for this are, first, depletion, by means of large vaginal douches, four to six quarts of hot water at a temperature of 110° to 115° F., once or twice daily, and firm pressure upon the uterus, by packing the vagina full of cotton soaked in boro-glyceride, or tannate of glycerine, or glycerine alone ; second, to facilitate a return of blood from the uterus by correcting any misplacement either by a pessary or tamponade ; and third, to directly attack the diseased tissues by medicated applications. To insure thoroughness in the application all the discharge must be removed from the canal, either by the uterine syringe or by the cotton applicator. The use of an alkali will facilitate this pro- cedure by rendering the mucus more soluble. The ordinary bi- valve speculum may be em- ployed ; but in this work, for easier manipulation, the Sims speculum and the side position are preferable. The cervix should be steadied by a tenacu- lum, and the exact direction of the canal ascertained. Then the application should be made ex- actly as described above in the section on Acute Endometritis, except that the medication does not extend above the os inter- num. The substance employed may be either in liquid or in solid form. The strength of the alterative may vary from the mildest, as tincture of iodine, to the strong- est caustic, nitric acid. Applications should be made at first biweekly, beginning with the milder topical appli- cations ; should these prove inefficient, the stronger, as pure carbolic acid, pyroligneous acid, or iodized phenol, should be used. The mixtures of iodine and carbolic acid should be applied not oftener than once a week, and, if their use is attended with increase in the amount of discharge and evidence of inflammatory disturbance, their application should be limited to once in two weeks. The stronger caustics should be applied not oftener than once a month. The vagina should be protected from the action of the stronger caustics by cotton soaked in neu- tralizing agents. With the stronger caustics treatment is best given at the patient's house. If the employment of these alteratives fails to effect a cure, curetting of the cervix is the next measure to be adopted. This is best performed under an anaesthetic, although cocaine may be substituted. The canal must be thoroughly dilated, either by a tent or by mechanical dilators. The sharp curette should be employed, removing all the hy- pertrophied tissue and diseased glands pos- sible. The curetting should be followed by an application of strong tincture of io- dine, and the patient must remain quietly in bed for at least forty-eight hours subse- quently. At least a month should be al- lowed to elapse before this operation is repeated. Schroeder's operation for complete abla- tion of the diseased glandular surfaces affords, in cases of long standing, the one sure metnoa of cure. The cervix is split bilaterally to the vaginal junction, then a transverse incision at this point separates entirely upon each side the diseased mu- cous membrane. Another incision is made from the lowest point of each lateral half of the split cervix up to this transverse incision, thus removing all the diseased tissue on each side. The lowest point of the cervix is then stitched to the part of the cervical canal at which Fig. 4408.-d, e, Transverse incision of the cervix ; e,f, incision carried from a point on the vaginal face of the cervix to meet the trans- verse incision, thus remov- ing all the diseased tissue g; b, c, represents the course of the suture which approxi- mates the points f and d. Fig. 4407.-Illustrating the Dila- tation of the Cervical Canal by the Retention of its Secretions following Stenosis of the Os Externum. Fig. 4409-The Suture b, c (Fig. 4408), tightened. 487 Items. Items. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the transverse incision was made, that is, close to the os internum. The cervix then presents the same appear- ance as though it had been torn bilaterally, and is repaired in the same way (Figs. 4408 and 4409). This operation replaces the degenerated endocervical membrane by healthy vaginal mucous membrane, and represents the one radical method of cure. Charles P. Strong. UTERUS, INVERSION OF THE. Definition.-The term inversion of the uterus is used to express the turn- ing of the uterus inside out. Frequency.-Fortunately this accident is quite un- common. A very large majority of the cases follow im- mediately upon labor. As a rule, inversion, in these cases, takes place after the birth of the child and before the delivery of the placenta. Certain cases have been reported in which inversion did not take place for several days after labor. In my second case the inversion took place in the seventh week after labor. The patient had passed through a severe attack of puerperal septicaemia. There had been no haemorrhage from the vagina- during this time. She arose from the bed, and while sitting at stool had an alarming haemorrhage. The physician who was called found the inverted uterus protruding through the vulva. Braun states that of 150,000 births in the clinics under the charge of Spaeth and himself not a single complete inversion had come to their notice. There was 1 case in 190,800 confinements at the Rotunda Hospital in Dub- lin. Out of 400 cases Crosse found that 350 occurred in the puerperal uterus. He also found that inversion, sec- ondary to uterine tumors, occurred in only 40 of these cases (ten per cent.). From the following it is seen that inversion may occur at any time after labor until involution has taken place and the uterus has regained its tone. Dr. J. C. Reeve, in the ninth volume of the " Gyneco- logical Transactions," gives a report of eight cases of puerperal inversion occurring some time after labor. In Case III., on the eighth day, after getting up, the patient had haemorrhage, and on the twenty-first day after delivery inversion was discovered. In Case IV., on the eighth day the pa- tient got out of bed to evacuate the bowels, and felt something protruding from the vulva, which, more than nine months after- ward, proved to be the inverted uterus. Case V.-Complete inversion occurred forty-eight hours after labor, while the pa- tient was sitting on the vessel at stool. Case VI.-A woman suffered from in- version of the uterus, discovered on the twelfth day after delivery, but probably having its origin at the time of labor. A second labor occurred, three years later, without anything abnormal. After a third labor there was another inversion of the uterus, occurring on the thirteenth day after delivery. Ane, excited to special vigilance by what had occurred previously, had made every effort to prevent the accident. He had examined the state of the womb on the sixth day after delivery, and ascertained that it was in the hy- pogastric region, above the pubes. It appeared then that the uterine walls were neither depressed nor in- verted. Case VII.-The uterus was contracted immediately, and was felt hard and round above the pubes. The attendant did not attempt to deliver the placenta for a quarter of an hour, and then proceeded with great care. A few moments afterward the patient became pale, felt badly, and lost a great deal of blood. The ute- rus was flaccid and without action, but it contracted anew under stimulation ; there were severe after-pains. The uterus was again felt above the pubes ; it was firm and round. The finger being carried into the vagina de- tected nothing abnormal. Toward the seventh day the nurse found a body in the vagina, which on the twenty- ninth day proved to be the inverted uterus. Case VIII.-Labor, occurring on June 5th, had been tedious, but the woman got up rapidly and was about her room on the eighth day. Date of commencement of haemorrhage unknown, but attendant was called to see her on August 24th, and several times in September, and she had some haemorrhage, which was deemed menor- rhagic. On January 10th the inverted womb was dis- covered. Varieties.-Various degrees of inversion may exist, from a depression of the fundus, one horn, or a portion Fig. 441U. Fig. 4411. Fig. 4412. Fig. 4410.-Inversion of the Uterus. First Degree. (Barnes.) Fig. 4411.-Inversion of the Uterus. Second Degree. (Barnes.) Fig. 4412.-Perversion of the Uterus. (Hart and Barbour.) of one side of the uterus, to the extreme form, in which the inversion is so complete that even the cervix is in- verted. But it is rare to find the anterior lip inverted, on account of its firm and broad union by connective tissue to the bladder and pelvic cavity. Dr. Crosse, in his admirable essay on this subject, makes the following division: 1. Depression.-The fundus or placental site falls in- ward, projecting into the cavity of the uterus. 2. Intussusception.-So great a part of the fundus falls Fig. 4413.-Inversion of Uterus. (Barnes.) in that it comes within the grasp of the non-inverted portion of the uterus. In the extreme form of this de- gree the fundus reaches to the os. 3. Perversion.-The fundus passes through the os (see Figs. 4410, 4411, and 4412). Dr. T. G. Thomas gives three views in explanation of inversion : 1. That some part of the relaxed body pro- lapses, and passing out of the cervix drags the entire 488 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Uterus. Uterus. uterine body with it. 2. That some part of the relaxed body prolapsing, acts as an excitant of uterine contrac- tion, which forces the remaining portion through the cervix, and this inverts the whole organ. 3. That lateral traction and direct pressure on a cervix, the tissue of which is abnormally soft, causes eversion of this part and gradually of the whole uterus. For practical purposes all these varieties may be con- sidered under two heads, viz., partial and complete. Cases of inversion, as regards the time of their occur- rence, are either acute or chronic. By acute we mean this condition having been styled by him paralysis of the placental seat. According to Fritsch this partial inver- sion will frequently be found on abdominal palpation in cases of post partum haemorrhage. This portion of the wall which has lost its tone falls in, or is depressed by muscular contraction of that part of the uterus which has not lost its tone, these contractions occurring spontaneously, or being produced by the presence of the placenta or by the administration of ergot. Just as soon as the portion that falls in or has been depressed comes within the grasp of the other part of the uterus, contrac- tion continuing, the organ may very easily invert itself. Dr. Mathews Duncan describes a passive inversion due to a loss of tone or inertia of the whole uterus, in which the organ is driven down entirely by intra-ab- dominal pressure, or by traction from below, and not by uterine contraction. Dr. T. G. Thomas once saw this perfectly illustrated in a cadaver upon which he was called to perform version soon after death. As he ex- tracted the child the flaccid uterus followed it directly and was completely inverted, the placenta still adhering. Dr. Denman observes, "there is reason to believe that the uterus has been inverted when, on account of a haemorrhage, or some other urgent symptom, the hand has been introduced within the cavity of the uterus while in a collapsed or wholly uncontracted state, and the placenta being withdrawn before it wras per- fectly loosened, the fundus of the uterus has unexpect- edly followed, and a complete inversion has resulted." Expressing the placenta when the uterine walls are relaxed, the fundus being grasped by the hand and forcibly squeezed, and pushed down directly toward the os, may produce inversion. Many think this is Crede's method of expressing the placenta. I thought it the proper way when I was a student in the Lying-in Hospital, and now ■wonder why I did not invert every uterus I took hold of in my frantic attempts to deliver the placenta. Dr. Thomas states that inversion may oc- cur, when there is complete relaxation, from a very insig- nificant exciting cause, as coughing, sneezing, or change of position. Meissner attributes this accident to a bodily predisposition, owing to a laxity of fibre. Siebold says that atony of the uterus, with a large pelvis, and the too rapid abstraction of the contents of the uterus, may ex- pose the patient to inversion. Shortness of the cord has also been alleged as a cause, but a cord ten inches long will permit, and has permit- ted, the expulsion of the foetus without displacement of the uterus ; and it is very rare indeed to find the cord as short as ten inches. As to the shortening of the cord when it is twisted around the neck, this can rarely be the cause of inversion, since it seldom occurs unless the cord is longer than usual, and it very seldom reduces the cord below twelve inches (Churchill). After considering the above causes, which have un- questionably been potent factors in producing inversion, I think the explanations given by Drs. Thomas, Den- man, and Taylor cover the whole subject in respect to the puerperal uterus. Diagnosis.-Ordinarily the diagnosis, in cases occurring at the time of labor, is made with no difficulty. The patient usually feels something give way and is seized with pain, and often with tenesmus of the bladder and rectum. The pain may be so severe, or the haemorrhage so profuse, that collapse takes place and death ensues in a very short time. The shock, according to Dr. Lusk, is due, in part at least, to the sudden diminution of the intra-abdominal pressure and consequent plethora of the abdominal veins. In part it may be due to irritation and partial strangulation of the peritoneum, tubes, and ova- ries. The shock is often out of all proportion to the actual loss of blood. Shock without haemorrhage has been so great as to quickly produce death. There are authentic cases where shock attending simple depres- sion has been fatal. Often there is a sudden feeling of exhaustion, not dependent on the haemorrhage, for it may occur when there is no haemorrhage. There is at times pallor, the pulse becoming rapid. Nausea and vomiting are often present. These may be produced by Fig. 4414.-Inversion of Uterus. (Barnes.) those cases that occur during labor or before involution has taken place ; the chronic cases being those that occur after this time. Etiology.-In all cases the following conditions are absolutely necessary for the production of inversion : Dil- atation of the uterine cavity, and relaxation, thinness, or diminished resistance of the uterine walls at various points. Acute Inversion.-Causes.-Mathews Duncan's the- ory, according to Dr. Playfair, is as follows : The fun- dus is relaxed, while the lower portion is spasmodically contracted, a condition closely allied to the so-called hour-glass contraction. Supposing, now, any cause pro- duces a partial depression of the fundus, it is easy to understand how it may be grasped by the contracted portion, and carried more and more down, in the man- ner of an intro-susception, until complete inversion re- sults. Dr. Taylor maintains that spontaneous active inver- sion of the uterus rests upon prolonged natural and en- ergetic action of the body and fundus ; the cervix, the lower part, yielding first, is then rolled out, everted, or doubled up, as there is no obstruction from the contrac- tility of the cervix, which is at rest or functionally para- lyzed ; the body is gradually, sometimes instantaneously, forced lower and lower, or inverted. A dilated condi- tion of the uterus, or a flaccid condition of the walls, favors inversion. Traction made on the umbilical cord in the delivery of the placenta is, even at the present day, justly con- sidered to be a very common cause of this accident. If the placenta is attached to the fundus, and the uterus is in a state of relaxation, strong traction on the cord may invert the uterus. But where the walls of the uterus are not relaxed, this cause cannot be very active, especially when we consider how many old women (as Dr. Emmet puts it), both within and without the profession, deliver, or try to deliver, the placenta by pulling on the cord. In the Edinburgh Medical Journal a case is related in which the midwife pulled on the cord while the patient herself clasped her hands and pushed down her abdomen, at the same time straining forcibly, when the uterus be- came inverted, and the patient died of haemorrhage. The sudden emptying of the uterus, by rapid labor or by the forceps, may be followed by inversion, there be- ing no time for the uterine walls to contract sufficiently to prevent the accident. Rokitansky has described a loss of tone of that por- tion of the wall to which the placenta had been attached, 489 Uterus. Uterus. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the dragging in of the tubes and ovaries, which always takes place in inversion following labor. Occasionally there is severe abdominal pain with bearing down. When the inversion is complicated with inertia of the uterus, which unfortunately is often the case, the haem- orrhage is frightful. But there is a class of cases in which inversion takes places with few symptoms and very little disturbance. Dr. Reeve, in the article men- tioned above, reports two cases which sustain the above assertion. The absence of symptoms could not be ex- plained by the inversion being only partial. As a rule, no complication of labor is ushered in by more sudden and striking change in the patient's condition. I report the cases as Dr. Reeve gives them : Case I.-Reported by Dr. F. N. Montgomery, Professor of Midwifery in King's and Queen's College of Physicians. The patient, aged twenty-eight, was attended in her fourth labor by "a physician and accoucheur of experience and dis- cretion," who was present from 11 a.m. until 7.30 p.m., when delivery occurred. The labor had been slow, and two half-drachm doses of ergot and a dose of laudanum and peppermint were given during the night. There was no haemorrhage, but the placenta not coming away the nurse was directed to make pressure over the uterus while the doctor drew down the cord. When the pla- centa came it was followed by a tumor as large as a child's head-the inverted uterus. There was some haemorrhage, but not much. The patient felt a pressing desire to urinate, there was little change in the counte- nance or pulse, and no faintness. Dr. Montgomery saw the patient two and a half hours after delivery, and says, " I found her looking tranquil, her pulse good, firm, and quiet; there was not the least approach to that kind of overwhelming nervous distress which so often accom- panies so serious an accident." Case II.-Patient, aged thirty-five, mother of several children, was taken in labor in the eighth month of preg- nancy. She had a large pelvis. The pains were feeble at first, when suddenly a violent throe thrust foetus, placenta, and inverted body of the uterus beyond the labia externa. The uterus was as flaccid as a wet blad- der. It was carried back to its normal position, but no contraction took place, and on withdrawing the hand the fundus followed it. The organ could not be kept in place until ergot had been given and fifteen minutes had elapsed, when contraction took place. There was no haemorrhage, no pain, no syncope, nor any of the usual attendants on this accident. It is easy in acute cases to prove that an inversion ex- ists, by placing the hand on the abdomen, when it will be found that the uterine body is absent and in its place is a cup-shaped hollow. This is more easily felt as the cervix is lifted up, as has been shown by Crosse, " high above the pubes, even near the umbilicus." On passing the finger into the vagina, if the placenta has been expelled, a round, smooth tumor projecting into, or quite filling, the vagina, will be found. This, under the circum- stances, can be nothing except the inverted uterus. It is absurd to suppose that a polypus or tumor of any kind, of sufficient size to be mistaken for the inverted uterus, could be retained with a foetus in the uterus until the ninth month. Prognosis. -At the best the prognosis is serious. Crosse says that over one-third of all the cases, under whatever circumstances, or in whatever degree they oc- cur, prove fatal either very soon, or within one month. He analyzed 109 fatal cases : 72 resulted fatally within a few hours, most of them within half an hour ; 8 cases proved fatal in from one to seven days ; and 6 in from one to four weeks. According to Dr. Crampton, who has written a very able article on this subject, death ensues in about twenty per cent, of recent inversions, whatever the treatment. He states that of 120 recent cases, 87 recovered, 32 died, 1 remained unrelieved-a mortality of over twenty-six per cent. In 12 of these 120 cases the patient was moribund when first visited. If the patient survive a month the immediate danger is small, but there is a period of danger when weaning takes place or men- struation is resumed. At this time profuse haemorrhage may set in, and many of these patients die within two years. There are numerous cases on record in which the pa- tient has recovered perfect health, the uterus being still inverted. Chronic inflammation, thickening, and indura- tion of the parts ensue in such cases, the surface be- coming dry and feeling like skin. On the other hand, abrasion of the surface and ulceration may give rise to a profuse muco-purulent discharge which exhausts the patient, who finally dies from septica?mia or anaemia. Strangulation of the intestine in the uterus has been ob- served as a cause of death in one case. Inflammation of the bladder may ensue, thus adding another danger to the already long list. Even years ago it was noticed that the inverted portion became the seat of malignant disease, probably from constant irritation of the parts with an acrid discharge. If the displacement is not re- ducible and the parts are too tightly constricted, inflam- mation may set in, running into sloughing and gangrene. When reduction has been effected the uterus may recov- er its functions and pregnancy ensue. Treatment.-If the placenta is separated only to a slight extent, it is best to replace it with the uterus. If by its bulk it interferes with replacement, it should quickly be separated by running the fingers between it and its attachment, and an attempt at once be made to re- place the uterus without it. Under no circumstance should ergot be given, as it would probably frustrate any attempt at reposition by causing contraction of the uterus. In the discussion of Dr. J. C. Reeve's paper ("Gyneco- logical Transactions," vol. ix.), Dr. E. W. Sawyer, of Chicago, reported a case occurring in his own practice, where he gave ergot. " After removal of the placenta, perhaps five minutes after it, I placed the husband's hand upon the fundus, so that I might be at liberty to change some of the saturated bedding. While I was occupied I observed a great flow of blood ; I immediately adminis- tered a drachm of ergot, then placed my hand upon the abdomen, and found that the fundus had disappeared. Placing my fingers in the vagina, I encountered a rounded body presenting through the cervix. I recog- nized it at once as the fundus of the uterus, and made efforts to replace it, but I was unable to do more than dimple the inverted organ. After the lapse of ten or fifteen minutes the uterus hardened, for it was ergotized, and that condition prevented replacement of the organ. The patient quickly passed into a condition of collapse and died within three hours. The reason why I was un- able to reduce the inversion immediately was because I had ergotized the uterus, which condition seemed indi- cated to arrest the haemorrhage." While reposition is being attempted the patient, if cir- cumstances will allow of it, should be got under the influ- ence of ether. The patient being placed on the back, the whole hand should be introduced into the vagina, the fingers being brought together in the form of a cone. Direct pressure should be made upon the inverted fundus in the axis of the pelvis, the organ being pushed to one side so as to avoid the promontory of the sacrum (Barnes). Counter-pressure should be kept up by the other hand placed on the abdomen over the cup-shaped depression. If this method does not succeed in a few minutes, then an attempt should be made to put up the part that came down last. If this manoeuvre does not succeed, Merriman's suggestion may be carried out. This is, that an attempt be made to push up one wall of the uterus and then the other, alternating the upward pressure from one side to the other as the parts recede. If the uterus is too firmly contracted to allow of reposition after taxis by the above methods has been faithfully tried (the haemorrhage will probably not be beyond control in such cases), the best plan would be to thoroughly cleanse the vagina with a hot douche of a corrosive sublimate solution (1 part cor- rosive sublimate to 5,000 parts of water), and then pack the vagina-the patient being in the Sims position-with tampons of cotton which have been wet with a saturated solution of alum. It is not advisable to swab the inverted fundus with a solution of subsulphate of iron, as there always is a formation of pus in the separation of the slag 490 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Uterus. Uterus. produced by the iron, and thus the danger from septi- caemia is incurred. The packings of alum cotton can be removed in eight or ten hours, and after giving a hot douche of corrosive sublimate (1 part to 5,000 of water), fresh ones may be put in. Until involution has taken place the uterus lacks firm- ness and elasticity, so that before involution the organ is, in fact, undergoing a species of fatty degeneration, which renders the handling of it dangerous. Very little force would be necessary to rupture the organ. Reposition is, therefore, both difficult and dangerous in an imperfectly involuted uterus. A force that would be perfectly safe after involution had taken place might, in this condition, produce laceration. Again, an attempt may be made by gentle taxis, and if it is not successful the alum cotton is to be used until the haemorrhage has ceased, or until involution has taken place, which occurs in about five weeks. During the time that the vagina is tamponed, the physician should be ready to again resort to taxis if the os should relax, a condition which will be made known by an increase in the pains and by haemorrhage showing itself through the tampons. If the uterus is replaced, the hand should be kept with- in the cavity until contraction has been well established. Munde, in his work on "Minor Surgical Gynecology," describes the mechanism of spontaneous reduction in Spiegelberg's case. The reduction took place during an attack of profuse diarrhoea, with straining, whereby the uterus was forced down into the pelvis, the round liga- ments wrere put to their utmost tension, and, the diar- rhoea continuing, the inverted fundus was drawn up and gradually replaced by the traction of the round ligaments. Inversion of a Nulliparous, or Non-puerperal, Uterus, Independent of a Polypus or Tumor.-The possibility of inversion under this condition has been strenuously denied, but I think the following will prove without a shadow7 of a doubt that it can, and does, take place. Tyler Smith says: "The nulliparous organ has been knowm to invert itself, as the result of spasmodic action, in long-continued menorrhagia." Mathews Dun- can says that the walls of the uterus are so thick, and their consistence such, that even out of the body it can- not be inverted. Mathews Duncan again says that it is not rare, in connection with disease, to find the uterus en- larged, dilated, and softened. This is just the condition that favors inversion. Dr. J. C. Reeve (" Gynecological Transactions," vol. ix.) reports three cases w'hich seem to me to prove this point beyond question. I quote the cases in part as he gives them. Case I. By Baudelocque, 1790.-The patient was fif- teen years of age, and had had an habitual sanguineous flow for about two years. The flow, during seven or eight months, had been preceded by regular menstrua- tion. She was thin, extremely pale, and threatened to succumb to the incessant haemorrhage. Baudelocque found in the vagina, at the entrance of which was a hymen, an ovoid body the size of a hen's egg, larger below than at its attachment above. The hypogastric region, soft and flexible under the hand, allowed the ex- amining finger, carried up on all sides of the tumor, to be readily touched, and revealed nothing which could give suspicion of the existence of a uterus. The idea of a polypus presented itself. A diagnosis of an inverted uterus seemed better founded, and upon this Baudelocque rested ; but he regarded the inversion as congenital. Case II. By Boyer.-A woman, aged forty-four, was regular, and the mother of three children, the last con- finement having been fifteen years previously. She had never had flooding nor leucorrhcea. After having ex- perienced for a long time a sense of discomfort and heaviness in the pelvis and a dragging in the bowels, es- pecially after walking or standing, a tumor appeared at the entrance of the vagina, for which she did not consult anyone. Finally, the tumor became more and more ap- parent, and escaped from the vulva. The symptoms then becoming more severe, she consulted two medical men, who considered the tumor to be a .polypus, and proposed to ligate it. Boyer was then consulted. The tumor was pyriform in shape, a little larger than a nor- mal uterus ; its pedicle, short and thick, was surrounded by a fold under which the finger could penetrate to the depth of some lines; a probe could be passed no farther. It was slightly painful to the touch, its color grayish, its surface slightly unequal and villous, and presented at some points superficial ulcerations. At each menstrual period blood exuded from the surface of the tumor. The union of all these characteristics left no doubt as to the nature of the tumor. Case III. By T. G. Thomas, the history being fur- nished by Willard Parker.-A young woman, who had borne one child seven or eight years previously, and had never had any recognized uterine disease, while making a violent effort in rolling ten-pins, suddenly felt something give way within her, after which she suf- fered the most intense pain and became completely dis- abled. Dr. Parker being called to see her, after a hasty examination coincided with the opinion of the attending physician that a polypus had been suddenly expelled and w'as hanging in the vagina. Impressed with this belief he removed the whole mass, when, to his surprise, he found that he held in his hands the inverted uterus with its tubes and ligaments. The patient recovered. Fig. 4415.-Suture of the Os in a Case of Partial Inversion. (Hart and Barbour.) At the same time ergot should be given. Such patients should be kept in bed for at least six weeks. The bed- pan should invariably be used, and mild laxatives be given to obviate the necessity for straining at stool. Whenever inversion has occurred the greatest care should be resorted to in subsequent labors, from the well-known fact that this accident is likely to again take place. If the fundus can be got within the os, but no farther, after taxis has been tried as long as it seems best, the cervix may be closed by passing silver-wire sutures through it without denuding. The inversion being so recent, the uterus will probably then replace itself (see Fig. 4415.) Dr. T. A. Emmet was the first to suggest and success- fully practise this method. It was twice tried in my first case, the wires being once torn out by the forcing down of the fundus through the os. The second attempt proved successful. Dr. T. G. Thomas has reported twelve cases in which spontaneous reinversion and cure took place. Winckel mentions three other cases ; Abarbanell, Schw'artz, and Schultze being the observers. Hart and Barbour regard spontaneous reinversion as a curiosity, and affirm that the manner of its production is not as yet known. 491 IT terns. Uterus. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dr. B. B. Browne, of Baltimore, reported a case in the New York Medical Journal of November 24, 1883. I quote from him: " I saw a case last year in which a woman had been attended by a competent physician, who examined the uterus after confinement, and said everything was all right. She went on, without haemor- rhage or any abnormal symptom, until the sixth month after labor, when, upon rising one day, she was taken suddenly with severe haemorrhage, followed by syncope, and most probably at that time the inversion took place. In this case there was a lacerated cervix." Hart and Barbour state that inversion has "occurred independent of the puerperal condition and of tumor growth ; this is quite exceptional." Chronic Inversion.-Under this head are included all cases of inversion which take place after the puerperal month and are not connected with parturition ; also the treatment of those cases of puerperal inversion which re- sisted replacement at the time of their occurrence ; also the treatment of the puerperal inversions which w'ere not discovered until some time after labor. Cause and Method of Production.-Crosse states that of 400 cases only 40 arose secondary to uterine tumors. I can find no case where it has followed on carcinoma of the uterus. Total inversion of the uterus in consequence of the growth of contained tumors is not uncommon. Partial inversion is a rarity (Werth). There seems to be a difference of opinion as to its frequency with fibromata and sarcomata. Hart and Barbour state that it has been observed in cases of pedunculated fibromata, while it is peculiarly frequent in connection with sarcoma. A. R. Simpson states that it occurs in sarcoma in 4 out of 48 cases. He attributes this to the paralysis of the muscular wall of the uterus through sarcomatous in- filtration, and to the peculiar dilatability of the cervix observed in some cases. Winckel states that it occurs especially in myomata, either polypoid or those sessile growths which lie near the fundus. According to Karafiath, Ollive, Schavnik, and Werth, about one-eighth of all inversions are prob- ably caused by myomata. Intra-uterine tumors frequently lead to inversion at the time of the menopause, when the uterine walls are weakened and deficient in contractile power. In sub- mucous fibroids situated near the fundus, whose pedicle does not admit of extension, inversion may be occa- sioned. The uterus may be partially inverted by being dragged down by a large fibroid situated at the fundus. The firm and resisting wall of the uterus may in time be overcome by the traction and dilatation exerted by a large fibrous polypus attached to the fundus. Schroeder gives the following explanation of inversion produced by tumors: "Inversion is doubtless brought about in this way : th# uterine foundation, or base of the tumor, which consists of normal uterine tissue, becomes atro- phied (either disappearing or undergoing fatty degener- ation) by means of the pressure which the tumor exerts. A gap is thus formed in the firm contractile uterine tis- sue ; the tumor sinks into the cavity of the womb, and is driven toward the mouth both by its own weight and by the contraction of the organ. The os then opens, and the tumor sinks into the canal of the cervix, and thus the adjacent portions of the uterine wall being drawn down, a complete inversion is gradually accom- plished. In some cases, however, after the tumor has sunk a certain distance into the cavity of the uterus, the inversion is rapidly accomplished by means of uterine contraction." Winckel describes the method of inversion, when produced by tumors, as follows : These tumors first dilate the uterine cavity, next the internal os and cervical canal, and then cause descent of that portion of the wail into which they are inserted, partly by their own weight and in part by the action of the other portions of the uterine walls. The uterine wall is thinned at the point of insertion, the muscular tissue wasted, or, as Schultze has shown in illustration, it may be drawn out into a funnel-shape. Diagnosis.-At first sight it would seem that the diag- nosis of this condition from a tumor projecting through the os into the vagina or outside the vulva, and the abil- ity to make a diagnosis when inversion, partial or com- plete, accompanies a tumor, would be very easy, espe- cially if the examination were made under ether. But in certain cases and under certain conditions the diagnosis is very difficult, and great care is necessary, else a sad mistake may be made. The most eminent men have made mistakes in these cases by not being thorough enough in their examination. The symptoms usually present in those cases that seek relief are loss of health, pain in the back, bearing and dragging down, menor- rhagia, metrorrhagia, or leucorrhcea. As a result of the menorrhagia and leucorrhcea, the patient gradually becomes pale, anaemic, and weak. Health having gone, life is a burden. When the ute- rus protrudes through the vulva, the parts become irri- tated and chafed; and being no longer able to walk or sit with any comfort, the patient is made as miserable as can well be conceived. When the uterus has been inverted for some time it is scarcely larger, and is often smaller, than in the normal state. In chronic inversion a voluminous tumor distend- ing the vagina cannot be simply an inverted uterus. If a shadow of doubt exists, it is best to consider the case under examination as one of inversion until the con- trary has been proved beyond question. The bowels and bladder should be emptied, and an ex- amination as thorough as possible should be made with- out ether; then, if any doubt exists, an examination should be made, the patient being thoroughly anaesthe- tized. If this is done, and the following points care- fully observed, I do not see how any mistake can be made. On introducing the fin- ger into the vagina, there is discovered a rounded and hard, or flattened and soft, body, projecting from the os uteri. The finger sweeps around it, and rec- ognizes that it is free on all sides except at its upper extremity. Surrounding this extremity may be felt the cervix and the vaginal fornices ; if the inversion has proceeded further, the cervix is thinned out to a prominent ring, and the fornices are obliterated. If the cervix is patulous, the finger will pass up the canal, on all sides of the extremity of the tumor, for from one and a half to two inches, and will find that the cervical mucous membrane is reflected equally all round on to the neck of the tumor. If the cervix has disappeared, there remains the prominent ring in its place. Passing a tape around the tumor (see Fig. 4416), and drawing it well down, causes an obliteration of the ring at the vault of the vagina; the insertion of the tu- mor in the vaginal vault being put on the stretch, the continuity of the two parts is made manifest to the finger in the vagina. A sign insisted on by Crosse is feeling the stretched round ligaments within the tumor, and pain being pro- duced in the groins on lowering the tumor a little, so as to render the tension greater. If an incision, not a punct- ure, be made in the tumor, no anaesthetic having been given, and the patient flinch, it is the uterus. If the chain of an ecraseur around the tumor be very slowly tightened, no anaesthetic being given, and the patient complain of great pain, the uterus has been noosed (Goodell). When the tumor, grasped by the fingers within the vagina, can be easily rotated on its vertical axis, it is probably a polypus, since such rotation could Fig. 4416.-Tape passed around the Inverted Uterus, in order to draw the Tumor down, as an Aid in Di- agnosis. (Hart and Barbour.) 492 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Uterus. Uterus. not occur to any marked extent in an inverted uterus held taught as it is by the broad ligaments (Reamy). We must remember that as involution goes on, not only the muscular walls of the uterus become firmer and stiff- ened, but there are, in addition, the strong, tense suspen- sory bands furnished by the broad ligaments, which are more than ever tightened by being drawn down upon by the inverted uterus. Thus we can easily conceive how impossible rotation to any great extent would be. Again, the rotation must depend upon the size of attachment to the fixed structures above, which in the inverted uterus is the cervix, normally an inch and a half in diameter. When it is thickened by the increase of tissue incident to the irritation of chronic inversion, and when it con- tains the tense broad ligaments, it is much larger. Thus it may be seen how difficult it would be, with the uterine body between the fingers, to twist it upon the axis of its thick and tense attachment. A tu- mor filling the va- gina can often be rotated one-fourth -way round the pel- vis, or through an angle of ninety de- grees, as has been pointed out by Barnes. If by means of the finger in the vagina, the tumor be lifted to- ward the abdomi- nal wall, which is depressed by the other hand exter- nally, the external hand feels a body with a depression in the centre. Now, if the finger be passed into the rectum, and if it cannot get above the tumor found in the vagina, the mass should be dragged down by means of a tape passed around it. The finger in the rectum will then detect the absence of the fundus and will pass into the cup-shaped end. Now a sound is to be passed into the bladder and its point directed backward toward the finger in the rectum, which will disclose the fact that the uterine body is not in its place. The examination often produces contraction alternat- ing with dilatation, which condition, if observed, surely indicates that the tumor in the vagina is the uterus. Uncomplicated prolapse of the uterus ought never to be mistaken for inversion. In prolapse with inversion a sound passed into the bladder curves round and comes out of the vagina ante- rior to the inverted uterus. The tumor is to be felt con- tinuous by its origin with the inverted vagina. The diagnosis is especially difficult when inversion, partial or complete, is complicated with a tumor or a polypus. It may be easy to detect the polypus, but not the inversion. (See Fig. 4417.) W. H. Byford says that a polypus feels as if covered by a shining, smooth membrane, unless it is decomposed, while the surface of the uterus gives the sensation of push- ing the finger into plush or velvet. I have often noticed the above-mentioned sensation when examining a poly- pus with the finger. A fibroid with a short, thick, broad pedicle may be as fixed at its upper attachment as an in- verted uterus (Palmer), and thus interfere with rotation on its vertical axis. Granting that this is possible, it would be easy to find the body of the enlarged uterus- for it would be enlarged under these conditions-by pal- pation, the finger of one hand being in the rectum, and the other hand depressing the abdominal walls ; or one finger being passed well up the rectum and a sound passed through the urethra into the bladder and directed toward the rectum. When we have found what we suppose to be the fun- dus, a sound should be passed along the side of the ped- icle. If it is the uterus, the sound will pass more than two and a half inches; if it passes less than one inch, we may suspect that partial inversion complicates the polypus. In a partial inversion at the fundus, compli- cated by a polypus which is still within the uterus, the uterine cavity is always enlarged. This enlargement cannot always be made out with the sound, as the poly- pus may so fill the cavity that it is impossible to pass the sound beyond a short distance. One horn of the uterus may be inverted by a tumor and so drawn out that a sound passes up into the other horn, and thus the uterus seems of normal depth or deeper (Emmet). Under the above conditions a thorough examination under ether will disclose the cup-shaped depression. When the tumor has contracted adhesions to the cervi- cal canal on all sides, and thus prevents the passage of a sound, we are justified in breaking down these adhesions by the sound, so as to effect a passage into the uterine canal, just as soon as we have found the body with no cup-shaped depression by bimanual examination. We must not put too much reliance on the non-sensi- tiveness of the tumor in the vagina, as Emmet has found that in certain cases the uterus was as little sensitive as a polypus. If we find the vagina filled with a mass the size of a child's head, or larger, it may be impossible to get hold of it to determine if it can be rotated on its vertical axis; it is impossible to introduce a sound into the uterus, and if the patient is fat it will be impossible to palpate the uterus above the pubes. In such a case no harm can be done by carefully passing the hand, well oiled, up the rectum, the patient being etherized, and then, by pressing firmly on the abdominal walls above the pubes, the body of the uterus can be made out. If there is partial inver- sion, the cup-shaped depression will be detected. With the hand in the rectum and a sound in the bladder, the fundus may be felt. If there is still doubt, the hand may remain in the rectum while the urethra is slowly and gradually dilated until the index-finger passes in- side the bladder. Then a thorough examination can be made of the parts above the cervix. Treatment.-Formerly, after an attempt had been made for a short time to reduce the inversion, the patient was left to go through life with the deformity as best she could, or the uterus was amputated. At the present time, with the various methods at hand by which in- verted uteri have repeatedly been reduced, there is no excuse for amputation. In amputation the mortality is high, one in three (Crosse). The dangers in amputation are haemorrhage, peritonitis, septicaemia, and drawing up of the stump into the peritoneal cavity. The length of time that the uterus has been inverted is no argument for amputation. In other words, the operation for amputa- tion of an inverted uterus is unjustifiable, except when there is extensive or deep-seated sloughing, or when, after faithful attention, ulceration resists treatment. As a substitute for amputation I would advise Thomas's method of dilating the cervical ring, through an incision in the abdominal walls, with an instrument like a glove- stretcher, while the other hand in the vagina pushes up the fundus. (See Fig. 4418.) Time seems to be an unimportant factor in reduction, as a uterus which has been inverted for years is almost as easily reduced as a uterus inverted for only a few weeks. Fig. 4417.-Inversion of the Uterus, complicated with a Polypus. (Emmet.) 493 Uterus. Uterus. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tate has had a successful case of forty years' duration. White, of Buffalo, one of twenty-two years, and another of fifteen years. Every case of chronic inversion of the uterus can be cured by continued and properly directed elastic pressure. Gentle and continued attempts are pref- erable to more powerful and spasmodic efforts. No doubt inversion, when caused by a tumor, is slow part of the body immediately beyond the cervix, and is caused by a contraction of the uterine muscles. Emmet states that it is very doubtful whether the constricting cervix has anything to do with preventing reposition. Dangers and Disadvantages of Rapid Reduction.-Per- itonitis or cellulitis may follow the necessarily forcible manipulation of the inverted organ and adjacent struct- ures, and these affections may terminate fatally, or re- sult in the formation of adhesions between the peritoneal surfaces of the inverted uterus, or fixation of the organ in its inverted position, and thus render reduction at a future time impossible. If a cup is used it may unex- pectedly slip and rupture the fornix. After each attempt at reduction the patient must be put to bed and treated with opium, as if peritonitis or cellulitis were about to follow. Anaesthesia is required, both to relax the muscles and to relieve the pain which the necessarily forcible hand- ling of the uterus and adnexa invariably causes. If manual pressure is employed, it is necessary to have sev- eral assistants, and the pressure is to be kept up for from one-half to two hours only, according to the condition of the patient. In continued elastic pressure no anaesthetic is required, and little or no opium is needed. The danger from per- itonitis or cellulitis is very slight, and there is no dan- ger of rupturing the vagina. Cases have been reported in which the patient was up and attending in part to household duties while this method was being employed. In my second case the patient nursed her baby through- out its employment. Elastic pressure may be kept up for from one to three weeks. Dr. Jaggard, of Chicago, reduced an inversion of twenty months' standing by col- peurysis, after having failed on two occasions by taxis, the method employed being that proposed by Dr. Em- met. The colpeurynter was in the vagina altogether thirty-three days. Before resorting to either method the bladder and rectum should be emptied. The manual method for rapid reduction of Emmet, Barrier, Noeg- gerath, Courty, and Tate, and the instrumental method of White and Byrne, are the most practical. In Emmet's method the whole organ is grasped with the hand in the vagina, the palm forcing the fundus up while the fingers are separated to their utmost in the en- deavor to dilate the cervical ring. (See Fig. 4419.) At the same time the other hand exerts counter-pressure on the ring through the abdominal walls. When the uterus has been so far reinverted that the fundus is above the level of the os externum, the lips of the latter may be drawn together with wire sutures, and the further progress of the case left to natural forces. Barrier also grasps the uterus in the whole hand, and using the sacrum as a point of resistance, forces the cervix up against it; at the same time depressing the fundus with the thumb. Noeggarath's method is particularly applicable in re- cent cases of inversion. It consists in an attempt to in- dent and reinvert one horn or the other. The index- finger is placed on one horn of the uterus, the thumb on the other, and as much compression is used as is possible. Having succeeded in reinverting one horn, it is pushed up into the canal formed by the inversion, and is very quickly followed by the remainder of the fundus and the entire body of the uterus. Counter-pressure is ex- erted by the other hand through the abdominal walls. This method has achieved better results, probably, than any other. Dr. Thomas reports a successful result with it in three out of five cases. Courty's method consists in passing two fingers up the rectum and hooking them through the anterior rec- tal w'all into the cervical ring, the uterus having been drawn down, by a noose made of tape, to the vaginal outlet. Firm pressure is now made with the other hand in the vagina to push up the fundus, while the fingers in the rectum steady the uterus, and dilate and draw down the cervical ring. J. H. Tate, of Cincinnati, operated on a woman sev- enty-eight years of age, who had not been well since the Fig. 4418.-Thomas's Method of Dilating the Cervical Ring. in its progress and requires a long time for its comple- tion ; consequently it would seem that the method of re- duction which imitates this course would be the best one to employ. For as long a time as possible before reduction is at- tempted, vaginal douches of wrater as hot as possible- 116° F. or higher-should be given twice a day to soften the contracted uterine tissues. If there is haemorrhage er- got should never be given, if reduction is to be attempted soon after its administration. The bleeding in such cases may be arrested by the injection of very hot water. If ulceration exists, hot water should be freely used and astringents faithfully employed. The patient's general Fig. 4419.-Emmet's Method of Reducing an Inverted Uterus. (Hart and Barbour.) condition should be carefully attended to. The bowels should move each day. It was formerly supposed that reduction was hindered by constriction of the cervix, but the cervix does not constrict the inverted portion ; the constriction is in that 494 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Uterus. Uterus. birth of her child, thirty-six years before. There was complete procidentia, with the uterus entirely inverted. Only thirty minutes were occupied in accomplishing the reposition. He dilated the urethra, and introduced the index-finger of the left hand into the bladder, and back into the cervical ring, and the fore and middle fingers of plate attached to a rod which passes through the curved stem. The plate can be slowly propelled forward by a screw in the handle. " Another similar cup with a mov- able cone is placed on the abdomen over the cervical ring, and the cone advanced by means of a screw until it en- ters the ring. By now slowly screwing forward the plate in the vaginal cup, and exerting counter-pressure with the cup and cone on the abdomen, the uterus is replaced. " " It would be well to remark that the duty of the assist- ant in charge of the external parts will be simply to maintain a degree of passive counter-force sufficient to resist pressure from below." Continued Elastic Pressure.-Whatever method is em- ployed, great care should be taken to keep the instrument and vagina as clean as possible. The instrument should be removed from the vagina once each day and thor- oughly disinfected in a corrosive sublimate solution (1 to 1,000), and a hot vaginal douche should be given. The bowels should be moved every third day. An egg-shaped bulb of wood or hard rubber is passed into the vagina, and so placed that it covers the inverted fun- dus ; the stem to which the bulb is attached is fastened to a broad elastic belt, which passes between the thighs and is fastened in front and behind by buckles to an ab- dominal belt made of webbing. By tightening one or both ends of the strap the direc- tion of the bulb may be altered or the upward pressure increased. Counter-pressure through the abdominal walls over the cup-shaped depression should be secured by a firm roll of absorbent cotton several inches in diameter. This is to be kept in place by a broad strip of adhesive plaster passed entirely around the body. The vaginal vault around the fundus should be firmly packed with carbolized cotton which has been moistened in glycerine, to prevent the uterus from slipping to one side under the steady pressure of the bulb. Steady, firm, gentle pressure against the inverted fundus will tire out the contracted uterus more effectually than too much force. Reduction by the gradual pressure of an elastic bag in the vagina is quite as sure a method as the above. After packing the vaginal vault as above described, the bag is introduced and filled with hot water. It should be distended until the patient experiences a feeling of distention in the pelvis and some pain in the back. Kroner has collected six cases of inversion (the oldest Fig. 4420.-Reduction of the Inverted Uterus in Dr. Tate's case. (Hart and Barbour.) the right hand into the rectum, and pushed them up be- yond the uterus into the cervical ring. (See Fig. 4420.) " The uterus was thus firmly held between the fingers in the rectum and bladder at the cervical end, and the balls of the thumbs rested over the fundal extremity. In a few moments a decided impression was made, the fun- dus became deeply indented. At this point a star-candle, with a soft rag wound around its end, was planted against the fundus in place of the thumbs, and with strong pressure made against that part the inversion was soon completely reduced." Of all the methods for rapid reduction the principle of this one seems to me to be nearer perfect than any other which has yet been devised. It is also devoid of danger, and should be the one first tried if, in any case, rapid reduction seems at all called for. No previous preparation is needed, and there need be no fear of laceration of the ure- thra or incontinence of urine following the dilatation of the urethra, if this is done slowly and carefully. If there should be a tendency to incontinence of urine, it can be quickly ob- viated by following the directions laid down by Dr. Skene. If dilatation of the urethra seems unadvisable Dr. Emmet's advice may be followed, and the base of the bladder opened. As soon as the inversion is reduced the opening between the bladder and vagina may be readily closed by means of a few silver-wire sutures. White's method consists in pushing up the fundus, and thus putting the vaginal walls on the stretch, with a hard-rubber cup, attached to a stem and strong spiral spring, which rests against the body of the operator, so as to main- tain a steady pressure. (See Fig. 4421.) One hand is introduced into the vagina for the purpose of steadying the cup, while the other hand exercises pressure through the ab- dominal walls. Byrne's instrument consists of hard-rubber cups attached to a curved stem. The cups are of three sizes, the largest being two and one-half inches in diameter. The cup is intended to receive the whole inverted portion of the uterus, and not to simply indent a portion of it. In the bottom of the cup is a movable Fig. 4421.-White's Method of Reducing the Inverted Uterus. one of eleven years' standing) replaced by this means ; the pressure was applied for periods varying from one to eleven days. It is especially stated by several au- thorities, that they did not feel the reduction properly 495 Uterus. Uterus. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. commence until the vagina was stretched to its full ex- tent. Dr. Clifton E. Wing, of Boston, thus describes his method : " It is a well-known physiological fact that the strongest muscle, which would be powerful enough to resist great force applied for a comparatively short time, can yet be completely overcome and thoroughly stretched by the continued application of very little force. Now the whole uterus, and therefore, of course, that por- tion of it which in the given cases constitutes the im- pediment to reposition, is to all intents and purposes a muscle, a muscle strong enough to successfully resist in many cases the force applied in taxis-a force which can be applied but a little while at a time, and which more- over is often not very great, since the hand of the op- erator works at a great disadvantage and soon tires-but which cannot withstand the action of long-continued pres- sure upon the fundus, even when the amount of pressure is slight." He used a wooden instrument shaped some- thing like an old-fashioned wooden stethoscope, but with a very shallow depression for the fundus to prevent the edges from cutting into the tissues. Pressure is obtained by means of two pieces of elastic tubing passed between the thighs, where they are fastened to the stem of the instrument which projects beyond the vulva, and the ends in front and behind are attached to a waistband. By regulating these bands not only can the amount of pressure be controlled, but also the direction of the force. The instrument is to be removed daily and cleansed, and at the same time the vagina is to be well washed out. In two cases that I treated after Wing's method (one of twenty-three months', and the other of two and one-half months' duration) a soft rubber, inflated, dough- nut-shaped pessary was fastened to one end of a piece of broomstick, which had been made smooth by sand- paper. This pessary was just large enough to fill the upper part of the vagina without distending it. A piece of common hollow rubber tubing was tacked to the other end of the broomstick. One end of the tubing was car- ried forward and the other end backward, and both were fastened to a belt around the waist by safety-pins. As the inverted portion receded within the cervix, a smaller- sized doughnut was used, and the size was diminished until the fundus was well within the cervix. Then a round stick, such as drygoods-men use to wind braid on, was substituted for the broomstick, and for a pad, a rubber cap, such as is used on chair-legs to prevent scratching of the floor, was slipped over its end, and over this were tied two or three layers of a Martin rubber bandage. This was then placed against the fundus and made to follow it up to its proper place. F. W. Johnson. UTERUS, NEW-GROWTHS OF THE. The classifica- tion of the new-growths in the uterus is a difficult matter, but the following will serve its purpose as well as any. I. Neoplasms of the uterine mucous membrane. the uterus, generally from the cervix; but when found in the cavity of the uterus it is usually at the fundus. Uterine polypi may be mucous, fibrous, placental, or papillomatous in their structure. The mucous polypi are, as a rule, found in the cervix, and spring from the cervical mucous membrane. They are soft, bleed easily, and are about the size of an al- mond. The form of the polypi varies according to the amount of pressure which the cervix exerts upon them. The minute anatomy of these mucous polypi corre- sponds to the anatomy of the membrane from which they grow. The gland-ducts are dilated and appear as chan- nels on the surface. Underhill claims that these polypi may be the starting-point of malignant disease. Some authors affirm that polypi of the body are cov- ered by ciliated cylindrical epithelium, while those of the cervix have the columnar non-ciliated epithelium ; but KGstner has shown that stratified epithelium may be found in mucous polypi which have grown high up in the cervical canal. Etiology.-The glands of the cervix become enlarged by the retention of their normal secretion, and by the formation of a pedicle; they then become true polypi, which may be made up of several glands which have be- come diseased, and the polypus has then a rough or no- dulated appearance. The primary cause of this trouble is a chronic catarrhal endometritis ;] consequently there are usually several polypi where one is found. Symptoms.-There is first an increased secretion from the cervical mucous membrane, with irregular haemor- rhages and profuse and protracted menstruation. The tumors produce also considerable tension, and the patient complains of a bearing-down feeling, as if something were coming down and out of the pelvis. The pain is usually referred to the back, is spasmodic, and is de- scribed by the patient as being very much like labor- pains. Nausea and vomiting may occur as the result of the irritation of such tumors. Sterility is a common symptom, but is rather the effect of the catarrh than of the polypi, the secretions obstructing the entrance and interfering with the movements of the spermatozoa. Diagnosis.-The diagnosis is usually easy when the polypus protrudes through the os externum, but is diffi- cult when the tumor is soft and flabby and situated high up in the uterine canal. When the polypus is large, hard, and fibrous in its nature, it must be differentiated from an inverted uterus. The microscope will enable one to differentiate between a papillary cancroid or a simple mucous polypus. Prognosis.-This is favorable, as by removing the tu- mor the disease is cured, so far as that particular location is concerned; but, as is seen in the nose and elsewhere in the body, mucous polypi will recur, and the after- treatment, to prevent a recurrence, is of as much import- ance as the removal. Mucous polypi occur not only during menstrual life, but also after the menopause, and may be the starting- point of malignant disease. In a woman who has passed the climacteric the prognosis may not be as good as in a younger woman, when we consider that the tumors may at this period assume a malignant nature. Adenoma of the Body of the Uterus.-According to Schroeder this condition is to be considered as a local- ized hypertrophy of the glands of the uterus, and has been called by him adenoma polyposum. The anatomical changes resemble those of a glandular endometritis. Retention-cysts result from a chronic catarrh of the mucous membrane of the uterus, and as they reach a certain size they push out the mucous covering and be- come pedunculated. When a number of such small tu- mors lie close together and cause a circumscribed pro- jection, it is called a molluscum. In some cases these projections are so numerous that they may cause a grad- ual obliteration of the uterine canal. The tumors usu- ally grow to a larger size than those of the cervix, are dark in color, and have a roughened surface ; they con- tain a thick tenacious material, colloid in consistency. The membrane lining of the cavity of such a tumor is a typical cylindrical epithelium. The uterine mucous Mucous. Fibrous. Placental. Papillomatous. a. Benign polypi of the cervix and body. Adenomata of the body. b. Malignant. 1. Carcinoma. 2. Sarcoma. 3. Cancroid papillomata. 4. Cancroid ulcer. 5. Adeno-myxo-sarcoma. 6. Enchondroma of cervix. II. Muscular tumors of the uterus. Fibroid tumors of the uterus. a. Submucous. Fibrous polypi. b. Interstitial. c. Subperitoneal. d. Primary fibroma of cervix. e. Primary fibroma of broad ligament. Polypi.-The term polypus is used to define a pedun- culated tumor which grows from the inner surface of 496 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Uterus. Uterus. membrane is generally thickened from the chronic ca- tarrh, but in old women there may not be any such change. These polypi may contain masses of grape-like, thin-walled cysts, and then are no longer circumscribed, but diffuse. The stroma is dense and vascular, and the spindle-cells are infiltrated with small round cells. The term diffuse papillary adenoma is applied to this condi- tion. The mass of tumors may be so great as to project from the external os. Etiology.-In one-seventh of all cases they are associ- ated with uterine fibroids, and are then found on the wall corresponding to the situation of the fibroid tumor. The region of the internal os is the common seat of the dis- ease, which may be accounted for by the fact that the glands are very numerous in that situation. Seventy per cent, of all cases occur after the menopause, and then they seldom give sufficient discomfort to demand treatment. Gonorrhoeal infect on, by setting up a catar- rhal inflammation of the uterine mucous membrane, is a common cause of this disease. A strumous diathesis is also said to predispose a person to adenomatous disease of the uterine mucous membrane. According to Kiistner, such growths may result from patches of decidual membrane which have been left in Differential Diagnosis.- Mucous polypi differ from the fibrous in that they are soft, bleed easily, and are torn away without much difficulty. The position of such tumors, whether in the body or in the cervix, is not always easy to determine. They can most easily be felt during the menstrual flow, on account of the relaxation of the parts at that time, and the loca- tion can be determined by the character of the epithelial cells as seen under the microscope, the cervical tumors having epithelium with irregularly located nuclei. Treatment of tumors of the uterine mucous membrane consists in their removal and in preventing their return. They may be twisted off, cut with scissors, or, if the pedicle is thick, it is best to first surround it with a strong silk ligature and cut the polypus away with the scissors. Bleeding may be arrested by pressure, by styptics, or by tamponing the uterine canal. The re- moval of large cysts of the cervix sometimes requires the use of sutures to control the haemorrhage. If haem- orrhage is feared in the removal of these tumors, it is advisable at once to make use of the Paquelin or gal- vano-cautery. To remove tumors situated in the body of the uterus, the cervical canal must be dilated by forcible means under ether or by incision, and the tumor must then be removed by the cautery or by the ordinary polypus forceps. Diffuse adenomata are best removed by dilating the cervix, curetting the uterus with a sharp or dull instru- ment, washing out the uterus with an antiseptic solu- tion, and making applications every other day with the ordinary solution of tincture of iodine, or, better still, with the solutions of iodine known commonly as Battey's or Churchill's tincture. The former is known as iodized phenol, and consists of equal parts of tincture of iodine and carbolic acid. Churchill's tincture is made as follows : If. Potassium iodide gr. xv. Iodine gr. Ixxv. Alcohol 3 vj. Water, enough to make | j. Tampons may be retained in utero by packing the vagina firmly with vaginal tampons, which, however, should not remain in place over twelve hours. Subse- quent treatment consists in the use of an ice-bag to the abdomen, a light diet, and regular evacuations from the bowels. Opium is best administered by the rectum in the form of suppositories. Malignant New-growths of the uterine mucous membrane are carcinomatous and sarcomatous. The former variety is especially concerned with the epitheli- um, and is therefore an epithelial tumor. The essential feature of a carcinoma is the atypical proliferation of the epithelium. The cancroid or papillary form of carcinoma starts in the external covering of both lips of the cervix. It grows outward and involves the anterior wall of the vagina and base of the bladder, the posterior vaginal wall and rectum becoming diseased later. The growth sometimes takes the form of a fungoid or cauliflower tumor, so called from its resemblance to the irregular or nodular surface of that vegetable. The cancroid ulcer of the cervix originates in the deeper layer of the mucous membrane of the cervix, and is nodular in appearance and feel. Ulceration rapidly occurs in these nodules, they break down and cause great loss of tissue with the accompanying haemorrhages. Fistulae into the vagina and rectum are formed, the former being much the more common. The uterus be- comes fixed by the extension of the inflammation into the pelvic cellular tissue. The lumbar and pelvic glands become enlarged by cancerous disease as the growth extends to the body of the uterus, and invades the walls of the vagina and rectum. Metastatic deposits are rarely found in the other ab- dominal and thoracic viscera. Etiology.-Women are nearly three times more fre- Fig. 4422.-Adenoma. Section from the Region of the Pedicle. At the left is a part of cyst-wall covered with cylindrical epithelium. This cyst, as well as others, is surrounded by masses of connective tissue. Uterine muscular tissue is seen to the extreme right. the uterus, and they have therefore been called by him " deciduomata." Symptoms.-The symptoms of these benign inflamma- tions of the mucous membrane of the uterus are abdomi- nal and sacral pains. The abdominal pains are cramp- like in character, and irregular in their onset; haemor- rhage may be frequent and severe. These haemorrhages and a profuse watery or purulent discharge, with accom- panying anaemia, may give to the patient the appearance of one suffering from some malignant disease. Prognosis.-In cases of circumscribed mucous polypi of the cervix or body, the prognosis is good, for they are often expelled spontaneously, or are easily removed, and cause little discomfort to the patient after they have passed the external os. The prognosis for the diffuse adenomata should be guarded, for they are almost sure to recur ; they cause an alarming haemorrhage, and they may result in a malig- nant disease of the uterus. 497 Uterus. Uterus. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. quently the victims of cancerous disease than are men. Cancer of the uterus is almost as common as cancer of the stomach. Malignant disease of the uterus is most common dur- ing the first five years after the menopause, and about 3.5 per cent, of all women w'ho suffer from disease of the uterus during this time have cancer. The majority of women who have cancer are, or have been, married. Pregnancy and labor alone, however, do not cause a pre- disposition to cancer of the uterus, and multiparse show no greater tendency than others. Difficult and instru- mental labors, with great laceration of the parts, may pre- dispose the patient to malignant disease. Prostitutes are not particularly liable to cancer of the uterus. Schroeder has suggested that profound mental impres- sions, i.e., sorrow, trouble of any sort, might be a factor in accounting for the greater frequency of cancer among the poorer classes; but it would seem more probable that region of the kidneys or groin ; next in the thighs, stom- ach, or head. The pain is described as being sharp, bor- ing, tearing, darting, or burning. Bladder symptoms occur during the latter part of the disease, and consist in pain during and after micturition. Excoriations are often found about the vulva, and fistulse exist sooner or later in the course of the disease. (Edema of the lower extremities is the result of thrombosis of the pelvic veins from the extension of the inflammation. Patients are rapidly exhausted by the haemorrhages, the pain, and loss 'of appetite; they emaciate and have a peculiar sallow complexion which seems characteristic of the dis- ease. The conjunctivae have a bluish-white appearance, which is very characteristic. Gastric disturbances are very distressing; nausea, vomiting, and pyrosis persist to the end. If the kidneys are involved, we have symp- toms of uraemic coma, which may at any moment carry off the patient. Death in uraemic coma occurs in about forty-five per cent, of the cases. Duration.-This is usually from a few months to two years. Martin records the shortest duration of the dis- ease as nine weeks, and the longest, with repeated opera- tions, as five years. Seifert's average for medullary can- cer is eighteen months, for epithelial cancer thirty-six months. Winckel's case of recurrent papillary cancroid lived for three years and eight months. Diagnosis.-This must be made between malignant disease of the uterus and certain conditions which re- semble that disease under various circumstances. These are : 1. Conditions which follow premature labor or abor- tion with an incomplete discharge of the ovum, giving rise to an irritating, putrid discharge accompanied with severe pain and protracted haemorrhage. There may be in the same case extensive laceration of the cervix with erosions. 2. Condylomata of the vagina and portio vaginalis. 3. Sloughing submucous fibroids, which are easily mistaken for malignant disease. 4. Syphilitic ulceration of the cervix. 5. Ulcers and erosions of the cervix. When the affection is well advanced, it is easy to make a diagnosis of malignant disease by the appearance of the patient-the marked loss of flesh and strength, the pecul- iar expression of the face, the extension of the disease, the glandular enlargement, the induration of the parts, the irregular haemorrhages, and the profuse foul-smelling discharge. The prognosis is bad, but if the disease be recognized early and the portion involved be entirely removed, the patient may live for years in comfort. Treatment.-The medical treatment of malignant dis- ease of the uterus is practically nil, therefore the surgi- cal is the only one to be entertained. Cauterizing and curetting the parts are merely palliative measures, there being nothing curative in such procedures. The removal by the knife of all suspicious portions of the cervix, or the entire removal of the uterus, is regarded with more and more favor. Amputation of the cervix consists in the removal of the vaginal portion by the circular method and bringing the vaginal and cervical surfaces together with silver wire sutures ; the haemorrhage may be controlled by an elastic ligature above the point of amputation. This operation is performed with the patient on the back, the uterus being pulled down to, and outside of, the vulva with volsella forceps. Three or four silver wire sutures are passed through the cervix after constricting it with an india-rubber ring to prevent excessive haemor- rhage. The cervix is now split horizontally with the scissors, and is divided into a posterior and anterior lip, the in- cisions being carried as far as the silver w'ire sutures al- ready passed ; the latter are now drawn down through the wound, each loop is divided, and the sutures con- verted into anterior and posterior ones. The anterior and posterior lips are next amputated, and the silver sut- ures used to bring the vaginal and cervical surfaces to- gether and close the amputated surface. Fig. 4423.-Carcinoma Involving the Uterus, Anterior Vaginal Wall of the Vagina, and Posterior Cul-de-sac. a. a, Bladder with walls much thickened ; b. b. body of uterus with no carcinomatous infiltration; c, c, the growth affecting the anterior and posterior vaginal walls; d, lower portion of the vagina. poor food and poor hygienic surroundings would ac- count better for the greater prevalence of this disease among the lower classes. Traumatism is not considered a cause of the formation of uterine tumors. Cohnheim attributed the origin of cancer of the uterus and all other tumors to irregularities in the formation of embryonic development, an excessive proliferation of certain cells at a very early age of the in- dividual. Gusserow is in favor of this theory of Cohnheim, but Winckel opposes it, principally because the vaginal portion and not the vulva is the most maltreated part of the genital apparatus, and cancer of the former is ten times more common than cancer of the vulva. The fact that the number of single and sterile women who suffer from cancer is very small is not in harmony with Cohnheim's theory. Schroeder argues that if, as Cohnheim admits, many persons die within whom the germs of the disease lie undeveloped, the hypothesis will not explain why those germs should develop into tumors in others. Symptoms.-The first symptoms of malignant disease of the uterus may be pruritus vulvse, a slight increase in leucorrhoea, or a profuse watery, offensive discharge, and irregular and profuse haemorrhages. Pain is not an early or constant symptom, and is absent altogether in about six per cent. If present, it is at first sacral ; then in the 498 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Uterus* Uterus. The peculiarity of this operation is that the silver sut- ures are introduced before the cervix is amputated. The advantages are that it is easier to pass the needle through the dense tissue when the cervix is fixed with the vol- sella; the sutures serve as a means of traction when the cervix has been cut away. Other sutures are passed as it is found necessary to bring the edges of the cut surfaces together. The sutures are removed at the end of a week, the vagina being kept thoroughly clean in the meantime. Haemorrhage is controlled by this suture. When the tissues are diseased up to the region of the internal os, Schroeder's supra-vaginal excision of the whole cervix is to be recommended. The cervix is pulled down with the volsella, and the knife is carried through the vaginal mucous membrane of the anterior fornix, around the base of the anterior lip, into the cellular tissue below. The bladder is easily separated from the cervix almost as far as the utero-vesical pouch of the peritoneum. The cervix is now pulled forward and the mucous membrane of the posterior fornix is incised in the same manner. In clearing the cervix from the cellular tissue above the lateral fornix, it is better to use scissors, and any bleed- ing vessels can be tied at once. When the cervix has been made free all around, the knife is carried through the anterior lip until the cervical canal is opened. The anterior wall of the vagina is stitched to the anterior wall of the cervix before the posterior wall is cut. This prevents retrac- tion of the cervix. The wounds in the lateral fornices are closed by deep sutures which will control haemorrhage. When it is possible, by means of the supra- vaginal operation, to remove all of the can- ceroustissue.it answers every purpose ; but if the disease has extend- ed still further, the life of the patient can be saved only by total ex- tirpation of the uterus. Total Extirpation of the Uterus for Malig- nant Disease. - A n- dreas Cruce was the first to remove the uterus for carcinoma (1560); Osiander followed in 1808, Langenbeck in 1825, and Recamier in 1830. After this there wTere so many fatal cases that total extirpation of the uterus was almost forgotten, until W. A. Freund, of Strassburg, successfully removed the entire organ through an abdominal incision. Freund's Method.-The abdominal cavity having been opened, the uterus is laid hold of and each broad liga- ment is tied in three parts, the lowest ligature passing through the lateral fornix of the vagina. The uterus i§ then cut away from the broad ligaments and the knife is carried through the peritoneum of the utero-vesical pouch and pouch of Douglas, so that the whole organ is thus excised. The high mortality of this operation, seventy- two per cent., has caused most operators to abandon it for the vaginal methods. In 1879 Czerny advised the vaginal operation, and Schroeder, Martin, Billroth, Olhausen and others favored it. Different operators have made slight modifications, but they vary only in detail. Czerny's Method.-Czerny frees the cervix from the vagina, opening first the posterior cul-de-sac and turning the uterus backward. The utero-vesical pouch is opened on the anterior surface of the uterus with the fingers of the operator as a guide. Billroth and Martin do not turn the uterus, but drag it straight dowmward. Schroeder's Method.-Schroeder's operation differs from that of Czerny only in opening both anterior and posterior fornices before turning the uterus. 1. 1 lie uterus being drawn down to the vulva, the cer- vix is separated from the bladder as in the supra-vaginal amputation, but the peritoneum is not opened. The mucous membrane of the posterior fornix is incised and the cervix is freed all around. 2. The pouch of Douglas is opened and two fingers of the left hand passed in over the fundus uteri into the vesico uterine pouch, and the peritoneum is divided by cutting down on these two lingers. 3. The uterus is now retroverted on itself and the fun- dus is dragged through the wound in the posterior for- nix. 4. A needle, armed with a double thread, is made to transfix the broad ligament which is tied in two portions, an additional ligature being put around the whole. Whenever the tubes and ovaries can be brought down they should be removed. The uterus is then cut away from its attachments, and all bleeding points are secured. In regard to the closure of the vaginal wround, Winckel says: "It is generally believed that the vaginal wound can be best closed by sutures, and that it is prudent to place a large drainage- tube in Douglas' cul-de-sac, so that any secretions from the wound may find an exit. But it has been objected that it is unnecessary to provide for any discharge of the secretions except those immediately after the operation, since it is desirable that the parts should unite by primary union. The serum poured out after an operation is harm- less, as a •rule, and an exit is not necessary." The Ultimate Result of the Operations. - When cancer commen- ces in the vaginal por- tion of the cervix, the disease spreads to the vaginal fornices and cellular tissue, rarely through the cervix to the uterus; ^vlien it commences in the sub- stance of the cervix or mucous membrane of the canal, the disease extends to the cellular tissue and uterus. Ac- cording to llofmeier's statistics, the former produces the larger proportion of cases usually described as cancer of the cervix. The majority of cases, therefore, are not put in a safer position by extirpation of the uterus than by an amputation of the cervix. It would appear that the immunity is as great after the minor operation of amputation as after the major operation of extirpation. When, in consequence of extension of the disease, the radical operation is not advisable, the case must be treated symptomatically. Opium should be used freely to re- lieve pain, and the haemorrhage and discharge may be lessened by curetting, but this process must be repeated several times. When the haemorrhage is very profuse it is best controlled by hot vaginal injections of water, vinegar, dilute solutions of the subsulphate of iron, or tincture of iodine. Vaginal tampons, soaked in a saturated solution of alum or tannin, are useful, or the tampons may be applied with dry alum or tannin. Carcinoma of the body of the uterus is generally sec- ondary to that of the cervix, and it is rare to find it origi- nating in this part. It may originate in the ovaries and spread to the uterus secondarily, but the usual course is to begin with the cervix and spread to the fundus, and into the pelvic peritoneum and connective tissue. Pri- mary and secondary cancers of the body of the uterus are most common in very old women, and more frequent than cancer of the cervix in virgins and nulliparae, and their frequency lessens with recurring pregnancies. The symptoms are the same as those of cancer of the Fig. 4424.-Vaginal Amputation of the Cer- vix. To the right is seen the cervix with the ring constricting it; a suture, M, N, in position, the cervix split and the line of am- putation marked 1 to 6; a, f, anterior, and p, f, posterior, fornix. To the left is seen the cervix in cross section ; two threads are passed and the needle carried through, but not yet threaded with the wire w. (Hart and Barbour.) 499 Uterus. Uterus. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. cervix, but they are not so severe ; the discharge may be simply watery or mucous, tinged with blood ; pain is generally slight and paroxysmal. The diagnosis of can- cer of the body of the uterus is difficult: as soon as it is suspected the cervix should be dilated, and a portion of the ute- rine mucous membrane removed with the curette, for examina- tion. The prognosis isbad, the patient in all prob- ability will die within two years after the dis- ease is recognized. Treatment. - When the disease is recog- nized before the neigh- boring organs are in- volved, the whole uterus should be re- moved through the vagina. When the dis- ease has extended, or when the cancer is sec- ondary to cancer else- where, the treatment must be symptoma- tic. Sarcoma of the Ute- rus.-Sarcoma of the uterus may be mucous, muscular, or perito- neal. It may occur in the cervix as well as in the body, but is more common in the mucous membrane above the cervix. Sarcomata which do not originate in the mucous membrane may come from a pre-existing myoma. Sarcoma of the exterior of the uterus usually be- gins in the subserous tissue or in the peritoneum it- self. Symptoms.-Pain is not a constant symptom, and it is usually slight. When severe it is due to uterine colic caused by the effort to expel some portion of the tumor through the cervix. Menstruation is profuse and pro- tracted. The discharge becomes brownish and offensive when the papillary masses begin to degenerate. If the tumor is encapsulated, a pedicle may form, as shown in Fig. 4425, and the tumor may be expelled like an ordi- nary polypus. Inver- sion of the uterus has been caused by such tumors. Sarcoma of the ute- rus may be secondary to the same disease in the ovary. Patients with sarco- ma of the uterus are very pale, at times cyanotic, have consid- erable oedema, and are not uncommonly sup- posed to be suffering from some form of nephritis. Etiology.-There is nothing known as to he cause of these tu- nors. Winckel says that they are met with more frequently at the climacteric period. Of sixty- three patients, twenty-five were sterile. Sarcomatous degeneration of a uterine myoma is likewise rare. The growth of the uterine sarcoma is slow. Treatment.-Removal is the only rational treatment. Tumors of the mucous membrane may be scraped ; if pedunculated they must be cut away and the pedicle cauterized. If the uterus is enlarged and free, total ex- tirpation should be performed at once. Enchondroma of the Cervix.-Two authen- ticated cases have been reported, according to Winckel. The first by Thiede, in 1877. The patient was forty-five years of age ; she had a spongy tabulated tu- mor which had started in the cervical mu- cous membrane, and caused profuse haem- orrhages. The patient died finally from haemor- rhage and albuminu- ria. The tumor was warty, rough on its surface, and seemed to belong to the papillo- mata ; but upon sec- tion, islands of carti- lage could be seen lying in the connec- tive-tissue stroma. The second case was reported by Rein. Muscular Tumors of the Uterus.-These are usually called myoma- ta or fibroids. These tumors are also desig- nated according to the tissue in which they grow, or according to their situation (Fig. 4426). Thus we have submucous, interstitial, and subperitoneal fibroids, pri- mary fibroids of the cervix, and primary fibroids of the broad ligament. The great majority of myomata origi- nate in the walls of the body of the uterus, and rarely in the cervix, where there is more fibrous and less mus- cular tissue. Most of such tumors are interstitial and grow in the direction of least resistance. When fibroid tumors grow toward the peritoneum, they are classified as subserous, and finally, if a distinct pedicle is formed they become peritoneal polypi. Tumors without a distinct pedicle are called sessile ; these may grow to a great size, and may undergo fatty degeneration and give evidence of fluctuation, and thus may easily be mistaken for ovarian or parovarian tumors. Peritoneal polypi show a greater tendency toward calcification. Fibroids of the broad ligament are at first probably interstitial, next subserous, and finally push their way out between the folds of the ligament. Winckel sug- gests that some of these tumors must have their origin in the broad ligament, because they are too far removed from the uterus to have any evident connection whatever with it. Etiology.-The most common cause of uterine myoma is local irritation of the uterus, either direct or indirect, and tang continued ; this includes abortion, contusion, blows, falls, lifting heavy weights, and displacement of the uterus. Fibroids are most common in women between twenty- five and thirty-five years of age ; they are more common in the negress, and decidedly more common in married than in unmarried women. From Emmet's tables it may be seen that unmarried women are the least liable to fibroids ; sterile women are much more so ; while only a small proportion of fruitful women suffer from fibroids. The rate of growth is held in check by marriage and child-bearing, but these growths sometimes disappear during or after pregnancy. Fig. 4425.-Vesicular Polypus or Cysto sarcoma of Uterine Mucous Membrane Produced by a Degeneration of the Utricular Glands, aaa, Walls of the uterus : bbbb, utricular glands degenerated into cysts the size of a cherry : cc, section of cysto-sarcoma. Fig. 4426.-Interstitial and Submucous Fibroids. The submucous fibroid has developed as a polypus into the uterine cavity. 500 DEFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Uterus. Uterus. Between the ages of thirty and forty years the unmar- ried woman is fully twice as subject to fibrous tumors as the sterile or the fruitful. It seems as if the uterus should undergo the changes dependent upon pregnancy once in three years during the child-bearing period, and if the uterus is not so occupied with child-bearing, a fibrous tumor is very likely to develop. Symptoms.-The symptoms arising from the growth of a fibroid tumor of the uterus vary very much. Pain of a bearing-down character is a constant symptom and is usually mild, but at times it may be excruciating. Hys- terical symptoms develop, and the patients pass into an invalid condition before the tumor is recognized. Inter- course is painful. Dysmenorrhoea, menorrhagia, and metrorrhagia are constant sources of trouble if the tumor is submucous. After the cessation of the menstrual flow there may be spasmodic pains in the bladder or rectum, and a feeling as if something was moving about in the pelvis. Small fibrous peritoneal polypi cause but little incon- venience, but when they grow larger symptoms of press- ure become manifest. Adhesions usually form about the fibroid, and then we have symptoms of chronic peri- tonitis. Separation of subserous myomata from the uter- ine wall have been observed by many authors. Fatal haemorrhage may occur. The haemorrhage is mainly due to swelling of the mucous membrane of the uterus, but partly to the adenomata and mucous polypi which develop. Thrombi are sometimes formed in the large vessels of the tumors which give rise to haemor- rhage and suppuration. If an abscess results, fluctuation makes its appearance, and the patient has fever and pain. When the abscess is opened sloughing follows, and the patient may soon die from the suppurating process. Ponisky found profuse menstruation and mucous dis- charge to be the only constant symptoms in cervical myomata. Anaemia, headache, anorexia, nausea, vomit- ing, nervous twitchings, and oedema of the lower ex- tremities may also be present, if the tumor is of consider- able size. The menopause is a favorable time for a patient having a fibroid tumor, for the tumor at this time may atrophy and become so small as to cause no discomfort. Winckel, however, gives a case in which the haemorrhages con- tinued a year after the climacteric, and one day became so severe as to cause the death of the patient; so that we cannot safely or surely look upon the menopause as giv- ing entire relief to a person suffering from a fibroid tumor, particularly if it is submucous in character. The diagnosis is easy when the tumor is of large size and firm consistency. The chief conditions which must be differentiated from uterine fibroids are pregnancy, pelvic perimetritis, parametritis, displacements of the uterus, chronic metritis, ovarian tumor, and inversion of uterus. The pregnant uterus feels softer and more yielding on palpation. Menstruation is not interfered with in three- fourths of all cases of fibroid, but is more profuse, lasts longer, and recurs at frequent intervals. The size of the fibroid tumor may not correspond to the history of the patient as regards her last menstrual period. In the case of a fibroid the cervix remains hard and does not under- go the changes which are to be expected in pregnancy. Souffles are present in ovarian and fibroid tumors as well as in pregnancy. Hamatocele, Para- and Perimetritis.-The onset of these tumors is sudden, they fill more or less completely the true pelvis, and are attended wfith considerable pain and constitutional disturbance. An hsematocele is soon followed by anaemia and evidence of loss of blood. These tumors under treatment gradually diminish in size and become more uneven and compact, while fibroids undergo no such change except after a long period of time, or unless the menopause comes to the rescue of the patient. In inversion of the uterus the fundus is not in its usual place, there being a distinct ring with a depression in the centre. No pedicle can be found in inversion. An in- verted uterus bleeds easily. Prognosis.-A large number of patients retain fibroids with little discomfort, and with little change in size and consistency, for many years. In some women the meno- pause lessens the severity of the symptoms, wdiile in others it makes little or no change. In ten per cent, of all cases death is a direct result sooner or later, and it may occur in several ways: ex- cessive haemorrhage, anaemia, dyspnoea, emaciation, and exhaustion. Schroeder reports a mortality of 29.5 per cent, of his cases following operation. Treatment.-Medical treatment is confined almost en- tirely to the administration of ergot, either by the mouth or hypodermically, and to electrolysis.- The haemorrhage due to uterine fibroids may be con- trolled by the internal use of ergot or hydrastis, and by the use of vaginal douches of hot water (115°-120°). To relieve the neuralgic pains the bromides in large doses, with tampons of chloral and iodoform, may be used. This mixture is made of one part chloral, one part iodo- form, and four parts of glycerine. The bowels should be kept open with mild laxative drugs, and an occasional enema of salt and water may be given. The systematic use of ergot hypodermically will re- duce the size of some fibroids, and will hold others in check and prevent their further growth. The following is Winckel's solution of ergot for hypo- dermic use : 3. Ergotin gr. 37| Salicylic acid gr. f Distilled water § ss. Squibb's solution of ergot can also be used subcutane- ously without harm. Fluid extract of hydrastis, 25 drops, three times a day, may be combined with ergot or given alone. It controls the haemorrhage well and is the next best remedy to ergot. Chian turpentine, in doses of gr. iij. to v., is highly spoken of by some authors to control uterine haemor- rhage in cases of fibroid tumors. When all these remedies fail, and the haemorrhage threatens the life of the patient, the cervix must be dilated and the uterus curetted to determine whether or not an adenoma of the mucous membrane be present. The uterine cavity may be swabbed out with the sesquichlo- ride of iron or tincture of iodine, or washed out with the above drugs diluted with equal parts of water. Electric- ity is highly recommended in uterine myomata. The two electrode needles, about eight inches long, are in- serted into the tumor and the current is allowed to flow for fifteen or twenty minutes. The operation, repeated nineteen times, is said to have stopped the growth in twenty-six cases, but was without effect in ten others. In very large intra-uterine, submucous fibroids, Martin directs opening the wall of the uterus, enucleating the tumor, and then sewing up the incision in the manner suggested by Sanger. The removal of large tumors situated in the walls of the uterus is best performed by laparotomy. After the abdomen has been opened and the tumor brought out, the spermatic vessels are ligated on both sides in the broad ligament, outside the adnexa. A double ligature is passed around the round ligament, which is divided. The tumor is then lifted up and the cervix is constricted by an elastic ligature, and the an- terior and posterior peritoneal incisions prolonged so as to unite at least two inches above the elastic ligature. During the extirpation which follows, the uterine ar- tery is isolated and ligated, and the cut surfaces of the cervical mucous membrane are cauterized with a ten per cent, carbolic solution. The mucous membrane is united first, and then the two surfaces of the exsected wedge are sutured at different levels, and the stump is covered by the peritoneum. Finally, the elastic ligature is removed, haemorrhage is checked, the stump and the abdominal cavity are cleaned, and the abdominal wound is closed (Schroeder). When the tumor is very large and subserous, and its extirpation dangerous and contra-indicated, then the 501 Uterus. Uvula. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. menopause may be artificially anticipated by the removal of the normal ovaries, in view of the fact that the meno- pause exerts a favorable influence upon myomata. Electricity or electrolysis in the treatment of uterine fibroids.-Electrolysis is the resolving of compound bodies into their constituent elements by passing through them a current of electricity. Electrolysis would only take place in that part of the body which is in a fluid state. The strength of the current may vary from 100 to 250 milliamperes. Apostoli speaks of using a current as strong as 250 milliamperes with perfect safety. He des- ignates the electrodes as active and passive. The active electrodes used are of two kinds, usually combined in one instrument-a long, moderately thick probe, finished at one end like a uterine sound ; the other end straight and shaped like a spear with cutting edges. One end is guarded when the other is in use ; a rubber or glass tube is used as an insulator. The passive electrode consists of a pad of clay to cover the abdomen, the current is connected with a cop- per or lead plate which is placed on the clay pad. This arrangement makes the resistance stronger and distri- butes the current more evenly. The internal or active electrode is generally negative unless haemorrhage is a troublesome symptom, when the positive becomes neces- sary for haemostatic purposes. The sound is used more often than the spear ; the lat- ter is only used when the fibroid is within easy reach through the vagina, or when the tumor is intra-mural ; in such a case the spear is passed along the uterine canal and plunged a short distance into the fibrous mass. Martin, of Chicago, has devised a medical dynamo, operated by a small engine. It differs from the ordi- nary machine in being constructed so as to be capable of generating two distinct currents. Each current can be increased from zero to its full power without altering the speed of the machine. It also possesses an auto- matic device by which the current is not allowed to reach a strength which can do harm to either patient or machine. There is no symptom of fibroid tumors of the uterus which yields more readily to electricity than the severe pain which so often accompanies them. Engelmann uses gold or platinum electrodes which are insulated with glass or rubber. The abdominal dis- persing plate is made of thin lead or tin alloy, covered with absorbent lint or buckskin. Before placing the abdominal plate in position the abdomen must be ex- amined for abrasions or excrescences ; if there are any they should be protected by oil-silk. The instrument which is to be used in the uterus must be thoroughly disinfected and the vagina cleansed by a douche. When the discomfort caused by the introduction of the instru- ment has ceased, the current is established and gradually increased ; the first sitting should not last longer than five minutes, and the current should not exceed 150 mil liamperes. After the full current has been attained and has continued the stated time, it is slowly and gradually reduced cell by cell until zero is reached. If a puncture is made, greater care should be taken that all the details of the operation are antiseptically carried out, and the vagina should bejamponed for a short time afterward. The advocates of electricity in the treatment of fi- broids do not claim that the tumor is always made to disappear, but only that the growth has been arrested in nearly every case, and that in many instances it has been diminished in size. Charles Ware. UVULA AND SOFT PALATE. Anatomy.-The soft palate, or velum pendulum palati is, as its name implies, a movable curtain or fold formed by a duplication of the mucous membrane which covers the hard palate and is continued backward from it. It contains muscular fibres, an aponeurosis, vessels, nerves, and mucous glands, and forms a valve, more or less complete, be- tween the mouth and the pharynx. Its inferior border is free and pendulous, and is prolonged in the middle into a small conical process, the uvula. At each side it presents two curved folds known as the arches or pillars of the soft palate, and which, starting from above at a short distance outside the median line, extend down- ward and outward, diverging in their course to form the triangular space in which lies the tonsil. These folds are called respectively the anterior and the poste- rior pillars of the palate. "The anterior descends to the side of the tongue, while the posterior runs downward and backward into the pharynx. The space between the anterior arches of the palate, leading from the mouth to the pharynx, is called the isthmus of the fauces. The mucous membrane covering the greater part of the velum, as well as its free margin, is covered with pave- ment epithelium. At the upper part, however, and near the orifice of the Eustachian tube, ciliated and columnar epithelium is found. The epithelium of the gland-ducts is also, in many instances, of this character. At birth the whole posterior surface of the velum is lined with ciliated epithelium, which later becomes squamous. The soft palate is acted upon by five pairs of muscles, two superior, two inferior, and one intermediate. The superior muscles are the tensor palati and the levator palati, the two inferior are the palato-glossus and the palato-pharyngeus, and the intermediate is the azygos uvulae. The tensor palati, or circumflexus, arises from the an- terior aspect of the cartilaginous portion of the Eusta- chian tube, from the navicular fossa at the root of the internal pterygoid plate, from the spine of the sphenoid and the edge of the tympanic plate of the temporal bone; it descends vertically between the internal ptery- goid plate and the inner surface of the internal pterygoid muscle, and terminates in a tendon which winds around the hamular process, being retained in this situation by some of the fibres of origin of the internal pterygoid muscle, and lubricated by a bursa ; it extends horizon- tally inward, and terminates in the anterior part of the aponeurosis of the soft palate and the under surface of the palate bone. The levator palati muscle arises from the under sur- face of the apex of the petrous portion of the temporal bone, in front of the orifice of the carotid canal, and from the adjacent cartilaginous parts of the Eustachian tube. It passes downward and forward, approaching the median line, and is expanded upon the posterior sur- face of the soft palate as far as the median line, where its fibres blend with those of the opposite side. Supe- riorly, it is placed above the concave margin of the supe- rior constrictor. The palato-glossus muscle (constrictor isthmi faucium) is a fasciculus, narrower at the middle, which forms, with the mucous membrane covering it, the anterior pillar of the soft, palate. It arises from the anterior sur- face of the soft palate, on each side of the uvula, where its fibres are continuous with those of its fellow of the opposite side, and, passing forward and outward in front of the tonsil, is inserted into the side and dorsum of the tongue. The palato-pharyngeus muscle, occupying the poste- rior pillar of the palate and forming, with the palato- glossus the triangular space in which lies the tonsil, arises in the soft palate by fibres connected with those of the opposite side, and passing partly above and partly below those of the levator palati and azygos muscles. As the muscle descends it becomes greatly expanded and its fibres are found extending from the posterior cor- ner of the thyroid cartilage backward to the middle line of the pharynx, some of the fibres decussating posteri- orly with those of the opposite side. The azygos uvulae muscle, so called from having been supposed to be a single muscle, consists in reality of two fasciculi ; these arise from the posterior nasal spine of the palate bone and from the tendinous structure of the soft palate, and descend to be inserted into the uvula. The fasciculi are separated by a slight interval above and unite as they descend. Physiology.-Physiologically, the soft palate and uvula play an important part in two separate and dis- tinct functions ; namely, in deglutition, and in the pro- 502 Uteru*. Uvula, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. duction of the voice, or articulate tone. In general, the function of the soft palate is practically that of a curtain or valve, by means of which the buccal cavity and lower pharynx are shut off from the naso-pharynx. The office of the uvula is not so apparent. There can be little doubt, however, that it acts mechanically, in like man- ner with the corpora aurantii of the aortic valve of the heart, in filling the triangular space in the middle line of the posterior wall of the pharynx, made during the act of deglutition and at other times, by the contraction of the palato-pharyngeal muscles. It may also serve to direct the secretions of the nasal cavities, in their descent to the outer world, in such a manner as to leave them upon the base of the tongue, whence they may be readily removed. In vocalization the soft palate plays a most impor- essential part of it is a slender metallic rod (Fig. 4427). a is that part of the rod, four inches in length, which is inserted within the nose. The end to the left being fur- nished with a bulb, and that to the right with a screw thread for an attachment to b, which is a delicate piece of vulcanite, marked by a number of annular depres- sions. That part of the rod marked c extends from b, and represents the section of the instrument which is brought in contact with the Ludwig kymographion cyl- inder ; it measures four inches in length and terminates in a thin, flat, flexible end for the purpose of making a tracing. The arm a is inserted within the nose in such a manner that its extremity rests upon the posterior aspect of the soft palate, while the arm c is in apposition with the anterior nares and is held in position by a flexible copper wire as is shown in the illustration (Fig. 4428). The rod being adjusted so as to secure the best effects when the palate is raised, and the subject seated in front of the kymographion, already prepared with carbon-covered paper, it will be found that, when the free end of the lever touches the cylinder, the latter being in motion, and the palate raised, a distinct tracing will appear upon the cylinder, and the difference between the long and short sounds of the vow- els will be found to correspond with the curves made by the rod upon the kymographion. When the instrument is in position and the palate is raised, as in the first act of deglutition, a tracing is made which, when analyzed, is found to be composed of a number of acute depressions, interrupting a horizontal line. While it may be assumed that, as a rule, the out- lines are made by the upper surface of the soft palate striking the end of the rod as it lies within the naso- pharynx, it must be remembered that the rod may be pushed from side to side, horizontally, by the contraction of the two levator palati muscles. Accordingly, if the rod be placed in the right nostril, it will be pushed from left to right ; if in the left nostril, from right to left. These lateral curves are best recorded by placing the ky- mographion-cylinder in a horizontal position, The cor- relation between the two kinds of curves is sufficiently exact to permit either the one or the other to be used ; the upright position is, however, the more convenient. A large number of tracings are given by Dr. Allen, il- lustrating the principal sounds, and a fairly complete outline of the method is placed before the reader. By it, the fact that the soft palate is raised in the production of all articulate sounds, and that it is raised in the acts of swallowing, of coughing, and of hawking, can be readily demonstrated, and the length of time during which it re- mains elevated, and the duration of the time of ascent and descent, can also be ascertained. The palate is seen to be raised once only for some words, twice for others, and three times for others. The numbers of these motions are fixed within a narrow range of individual variation. The size of the curves, however, is not fixed, owing to the difficulty of always reaching precisely the same spot of the broad upper surface of the velum. But the curves, whether broad or shallow, hold the same pro- portion to one another as shown in various tracings of the same letter or word. By proper care in freeing the end of the rod from contact with the salpingo-palatal fold, the exaggeration of the curve can be in great meas- ure prevented. The bulb at' the end of the rod also should be always of uniform size and shape. The palate myograph may be of use in studying the mechanism of the soft palate in disease as well as in health. It is evident that in paralysis of the palate the motions would be absent, and that by this method a means of detection of this condition is available. It should also prove of service in the investigation of the mechanism of defects of speech, and in determining the degree of degeneration of the levator palati muscles in progressive dry aural catarrh. As the soft palate ascends, its oval surface becomes concave. This concavity is occupied by the convex tant part, as has been shown by three classes of experi- ments : 1, by direct observation ; 2, by the modification exerted by the palate on the expired air ; 3, by the de- grees of force exerted by the muscles themselves. Of the various methods of direct inspection, the fol- lowing may be noticed. J. Hilton, in a case of acquired defect of the face, was able to study directly the move- ments of the soft palate. Lennox Browne has examined it from the oral aspects, and has recorded some of the appearances present by means of photography; Du- chenne has studied the effects of electrical stimulation upon its muscles, while Konig and Hensen have endea- vored to record its movements by studying the effects of the expired air upon a flame. Various other impractica- ble means have been suggested, but no attempt seems to have been made, in any of the above experiments, to re- cord the degrees of elevation of the palate. Czermak, in his investigations, pursued the simple method of lying upon his back, filling his nasal cavities with tepid water, and then uttering the various vowel Fig. 4427.-The Palate Myograph. Fig 1428 -The Palate Myograph in Position. sounds. From the quantity required to force open the closure formed by the soft palate, the degree of fixity for each vowel is ascertained. He is said also to have constructed an apparatus by means of which he made a public demonstration. It was found that the soft palate was most relaxed in pronouncing the sound "ah," less relaxed for " oh," and most contracted for " ee." By far the most elaborate and scientific method yet proposed is that described by Harrison Allen, of Phila- delphia, by which he has been enabled not only to give tracings of the movements of the soft palate in the pro- duction of simple tones, but also to record accurately its variations in vocal efforts of any length or complexity. The instrument used is called a palate myograph. An 503 Uvula. Uvula, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. dorsum of the tongue, in certain sounds, but it is separ- ated from the tongue in other sounds. The correlation of the tongue and the palate is, as a rule, exact enough to warrant careful comparison of the two factors in the mechanism of speech, so that the palate myograph may, probably, be employed in the study of phonetics, to- gether with other forms of glossographs as accessory. It is possible also that the myographion may be made available for the comparative study of language, for the instruction of the deaf, and for the formation of a system of logography, or short-hand writing. Diseases.-The diseases of the soft palate and uvula may be classified into two groups, namely, general and local. In the first division may be grouped such as are symptomatic, and merely the local manifestation of a general condition, such as measles, scarlet fever, diph- theria, syphilis, tuberculosis, and lupus. Although the local lesion in any of the above affections cannot com- pare in importance with the general disease, there may arise certain conditions under which the throat affection may become of decided importance, as wull be seen later on in the study of chronic inflammation, diphtheria, and syphilis of the parts. Local affections of the soft palate include the various inflammations which may attack it, such as simple hyperaemia, acute, subacute, and chronic catarrh, oedema, and phlegmon, as well as gen- eral relaxation, dilatation of the superficial blood-vessels, paresis, new-growths, and congenital malformation. Inflammation.-Acute catarrhal inflapimation of the uvula and soft palate presents the following symptoms : The uvula is reddened, swollen, and somewhat sensitive, the sensitiveness increasing at each effort of deglutition, and the patient experiencing a sharp pain, as from the presence of a foreign body in the throat. If the inflam- mation be severe, oedema of the submucous connective tissue and of the muscular tissue beneath may occur, giving rise to an acute prolapsus of the uvula, and at- tended with much irritation and discomfort. These anatomical changes are usually temporary, and disappear with the subsidence of the attack. Follicular and her- petic inflammations of the uvula are usually associated with the same condition in the pharynx, and therefore show no features which are distinctive. Phlegmonous uvulitis is characterized by the greater intensity of the accompanying inflammation. The uvula is very much swollen and reddened, and the pain is ex- cessive. The sensation is as of a heavy, voluminous body in the mouth, which in the act of deglutition gives rise to lancinating, almost unbearable pain. Respiration, be- sides, is more or less seriously impeded. In such cases the inflammation involves both the mucous membrane and the submucous connective tissue, and also the azygos muscle, and it may extend to the neighboring parts. The causes of the above-mentioned forms of inflamma- tion of the uvula are, in general, as follows: Influence of cold, or of irritating substances, such as too hot food or drink, burning or irritating alkaline substances or mineral acids ; and finally, progressive inflammation ex- tending from the neighboring parts. As already men- tioned, the symptoms of acute uvulitis do not last long, and the disease can usually be shortened by the applica- tion of medicines such as are generally used for similar conditions elsewhere. Sometimes the disease becomes chronic, especially when the inflammation is often re- peated, or the patient is suffering from constitutional disease or general disturbance of nutrition. The chronic catarrhal form of uvulitis presents all the well-known changes in appearance which are common in like affections of the pharynx and larynx. A granu- lar condition of the mucous membrane is especially fre- quent, originating in a hyperplastic inflammation of the mucous glands. The surface of the uvula is hard, red- dened, and covered with small nodules. Between the latter the mucous membrane is indurated, hyperaemic, and insensitive. The condition is often associated with a similar disease of the pharynx, and it occurs most fre- quently in strumous and anaemic subjects, or in those whose general nutrition has become impaired. It is a somewhat stubborn affection, for which general as well as local treatment is required. Relaxed Uvula.-Chronic inflammation of the uvula usually ends in prolapse and hypertrophy, a condition which may give rise both to direct and to reflex irritation of a serious nature. One of the chief causes of relaxed uvula or, more properly speaking, of the catarrhal troubles which occasion it, are vicissitudes of climate and variations of temperature, especially in countries where there is a frequent combination of cold and wet weather. Exposure to night air, or to the vitiated atmosphere of crowded and over-heated rooms, over-indulgence in eating or drinking, and excessive smoking are among the causes of relaxed throat. It is a common companion of the alcoholic habit, often being associated with the gastric catarrh which attends that condition. Occurring in the morning, it is probably due to mouth-breathing from nasal or naso-pharyngeal obstruction ; in the evening, from fatigue. It is often seen in those suffering from general depression, and when it is observed in women in whom uterine disease is present, it is probably the result of the general enfeeblement caused by the latter, rather than of any distinct reflex influence. Marked elongation of the uvula is often present in strumous children and in those in whom the tonsils are enlarged. It is sometimes congenital. In general, any cause which may produce a relaxation of the velum palati may also be followed by relaxation and elongation of the uvula. The symptoms of an acute attack of relaxed palate are a sensation of fulness and stiffness of the throat, together sometimes ■with the sensation as of a foreign body. There is also an uncomfortable feeling of dryness, and a desire to make repeated efforts to dislodge the supposed foreign substance. The symptoms may quickly subside, or they may con- tinue for several days. Examination reveals more or less congestion of the parts, although this is sometimes so slight as hardly to be noticeable. There is also slight swelling, and often a varicose condition of the smaller veins. The elongated state of the uvula may give rise to a greater or less degree of local irritation. Sometimes this becomes excessive, giving rise to persistent and se- vere attacks of coughing. In case the uvula be long enough to touch the epiglottis or the larynx, severe par- oxysms of coughing may occur whenever the patient lies upon his back. This may cause him much distress upon lying down at night, and", should he turn upon his back during sleep, may waken him with a sense of impending suffocation. When the condition has become chronic, or is congenital, these suffocative attacks may be of al- most nightly occurrence, the patient being obliged to sleep with the head raised by several pillows to obtain any immunity from them. Sometimes the attendant hyperesthesia of the pharynx is so pronounced that the patient may be subject to sudden fits of violent, spas- modic cough upon the slightest provocation, or even without any apparent reason at all. The writer has seen a case of spasmodic stricture of the oesophagus, in a pa- tient suffering with elongated uvula and hyperaesthesia of the pharynx, which was cured by amputation of the uvula. Again, so great may be the irritation that cough, loss of appetite and sleep, and nausea and vomit- ing may result in such pronounced emaciation, anaemia, debility, and malaise that the case may, upon superficial examination, be taken for one of phthisis. Indeed this error is not infrequently made. Proper treatment of relaxed uvula generally results in the cure of the disease. The various exciting causes of the trouble should, if possible, be carefully avoided. The patient should be directed to live in a dry and bracing climate. Indigestion or constipation, if present, should be corrected. 2\.naemia and debility must be re- moved by the administration of tonics, and the local condition is to be treated by the application of mild as- tringent sprays or insufflations. If the uvula be much elongated, if it be a source of irritation, and if it refuse to retract under the influence of local treatment, it should be shortened. 504 Uvula. Uvula. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Amputation or abscission of the uvula has been prac- tised among many peoples from a very early date. Al- though in itself an apparently insignificant operation, it is one of such great utility and importance that a brief review of its history will prove interesting. For this we are indebted to a valuable and exhaustive article by Dr. Ethelbert Carroll Morgan, of Washington, D. C., according to whom it appears, from the Hippocratic and other treatises, that excision of the uvula was occasion- ally performed in early times. There is, according to the best reading and interpretation, evidence to prove that Hippocrates was at one time in the habit of ampu- tating uvulae by means of his finger-nails, although he also employed cutting instruments. Celsus seized as much of the organ as he deemed it advisable to retain with a pair of forceps, and cut below the instrument. Fabricius ab Aquapendente excised with scissors only, and applied a heated (not incandescent) spoon to the bleeding stump. No obstinate haemorrhage is mentioned by these authors. Albucasis, Avicenna, and Oribasius, also Aetius, removed the uvula by cutting instruments. Some of the older surgeons surrounded their operations upon the uvula with great ceremony, and a regard for details quite praiseworthy. Paulus uEgineta, for ex- ample, was accustomed to employ instruments expressly made for this operation : a staphylagrum to hold the uvula, a staphylatome to divide it, and a staphylacaus- tum to cauterize the wound. Galen, Mesue, Nuck, and Boss seem to have belonged chiefly to the expectant school, ignoring surgical procedures in treating elon- gated uvulae-the three latter advising traction upon the hair of the head to such a degree as to tear the skin from the cranium. This traction was accomplished by tying the hair up in a ribbon near its roots, and twisting until a top-knot was formed. It may not be generally knowm that, even to this day, the southern negroes of the United States, and the peasantry in many parts of Cen- tral Europe, resort to this grotesque procedure with im- plicit faith in its never-failing power to raise the palate. Mesue also directs the operation to be performed with a heated scalpel of gold. During the reigns of Antoninus and Severus, Aphrodesia violated the public confidence and made himself famous by seeking to inspire the fear that those persons who suffered excision of the uvula at its base would always die of consumption. Cauteriza- tion is first mentioned by Demosthenes, of Massilia. The Arabians destroyed uvulae by caustic and by the red-hot iron. Pare used the ligature, and the two Fa- bricii, at various periods, scissors, caustic, and ligature. M. Tholozan, in a note upon excision of the uvula by Persian barbers, says that, in the districts of Semnan and Fironz-Kouh, situated five days' march to the east of Teheran, excision of the uvula is practised by the Per- sian barbers on nearly all the children, as a prophylactic against inflammation of the throat. They use a strong wooden spatula and a thick steel rod, whose sharp end is curved on the flat or shaped sometimes as a complete ring, 7 to 8 mm. in diameter. They are so constructed as not to endanger neighboring parts. The barber passes the spatula rapidly into the throat and presses it from behind forward against the uvula. He then applies the cutting instrument to the concavity of the uvula pro- duced by the pressure of the spatula. The uvula is then cut by pressure combined with lateral movements. The piece cut off is withdrawn by the two instruments held in juxtaposition. They practise this operation very dex- terously, charging for it a few centimes. Women per- form it also in the harem. The practice dates back many generations. It is usually done at the age of one, two, or three years. In addition to preserving them, as they suppose, from danger of frequent and severe sore throats, they think the danger of suffocation is lessened. No ac- cident seems to occur in connection with this operation. The practice is confined to the districts mentioned, where inflammation and catarrh of the throat are very frequent. According to the learned Professor Wilhelm Meyer, of Copenhagen, the cutting of the uvula has been cus- tomary in the northern provinces of Iceland, if not over the whole country, from the earliest times. The opera- tion is performed, as a rule, during childhood ; if not then, later in life. It is done partly because it is sup- posed to be able to prevent diseases of the throat, and partly because there is a great deal of superstition con- nected with the results of the operation-for example, in preventing sickness and general indisposition. It is stated by a merchant from Iceland that he knew a child of seven or eight years, who was very small, and its slow growth was supposed to be caused by the fact of its uvula not having been removed at an early age ; the operation was performed in the hope that the child, would thrive better in consequence. The same gentle- man also says that the uvula has been cut in grown-up persons after angina, to prevent relapse, but never during the disease. He never heard of any case where an un- fortunate result such as haemorrhage followed the op- eration. Dr. Meyer has himself seen two vela, whose uvulae had been cut away, in residents of Ofiord and Husavik, in the north part of Iceland. In both cases the uvula was cut off at the root, and in both it was done in children one or two years of age. The operation, which is thought as necessary as vac- cination, is performed by peasants who are accustomed to do it, and of whom there are one or more in each par- ish. They do it with an instrument which is a little like Physick's tonsillotome, and the instrument is called Ufurskaeri and made with great skill by the smiths. It is said to have been performed less frequently during the last few years. Thus, it appears that the principle upon which is constructed one of the most useful and popular surgical instruments of to-day, owes its origin not to the present time but, perhaps, to remote antiquity, the idea of the ring tonsillotome having been suggested to Phy- sick, of Philadelphia, sixty years ago, by the ring uvula- tome then in use in England, which, in its turn was evi- dently derived from the prehistoric Norseman. At the present day uvulotomy is practised with an increasing degree of discretion, as some reproach has been cast upon it by the indiscriminate and clumsy man- ner in which it has sometimes been performed. For the more convenient and perfect performance of the operation many instruments have been devised, and the instrument-makers present a great variety of ring uvulatomes, with spring and trigger arrangement, by which the operation is intended to be accomplished in- stantaneously ; ring uvulatomes without the above com- plications ; scissors straight, curved, or hooked, and armed with serrated clamps by which the uvula may be seized and held, while the scissors are accomplishing the process of separation ; hooks, forceps, and various other appliances for holding the organ while it is being cut by some other weapon ; each instrument bearing the name of some contemporary authority, and each, as may be in- ferred from the above historical record, of great proba- ble antiquity. Unfortunately, age does not add to their value, and in the vast majority of instances they are un- necessarily complicated, expensive, and clumsy, hinder- ing the operator rather than assisting him in the skilful performance of the operation. By far the simplest and best instrument is a pair of long-handled scissors, having the blades curved side- ways toward the right hand, and one blade hooked at its tip so that the uvula may not slip from its grasp. A holder, made on the principle of Sims' uterine thumb- forceps, an instrument about eight inches in length, pos- sesses the advantages over other forceps that it has not the inconvenient scissors-handle, that it may be held firmly and with great steadiness by allowing'its proxi- mate end to rest in the hollow between the thumb and forefinger, the whole hand meanwhile being steadied by resting the fourth and fifth fingers against the patient's chin, and, finally, that in applying the scissors the for- ceps may be used as a guide. In operating, the patient's tongue should be held down by himself, or by an assistant, with a tongue-depressor. The amount necessary to be removed having been care- fully estimated, the uvula is grasped by the forceps at a point below the proposed line of incision and drawn 505 Uvula. Uvula. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. slightly forward. The scissors, carefully guided by the hand and eye of the operator, are then applied, and the separation of the redundant tissue is completed. The same result may be obtained by means of the Jarvis snare, in the use of which it is only necessary to seize the part to be removed in the loop of the Scraseur, with- out the aid of the forceps. This latter method is not painful, if cocaine anaesthesia be employed, and it has been found by the writer to be particularly convenient and effective. Should there be any fear of exciting un- due bleeding, the galvano-caustic loop may be used, the uvula being first drawn forward as in abscission by the scissors. As was long ago pointed out by Llewellyn Thomas, the line of incision should be directed from be- low obliquely upward and backward, in order that the wound may be exposed as little as possible in the act of deglutition. Local anaesthesia should always be secured before the operation by the application of a solution of cocaine, from four to eight per cent. Pain during and after the operation will vary greatly in different cases. While in the case of a slender, anaemic uvula it may be very slight, in a thick, congested, hyperaesthetic one it may be severe and annoying, and the process of healing may be protracted frorq two days to a week. Morell Mackenzie insists that, where there is any follicular dis- ease of the throat, it is most important to cure that affec- tion before the uvula is amputated, as, owing to the after- pain caused by the removal of the uvula, patients will not submit to any further treatment when they have re- covered from the operation. Hence the patient remains uncured, and the operation, and he who performed it, are brought into discredit. The amount of relief, however, possible from this apparently insignificant procedure, is sometimes remarkable, the whole train of symptoms, lo- cal and reflex, vanishing as if by magic, the general health returning to a normal basis, and voice gaining markedly in quality and power. This, however, is not invariably the case, as the reflex symptoms may be slow in leaving, not disappearing entirely until a considerable length of time has elapsed. This possibility should be recognized and explained to the patient to avoid disappointment. While the operation of uvulotomy is attended with the slightest possible degree of danger, and the bleeding which follows it is seldom more than a few drops in amount, in certain rare instances haemorrhage more or less troublesome in its character has resulted. In his exhaustive thesis upon this subject, already quoted in another part of this article, Dr. E. C. Morgan has col- lected and reported no less than twenty-three cases of severe bleeding after uvulotomy. Of these, one, of great antiquity, dating back to a.d. 1035, is found in one of the sagas of Iceland. In this it is stated that Erick, an earl, the son of Hakon, was on his way to Rome, but died in England from an uncontrollable haemorrhage, which resulted from cutting his uvula. As the result of his investigations Dr. Morgan believes that, excluding the snare and the galvano-cautery, the particular instrument used does not play an important part in the production of haemorrhage. In the vast majority of instances, the scissors or uvulatome was employed. On the other hand, the existence of an anomalous distribution of the arteries or veins of the velum palati may be an impor- tant factor in producing haemorrhage, while excessive hypertrophy, or the existence of a varicose or haemor- rhoidal condition of the vessels, would certainly predis- pose to bleeding. Operations performed during the ex- istence of acute inflammation, oedema, or ulceration, are more likely to be succeeded by bleeding than when made for simple prolapsus. The character of the bleeding is usually arterial, as is evidenced by the color of the blood, the spurting of the vessels, and the pulsation of the stump. Nevertheless, venous haemorrhage is sometimes noticed. Troublesome bleeding is not necessarily attributable to the removal of too much of the uvula, for a simple clipping has caused profuse haemorrhage, while extensive removals may be almost bloodless. The existence of the haemorrhagic diathesis would of course exert an influ- ence in rendering bleeding after uvulotomy persistent, although there is not a clearly established case of this nature on record. Morgan offers the following conclusions : A fatal or uncontrollable haemorrhage has in one instance followed uvulotomy. A persistent, obstinate, or alarming haemorrhage is only encountered in the rarest instances. A moderate bleeding, ceasing spontaneously or by the use of mild styptics, occasionally happens. The loss of a few drops of blood at the time of operat- ing, followed by slight oozing, is of common occurrence. The most reliable surgical methods for controlling uvular luemorrhage are the ligature, compression by the Fig. 4429.-Spring-clamp for Arresting Haemorrhage after Amputation of the Uvula. clamp or forceps, or the use of the galvano- or actual cautery. The most reliable styptics are, in the order named, solid silver nitrate, or iron persulphate, directly applied to the bleeding stump, and solutions of gallo-tannic acid, or alum. To these may be added the local use of ice, ice-water, and vinegar. The most reliable systemic means are opium, lead acetate, sulphuric acid, and ergot. Ordinarily, the best plan to avoid bleeding is to urge the patient to refrain from attempts at clearing the throat. Should it persist, it may usually be checked by the sucking of cracked ice, or gargling the pharynx with hot water. Applications of the solid nitrate of silver, or of the galvano-cautery, are also effective, or in severe cases a ligature may be applied to the stump. A device at once simple and effective is the method of applying direct pressure. One of the small spring- clamps used in retaining shirt-sleeves in position, is trimmed down with shears, the spring weakened, and a string attached to a perforation made in one of its arms. The arms of this improvised instrument are widely sepa- rated by means of a dressing-forceps, and quickly slipped over the uvula and well up on the soft palate ; the for- ceps are then withdrawn, and the clamp remains securely fastened and in the desired position. The teeth of the clamp should be slightly filed down prior to introduc- tion, and the string attached to the instrument secured to the patient's ear. Occasionally, the operation of uvulotomy is followed by a somewhat slow process of healing, and attended with considerable pain, deglutition becoming almost impossible, and even the swallowing of the saliva caus- ing inconvenience. In such cases the patient should be 506 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Uvula, Uvula. directed to abstain from such articles of diet as seem likely to increase the irritation. Indeed, it is well in all cases to recommend that bland and unirritating food be taken until the healing process is fairly completed. Gum arabic, or a marsh-mallow drop allowed to dissolve in the mouth, will give decided relief, while, in case the granulations become exuberant, an application of the solid nitrate of silver will hasten recovery. When much pain is experienced in swallowing, the applica- tion of a four per cent, solution of cocaine is indicated. Pain reflected to the ears may be annoying, for which applications of laudanum, atropine, or cocaine, by means of absorbent cotton, to the external auditory meatus, are recommended. The highest authorities are unanimous in insisting upon the deleterious effects of an elongated uvula upon the voice, and upon the vital importance to that function of remedying the evil. Malformations of the uvula are not infrequently ob- served. In addition to asymmetry or absence of the part, two common varieties of deformity are met with, viz., congenital elongation or undue length, and the con- dition known as bifid or double uvula. In the former the whole structure, including the muscular tissue, is lengthened to a greater or less degree beyond the normal limit, the amount of elongation in some recorded in- stances being incredible. Rankin, of Pittsburg, an un- impeachable authority, has reported the case of a farmer who consulted him for a chronic and persistent cough, and attacks of suffocation, the latter being more severe when he was lying down. Examination revealed the fact that the uvula had grown to an immense size, and that it was so much elongated that the patient could take it between his teeth. Upon its removal it was found by actual measurement to be over four inches in length. At its lower extremity there was a knob or expansion, the size of a large hazel-nut. This terminal enlargement had probably been of great service, for it was too large to allow the uvula to pass into the glottis, and therefore probably prevented frequent attacks of laryngeal spasm. Congenital elongation of the uvula has been observed by the writer as an hereditary trait, several members of the same family showing the same condition of general hypertrophy and lengthening. The condition is easily remedied by the amputation of the redundant part. Bifurcation of the uvula, a result of arrested develop- ment, is quite common. It may be regarded as the least possible manifestation of cleft palate, and may occur in any degree, from a slight indentation at the tip of the or- gan to complete division of it to its base. It often exists without giving rise to symptoms indicative of its pres- ence. When it is attended with much hypertrophy it causes the same abnormal symptoms which are observed in ordinary hypertrophy. Abscission of the redundant portion is effective in securing relief. This, however, is a clumsy method of operation, since, if the bifurcation be extensive, a broad, truncated stump is left. To avoid this, in the opinion of the writer, some attempt at a plastic operation should be made, in order to secure, if possible, the union of the two stumps in the median line. This may be accomplished, in the majority of instances, by first removing the tips of the two uvulae, and then de- nuding, with small curved scissors or the galvano-cautery, the inner aspect of each well up to the base. New-growths.-Papillomatous growths, generally of small size, but sometimes of sufficient dimensions to cause irritation, are occasionally seen upon the uvula. They are usually located near its free extremity, and may be either pedunculated or sessile. Two specimens of extraordinary size may be found in the collection of Professor Lefferts, deposited in the Museum of the Col- lege of Physicians and Surgeons, New York. These growths seem to occur more commonly in patients suf- fering from tubercular disease or syphilis. They are also found independently of any diathesis. Myxomata of the uvula are occasionally seen. Angeiomata or vascu- lar growths may also occur. Such a case is reported by Phillips, in a man thirty-nine years of age, in whom the uvula was greatly enlarged in all directions. Its length was two inches, its diameter five-eighths of an inch, and it terminated in a bulbous expansion considerably larger than the diameter of the uvula above. When in repose this mass hung well down behind the base of the tongue, but caused little annoyance except when the patient was eating. With slight effort the tumor could be forced forward upon the tongue. Numerous small, dark blue, apparently venous dilatations, were visible over the en- tire surface of the growth. The condition had existed about two months ; the tumor continued to increase in size, and, within three months, was about one-fifth larger than as above described. It was successfully removed, with but slight haemorrhage, by means of the galvano- cautery, and the patient made a prompt recovery. Mi- croscopic examination showed the growth to be a cav- ernous angeioma. Occasionally a benign growth may be attached to a pedicle so long that the tumor itself escapes observation until drawn upward and forward. In all of these cases amputation of the uvula above the site of the growth is at once successful in relieving the difficulty. Malignant growths of the uvula and soft palate are occasionally encountered, usually, however, as an exten- sion of the disease from adjacent parts. Syphilis, tuberculosis, lupus, and lepra of the velum and uvula are met with, the first often, the last three rarely. The main points in the differential diagnosis between them are, that in syphilis the various lesions common to this disease are usually disposed upon the soft palate in a markedly symmetrical arrangement, they are but slightly painful, and they yield quickly to specific treat- ment. Tubercular ulcers are far less common than the former ; they are usually superficial ; they often give rise to extreme pain, and they coexist with well-marked disease of the lungs, and generally with other manifesta- tions of ulceration in the pharynx. The differentiation of lupus from syphilis of the soft palate is sometimes difficult, especially if the patient be also suffering from general syphilis. The chief characteristics of lupus are that the normal sensitiveness of the part is maintained; or, if altered, there is anaesthesia. The tubercles are multiple, which distinguishes it from carcinoma ; they are rounded, their surface is smooth and glistening, and their color is bright red. They are firm in consistency, but less firm than epithelioma. The diagnosis may be confirmed by the presence of external manifestations of the disease. Lesions of the mucous membranes, com- mon in leprosy, never occur until the disease has clearly manifested itself in other parts of the body. As a rule, therefore, little doubt can arise as to the true nature of the pharyngeal disease. Here, as elsewhere, the course of lepra is one of active and widespread destruction. Syphilis of the Velum Palati.-The occurrence of the primary lesion of syphilis, although now and then observed upon the tonsil, is, upon the velum, almost un- known. In the secondary manifestations of the disease, howr- ever, the soft palate and uvula are frequently involved. The conditions presented are those commonly seen in the adjacent parts of the oral cavity, and include simple erythema or congestive patches symmetrically disposed, submucous infiltration, mucous tubercles, followed by mucous patches, or by the formation of condylomata. A peculiar feature of these manifestations is their sym- metry, which, as is often seen upon the uvula, is so well marked as to attract the attention of the observer. Early in the disease the congestion may be so indistinct as to escape observation. Gentle irritation, however, will often cause the distinctive character to be intensified. Considerable rise of temperature often accompanies the first appearance of this form of sore throat. The tertiary form of syphilis may occur in the soft palate at any period of time beyond two years after the primary infection. It is characterized by true ulcer- ation or loss of tissue, and is the result of the degener- ation of gummatous deposit. The effects upon the velum palati of tertiary syphilis are often most disastrous. A frequent seat of gum- matous infiltration, its exposed situation and delicate 507 V villa. V a ('dilation. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. texture, render it liable to serious injury as the result of tertiary ulcerative processes. These are often character- ized by extensive loss of substance, and are followed by marked cicatricial contraction, and the formation of ad- hesions between the remaining tissue and the neighbor- ing soft parts, which not only destroy the velum itself and abolish its functions, but result in a closure or a shutting off of the upper pharynx from the lower. This closure is more or less complete in proportion to the extent of adhesion present, and may vary from a slight narrowing of the aperture, due to adhesions at the outside angles of the velum, up to a degree of occlusion which seems absolute. Two varieties of cases may be described : 1. Those in which simple ulceration has taken place, at or near the margins of the velum, with- out material loss of substance. In such cases, the ad- hesions being limited to a somewhat narrow band of union between the edge of the velum and the pharynx, and the greater part of the velum itself being intact, the prognosis is good. 2. When the loss of substance has been considerable, and when the soft palate has become extensively adherent to the pharynx, relief becomes a matter of extreme difficulty, and, in many cases, is next to impossible by any known plan of treatment. In the worst cases the whole posterior surface of the velum, and the superior surface of the soft palate, seem to be firmly incorporated with the posterior pharyngeal wall. In these cases the roof of the mouth and the posterior wall of the pharynx seem to be continuous, the line of adhesion not being traceable in the confused mass of cicatricial bands which represent the original structures, and which are sometimes disposed in the shape of ir- regular vertical digitations, between which there may be one or more places in which the adhesion is incomplete, and through which a probe may be passed. Cases, how- ever, in which complete occlusion has actually taken place must be extremely rare, as the possibility of such an occurrence has been denied by many good author- ities. The writer has never seen one in which, by care- ful search, a communication between the upper and lower pharynx sufficiently large to admit a probe could not be found. Should the opening be invisible upon in- spection of the pharynx, it may generally be demon- strated by forcing air into the nasal cavities by means of a Politzer inflator, observing meanwhile, from the presence of bubbles in the pharynx, any points of exit which may exist. The results of extensive adhesion of the velum to the pharynx are most distressing, and may be summed up as follows : 1, Mouth-breathing, with all of its attendant evil results ; 2, impairment of the quality and tone of the voice ; 3, interference with drainage from the nasal cavities and naso-pharynx ; 4, consequent upon this, loss of hearing from irritation of the Eustachian tube, and the almost inevitable occurrence of serious middle- ear disease ; 5, loss of the sense of olfaction, owing to the lack of air-current through the nasal passages, nec- essary to bring the odoriferous particles in contact with the olfactory membrane. When the passage to the lower part of the pharynx is contracted, there is sometimes dysphagia and dyspnoea. The treatment of this condition consists in the attempt to separate the adherent tissues, and to establish, more or less perfectly, communication between the upper and lower pharynx. To carry out this design w'ith success is one of the most difficult problems of surgery. Perfo- ration of the velum through the breaking down of gum- matous deposits is said to be a cause of serious danger to that organ, since, having thereby lost to a greater or less degree its muscular vigor and resiliency, it is liable to swing backward against the pharynx, instead of being held at a normal distance from it, so that perforation renders it all the more liable to subsequent adhesion. The common mechanism by which adhesion takes place, however, is the same as is observed in the cicatricial union of the fingers of the hand following burns. De- spite all possible care, the cicatrizing surfaces begin to unite at the bottom of the angle between the members, and the process of adhesion continues until the denuded surfaces, throughout their whole extent, have become firmly joined to each other. In the treatment of these unfortunate cases the first care should be to prevent adhesion, by checking with all possible diligence the appearance and spread of ulcer- ation upon the parts. Not only should the iodide of potassium be freely administered, combined if neces- sary with mercury, but local applications of nitrate of silver, or the acid nitrate of mercury, to the ulcers, if they be spreading, or, if indolent, of a solution of sul- phate of copper (gr. xv.- § j.) should be made. Failing in this, means should be used to keep the ulcerated sur- faces apart. For this purpose several methods have been proposed, but as they apply as well to the sepa- ration of the parts after operation, they will be described later. The prognosis as to the results of operation must depend largely upon the extent of deformity present in a given case. Where the degree of adhesion is comparatively slight, the adherent surfaces may be separated by means of a small, flat knife. As the tendency to reunion is inevitable, it will be necessary, after operation, to use means for preventing this. Of these the simplest is the application to the cut surfaces of monochloracetic acid. This forms an adherent eschar, under which the healing process seems to progress to such a degree that, when the eschar separates and comes away, the period in which adhesion would have taken place has passed, and the parts heal without uniting. Few cases, however, are so simple as to render the above method possible. Perhaps the most valuable plan of treatment yet suggested, is to separate the united parts by means of the galvano-cautery, and then to use great diligence in keeping them apart, and in maintain- ing full dilatation of the passage. This may be done by repeatedly- drawing forward the remnant of the velum by means of a palate-hook, used by the patient himself ; or, as has been suggested, a piece of tape may be passed through each nostril and out at the corresponding angle of the mouth, the velum being thus drawn away from the posterior pharyngeal wall ; or, as is claimed to have given the best results, a piece of metal shaped to fit the space between the velum and the pharynx may be sus- pended from two stout threads passed forward through the nose, and tied so as to hold the plate in position. This, worn constantly, serves as a permanent dilator. In cases in which the degree of deformity is excessive, the best that has been accomplished is to widen the channel of communication between the upper and lower pharynx sufficiently to allow the nasal secretions to be drained away. This has been done by applications of the galvano-caustic knife, followed by constant dilatation, practised by the patient himself by means of some form of sound. It is highly probable that by the last-men- tioned method an opening of considerable size may be maintained. Preliminary to operating upon such a case, much aid may be secured by passing a sound backward through the nose, and demonstrating the lowest and most superficial point of the pharyngeal pouch. By cutting against the point of the sound used as a guide, an en- trance may easily be effected. Finally, it must be said that, although the prognosis as to relief of adhesion of the soft palate to the pharynx is often most unpromising, much may be done to help the sufferer by skill, ingenuity, and unremitting patience in the application of the means already at hand. Neuroses of the Velum Palati and Uvula.- These may be either sensory or motor. With the former may be classed anaesthesia, hyperaesthesia, paraesthesia, to which may be added vaso motor neuroses, and, pos- sibly, neuralgia. Motor disturbances include spasm, or increased mobility, and paralysis, or diminished mobility. The causes of these neuroses may be either central or pe- ripheral, and they may be either unilateral or bilateral. In addition to the central causes which may produce anaesthesia of the velum, it may also be present in epi- lepsy, chorea, and hysteria. It commonly occurs after diphtheria. It may be caused artificially by certain drugs, among which may be mentioned cocaine, mor- 508 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Uvula. Vaccination. phine, chloral, and bromide of potash. The symptoms, if present, consist usually in a feeling of relaxation of the part, or a sensation as of the presence of cotton or wool in the pharynx, sometimes associated with a feel- ing of pain. Hyperaesthesia is often met with, and may be due to elongation of the uvula, inflammations of the pharynx, acute and chronic, the presence of a new-growth, or a dilated condition of the blood-vessels. Neuralgia seems to exist in certain rare cases, in which, without apparent cause, lancinating pain is experienced, and areas of localized tenderness may be found. Paraesthesia often occurs. Schech observes that the affection, when independent of disease of the mucous membrane, is most frequently associated with hysteria and hypochondriasis, or with a fear of diphtheria or syphilis. Those individuals are most prone to it whose occupation demands excessive use of the vocal organs, as also are chlorotic or anaemic persons, women who suffer from gastric or uterine disease, and those whose temperament is excitable; more rarely it is a symptom of disease of the brain, or of bulbar paralysis. Of the motor disturbances from which the velum may suffer, spasm is the more unusual. It is almost always associated with a similar conation of the pharynx, and is found in the same conditions which cause it in the latter. Paralysis of the velum is a common condition, and one of much importance. It may be due to central causes, such as acute, chronic, and degenerative diseases of the brain ; to diphtheria ; to local diseases, or, finally, it may be associated with facial paralysis. The paralysis may be either unilateral or bilateral, partial or complete. When unilateral the velum and uvula are drawn toward the unaffected side, the faucial arch on the affected side is wider, and that of the sound side is narrower than nor- mal. During phonation there is distinct distortion to- ward the healthy side. In bilateral paralysis the uvula hangs loosely in the pharynx, showing no sign of volun- tary motion, and flapping back and forth with the acts of respiration. During phonation, in partial paralysis, a slight upward movement of the soft palate may be no- ticed, while, when the paralysis is complete, it remains immovable. Besides the causes mentioned, there are several influ- ences under which paretic conditions of the velum may occur. Thus, it is not uncommon to find it more or less paralyzed after severe acute affections of the pharynx other than diphtheria, and while its presence, after what appeared to have been a simple follicular tonsillitis, may cause the accuracy of the diagnosis to be held in ques- tion and suggest the presence of diphtheria, there are so many other conditions, evidently not diphtheritic, by which it may be brought about, that the possibility of its occurrence from simple causes is beyond doubt. Not only may it be found after acute affections of the throat and naso-pharynx, but, as is more common, it may be present in chronic conditions, as, for instance, chronic pharyngeal catarrh, chronic hypertrophy of the tonsils, and hypertrophy of the adenofd tissue at the pharyngeal vault. It is found also in cases of chronic nasal catarrh, and associated with posterior hypertrophy of the inferior turbinated bodies. It may also occur as an accompani- ment of an elongated uvula. The results of this condition are generally evident, both to the patient and to the observer, and it is probable that the defects of speech generally present in, and attributed to, adenoid hypertrophy at the vault, are due rather to the attendant paresis of the soft palate than to the me- chanical obstruction of the pharynx. The treatment of neuroses of the soft palate must be conducted in accordance with the exciting cause present in a given case. This must be demonstrated, and, if pos- sible, removed. Catarrhal conditions must be treated, adenoid hypertrophies removed, and the various systemic disorders with which it may be associated properly dealt with. Locally, direct therapeutic measures are important, the principle involved being the effort to restore tone to the enfeebled muscular structures. To this end the fa- radic current is valuable, the negative pole being applied to the affected part, or outside, along the angle of the jaw. Systematic exercise of the velum is also beneficial, and may be secured by such gymnastic exercises as fre- quent gargling, the singing of high notes, or, better still, blowing through a small tube. In the case of children this may be accomplished by allowing the patient to practise daily at blowing soap-bubbles. D. Bryson Delavan. VACCINATION is a process by which a definite, speci- fic disease, with well-marked characteristics, known as vaccinia or cow-pox, is introduced from one animal into another animal, either of the same or of another species, by inoculation. So far as is known, the species which are susceptible to this process are all mammals, and are few in number, the human species and the cow being alone worthy of mention as having special importance in this connection. The term vaccination is occasionally used in a broader sense to denote the inoculation of any disease, susceptible of transmission by artificial processes, from one individ- ual to another, either of the same or of another species- as the inoculation of cholera. In this article the term will be employed only in its limited sense, as applied to the specific disease vaccinia or cow-pox. The object of vaccination is, ultimately, protection against small-pox. As a means to the same end it is also largely employed for the purpose of propagation, continuance, and multiplication of the virus of vac- cinia. History.-To Edward Jenner, an English surgeon of the last century, must be accorded the honor of intro- ducing and establishing the practice of vaccination as a protective measure against small-pox. The history of vaccination is like that of many other important discov- eries. It had a traditional existence from an earlier period, and had undoubtedly been practised to a limited degree in other countries. Von Humboldt states that it had been known and practised from an early period among the Mexicans. Sulzer in 1713, and Sutton and Fewster in 1765, called attention to the properties of vaccine.1 But no one had given to the subject careful observation and study until Jenner, then a surgeon's ap- prentice living at Sodbury, near Bristol, noticed that people who acquired cow-pox by milking cows affected with that disease, acquired an immunity from small-pox. From the time of his first observation, in 1768, to the date of his announcement of the result of his researches to the world, a period of thirty years elapsed, during which time he had patiently and carefully investigated the sub- ject both by observation and experiment. Dr. H. A. Martin says of him, " He was a truly great and philo- sophic man, worthy to be, as he was, the chosen pupil and life-long friend of John Hunter. If ever a dis- covery was announced to the world with due delibera- tion, it was that of vaccination. We have evidence that for at least thirty years, during which he encountered many perplexing and discouraging obstacles, and one by one mastered and overcame them, this mighty matter occupied the brain of Jenner before he published ' An Inquiry into the Causes and Effects of the VariolaVoc- cince, a Disease discovered in some of the Western Coun- ties of England, particularly Gloucestershire, and known by the name of Cow pox.' It was ten years after the discovery first engaged his attention that, in the year 1780, timidly, and under the seal of confidence, he re- vealed to his bosom friend, Gardner, his mighty hopes for the great good of his fellow-creatures. . . . Such was the slow, careful, almost painful deliberation and completeness with which the mind of Jenner moved to its great goal."2 Jenner made his first vaccination upon the human sub- ject in 1796, published the results of his inquiries in 1798, and established the first public institution for the performance of vaccination in 1799. In 1800 the prac- tice was introduced into Germany, France, and the United States. 509 Vaccination. Vaccination. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The following were the principal points which Jenner had established by his inquiries : (1) That the vaccine disease casually communicated to man has the power of rendering him insusceptible to small-pox. (2) That the specific cow-pox • alone, and not other eruptions affecting the cow which might be confounded with it, has this protective power. (3) That the cow-pox may be communicated at will from the cow to man, by the hand of the surgeon, when- ever the requisite opportunity exists ; and (4) That the cow-pox, once engrafted on the human subject, may be continued from individual to individual by successive transmissions, conferring on each the same immunity against small-pox as was produced in the one first infected directly from the cow. The practical usefulness of this great discovery lies in the possibility of transmitting vaccinia from one human being to another, or, as is quite largely practised at the present time, from the cow to the human species. Phenomena of Vaccinia in the Cow.-Vaccinia in the cow is an eruptive vesicular disease, the eruption being usually limited to the udder and the teats. It may oc- cur in single cases, either in an animal kept alone, or in a single animal of a herd, or it may attack a whole herd, or a part only. It is confined almost exclusively to milch-cows. Ceeley's earlier observations supported this statement ; but in a later paper he reports a single case of primary infection in an animal not giving milk. The earlier stages of the disease are so mild as rarely to attract at- tention, and hence are rarely seen by the expert at this period, except in herds where the disease attacks a con- siderable number. After its first appearance in a herd, it is readily conveyed from one animal to another by the milker's hands, unless the greatest care is taken to pre- vent infection. Distribution.-Vaccinia has been met with and de- scribed in all parts of the world where the cow exists. In Great Britain, France, Germany, Holland, Italy, Ben- gal, South America, Mexico, New England, Pennsyl- vania, and California, cases have been reported and described, and in not a few of these the genuine charac- ter of the disease was proven by experiment. It was found in epidemic form at Valladolid and at Atlisco, in Mexico (near Puebla), in 1803. Genuine cow-pox was also observed in Wiirtemberg, on sixty-nine different oc- casions, between 1827 and 1837, and was transferred suc- cessfully to the human subject in at least 170 out of 210 trials (Hering : " Ueber Kuhpocken an Kiihen"). Seaton says of its prevalence : " After the first ardor of search had relaxed, there were for many years but few recorded instances of the disease being found, and it was believed to have become much rarer, in great measure, no doubt, because it was less sought for. There can be no doubt that much more would be found than really is found, if it were only looked for." Other noted cases were those which were observed at Passy (1836), at Esneux (1868), at Rouen, at Dijon, at Stuttgart, at Beaugency (1866), at St. Mande, and at Cerons (1884). In support of this statement of Dr. Seaton, the later observations of Dr. Sanderson, an inspector of the Privy Council of England, in 1863, are presented (" Sixth Privy Council Report," London, 1863, p. 213) : "Mr. Hancock, of Wedmore, sees cases of cow-pox com- municated to milkers every spring, without exception, the vesicles very rarely extending beyond the margin of the hand which comes in contact with the teat in milk- ing. He had made one experiment with vaccine-lymph derived directly from the cow. The local effects were described as severe. " Mr. Leonard, of Dursley, says that cow-pox appears in the Dursley dairies about once in three years, and during its prevalence inoculation of the hands of the milkers is of frequent occurrence. "Mr. Larke, of Rendcombe, Cirencester, took me to see a dairy where I examined four or five animals. In all, the teats were beset with irregularly disposed vesicles and scabs. " Mr. Ormond, of Westbury-on-Trim, Clifton, intro- duced vaccine-lymph directly from the cow into his district about four years ago, and has since vaccinated continuously from this supply. "Mr. J. J. Evans, of Bristol, obtained vaccine-lymph from the cow about fifteen months ago, and has success- fully taken such lymph eight or ten times." Other cases have been observed in recent years in the same vale of Gloucester in which Jenner made his orig- inal researches. The writer has observed at least twenty cases in Mas- sachusetts, in seven different dairies, in the towns of Lynnfield, Reading, Wakefield, Saugus, Woburn, and Lexington, all within a radius of not more than fifteen miles. These all occurred during the variola epidemics of 1872-73 and 1881-82. They were examined at differ- ent stages of the disease, and were found to have the characteristic appearances described by the earlier inves- tigators upon the same subject. At one large dairy-farm, where about ninety cows were kept, several cases were seen in different stages, and the disease was only prevent- ed from spreading by isolation and absolute separation from the milkers who milked the remainder of the herd. Dr. Petry, anoted veterinarian, of Esneux, says, " This disease is much more frequent than is commonly believed. Spontaneous cow-pox may be found in every place, in every land, and in every season of the year ; but oft- ener, it is true, in spring, and in summer at the time of calving " (Quelques reflexions sur la pretendue rarete du cow-pox chez la vache. Par M. Petry, M.V. a Es- neux. Annales de la Soc. Med.-Chirurg. de Liege, 17, 1878). The writer also has examined dairies at which animals were pointed out by the owners as having had cow-pox in previous years. In several of these, by way of experi- ment, the animals were vaccinated by an expert vaccina- tor, and in such cases the vaccination invariably proved unsuccessful-a point which may be adduced in support of the genuineness of the disease as at first observed. In a case observed by the writer at Saugus, in the winter of 1881-82, a lad, twelve years of age, presented the characteristic appearances of infection upon the grasp- ing surface of the index-finger and thumb. When first observed most of the vesicles had broken by the use of the hand in milking. The herd consisted of thirteen ani- mals, but one only of which was found to be suffering with cow-pox. The disease, though not by any means of rare occur- rence, is evidently not so common as it was in the last century, and Dr. Seaton reasonably adduces as causes of its comparative rarity the more common practice of vaccination, whereby milkers do not become susceptible of infection, and, as a consequence, are not the conveyers of such infection from one animal to another; and sec- ondly, the more limited diffusion of variola. Incubation.-The incubative period is probably about three or four days, prolonged occasionally to seven or eight days (Ceeley). At first there is heat, swelling, and tenderness of the parts affected, hard papules are devel- oped of the size of a small pea, especially at the base of the teats, at their junction with the udder. The signs of constitutional disturbances at this time are but slight. In thin-skinned animals the disease may be found, by careful observation, when accidentally transmitted, as early as the fifth day. The papules increase daily, and in three or four days from their first appearance become distinctly vesicular, and have a more or less central de- pression. The change from the papular to the vesicular stage is indicated by the appearance of a dull yellowish point at the apex of the prominence ; the circumference then in- creases in substance and extent, and the centre becomes wider and deeper, till at last the flattened vesicle with depressed centre is formed. It increases in size until, in three or four days more, its full development is reached. Their number and size vary. The amount of eruption varies with the severity of the disease. With animals having loose, fleshy, hairless udders, and long, thin- skiuned teats, the eruption is usually copious. The shape 510 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vaccination. Vaccination. of the lesions is usually determined by their position, be- ing for the most part circular at the base or neck of the teats, and oval on the body of the teats. Their color varies with the stage of the disease and the color of the skin. When completely formed the vesicle is often from 15 to 20 mm. in diameter, and has a solid, tense, shining margin of a glistening white or silvery hue, and a bluish or slate-colored centre. It contains a viscid, clear lymph, which is at this period quite scanty. Around the base a narrow, rose-colored areola begins to spread with a cir- cumscribed induration. The color of the areola varies with that of the skin. The disease reaches its crisis about the tenth or eleventh day. The lymph becomes more copious, the vesicle becomes more globular in form, and if broken, the lymph flows freely. At first it is of a light amber color, and then becomes turbid and opaque. In- crustation now begins at the centre, and advances stead- ily, the crusts attaining their largest size by the thirteenth or fourteenth day. They are of a dark-brown color, and adhere more or less firmly to the skin, the areola and the induration gradually subsiding. The crusts continue to dry and to diminish in size, and become loose and fall off about the twentieth to the twenty-third day. The cicatrices left are shallow, smooth, and of a pale-rose or whitish hue. These are the appearances of undisturbed vaccinia in the cow, and they are rarely seen in their perfect form, since the handling of the teats by the milkers injures the vesicles, rupturing the cuticle, and allowing the serum to exude. Raw surfaces and dark crusts are often seen coalescing, and becoming rapidly detached by rough usage. The tender teats, with their raw surfaces, bleed, and finally heal, leaving cicatrices of varying size. Constitutional Symptoms.-These are usually slight. The appetite of the animal appears to be affected but little. The secretion of milk may be slightly diminished, and the amount actually obtained may be much lessened in consequence of the annoyance to the milkers and trouble in milking. There is no evidence that the quality of the milk is in the least modified. Both in the casual form of vaccinia, and in that which is artificially or intentionally produced, animals have been known to give milk uninterruptedly through the course of the infection, and such milk has been in constant use, without perceptible detriment to consumers. Spurious Eruptions.-The cow is liable to other erup- tive diseases which may be mistaken for vaccinia. Ceeley mentions three varieties, under the names of the yellow, the black, and the white or blister-pock, the latter being quite contagious. More recently other eruptions of a contagious nature have been observed and described, especially that which is associated with scarlatina, and which appears to have given rise to that disease in hu- man beings, either through the medium of the milk or otherwise (" Local Government Board Report, 1882." Inquiries by Mr. Power and Dr. Klein, p. 63). With reference to the origin of cow-pox, Jenner con- cluded that it was not a natural disease of the cow, but was derived from the horse, since it so happened that the cases of cow-pox which he first observed occurred in animals which were milked by men who had sores on their hands, contracted by dressing the feet of horses suffering with so-called " grease." It is more probable, as Dr. Seaton states, that the cow-pox and the horse- pox simply have a common origin or infection ; but by whatever name it is called, it has undoubtedly been met with independently in both animals, the horse and the cow, so often, that it appears to be as natural to the one animal as to the other (Seaton's "Handbook of Vacci- nation," p. 22). The Relation of Vaccinia to Variola.-Seaton states that the common origin of the cow-pox, horse-pox, and small-pox has been established by conclusive experi- ments, and adduces the experiments of Gassner, of Giinsburg, in 1801,* who inoculated eleven cows with small-pox virus, in one of which vesicles appeared, from which several children were successfully vaccinated, the ordinary phenomena of vaccination ensuing {Henke's Zeitschrift Erganzungs, p. 57). In 1830, Dr. Sunderland, of Barmen, succeeded in in- fecting cows by hanging about them blankets taken from the beds of patients sick with the small-pox. Genuine cow pox was developed, and lymph taken from these animals produced the typical phenomena of vacci- nation {Hufeland's Journal, January, 1831.) In 1836, Dr. Thiele, of Kasan, succeeded, after several failures, in producing the genuine vaccinia by infection with variolous virus, and with the lymph thus produced, he raised a stock for human vaccination ; seventy-five transmissions were made with normal results, and he re- peated the experiment successfully in 1838 {Henke's Zeit- schrift, 1839). Other observations have been made as to the coinci- dent prevalence of cow-pox among cattle at the same time with the small-pox among men, and the probable origin of the former from the latter. In a report of the Provincial Medical Association, of 1840, it is stated that the natives of Bengal apply to cow-pox the same name which they.give to small-pox in the human subject. Mr. Gibson, in the " Transactions of the Medical and Physical Society of Bombay," vol. i., states that variola carries off annually many persons in Guzerat, and " the same disorder is at times fatal among the cattle. " Mr. Macpherson, writing from Murshidabad in 1836, commenting upon the prevalence of variola in that dis- trict, infers that " the unknown causes which favor the disease in the human subject have the same tendency in the cattle ; in fact, that the two diseases owe their origin to the same cause." Mr. Ceeley's observations confirmed these statements. Dr. Waterhouse, of Cambridge, Mass., in a letter to J en- ner, related the following interesting observation : "At one of our periodical inoculations, which occur in New England once in eight or nine years, several people drove their cows to an hospital near a populous village, in order that their families might have the daily benefit of their milk. These cows were milked by persons in all stages of small-pox ; the consequence was, the cows had an eruptive disorder on their teats and udders so like the small-pox pustule that everyone in the hospital, as well as the physicians who told me, declared the cows had the small-pox." Dr. J. C. Martin, of Attleboro', Mass., inoculated a cow with small-pox lymph in October, 1835, and from the resulting vesicles vaccinated twenty-three persons, the results being variously interpreted. On account of its severity it was by some considered to be variola, and by others vaccinia. Public excitement appears to have interfered greatly with the success of these experiments. With reference to the experiments already cited, and also those of Badcock and others, in which small-pox virus was successfully transmitted through cows, pro- ducing in them genuine vaccinia, it should be stated that all experimenters acknowledge the difficulty of obtain- ing successful results; and, on the other hand, very severe results are sometimes experienced in the primary vaccinations which follow such experiments. The num- ber of fairly successful experiments is so great as to place the question beyond a reasonable doubt. In 1873 the writer made the following observation in Middlesex County, Mass.: A physician was daily attend- ing a case of confluent small-pox. As a measure of pre- vention he wore an old overcoat, which was hung upon a nail in his stable after each visit, near to a cow which was near her time of calving. This cow was occasional- ly milked by the physician in the absence of the domes- tic whose duty it was to milk the animal. The physician milked the cow several times while attending the case of variola. In less than a fortnight after his first visit to the case of variola, this cow was attacked with cow-pox, which ran its regular course. No tests were made with virus from the vesicles, but the cow, and also her calf, were afterward vaccinated by an expert animal vaccina- tor without success. Curschmann says upon this point: " A definite disease, 511 Vaccination. Vaccination. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. having quite similar phenomena, has been observed in the cow, horse, pig, sheep, goat, ass, and monkey, and the attending circumstances are so favorable to an identity of origin, that we must at least admit the probability that the vaccine disease is small-pox, so modified by the nature of the soil that it retains its tendency to strict lo- calization, even when engrafted on the human species" ("Ziemssen's Cyclopaedia," vol. ii., p. 403). With reference to the same question, Warlomont says in reply to the inquiry, " Have these diseases, which evi- dently belong to the class of parasitic diseases, a common germ, or has each its special microbe 'I " "Depaul had already formulated the following propo- sition in 1864 : " ' There is no vaccine-virus. Vaccine is nothing but modified small-pox, attenuated in its passage through the system of the horse or of the cow. ' "These propositions, which not long ago were ener- getically controverted, demand henceforth to be treated with more respect." He also cites, by way of analogy, the ex- periments of Pasteur in depriving the virus of chicken- cholera of its energy, and thus rendering animals invul- nerable to future attacks, and also further experiments of a like character with the virus of anthrax. After summing up the argument in regard to the re- lation between variola and vaccinia, he says : " However it may be, we are compelled for the present, and we are sorry for it, to consider the theory of unicity as simply a hypothesis. A respectable hypothesis, however, for there is no other that gives so well a key to the complex problem of which we have been seeking the solution." It appears to be acknowledged by the more recent ex- perimenters in the direct inoculation of the cow with variolous lymph, that in cases of success the results are unusually severe, so much so as to resemble variola quite closely, when the lymph is transmitted directly from the inoculated animal to the human species, without further transmission through a series of animals. This may explain the severe results recorded, as in the cases reported by Dr. Martin, of Attleboro', and others. Dr. Voigt, of Hamburg, in a recent paper based partly on his own experience, says : "In regard to the use of cow-pox propagated from variola, I advise pa- tience, since only the fourth or fifth generation can be in- nocuous ; furthermore, limit the number of vaccine- punctures and keep them well apart." In the same paper Dr. Voigt gives accurate details of the different forms of eruption which may ensue as a result of such variolous inoculations. The Phenomena of Vaccinia in Man.-Vaccinia is only communicable to man by inoculation, and may be com- municated with equal certainty from the cow or from other human beings. When fresh vaccine-lymph is introduced into the un- vaccinated human subject, either by puncture or by abra- sion of the skin, local effects are not usually noticeable within the first forty-eight hours. The period of incuba- tion is brief, and if the vaccination is successful, at about the end of the second day a slight redness and swelling is observed at the seat of insertion. On the third or fourth day a little vesicle appears at the summit of the papule, filled with a clear liquid, which gradually grows larger and larger. As the size of the efflorescence increases, an umbilication appears, similar to that of the genuine vari- ola pustule, which corresponds to the shape of the orig- inal wound of insertion ; an insertion by simple punct- ure producing a circular vesicle, and an insertion by a longitudinal incision producing an oval vesicle. The vesicle attains its largest size about the seventh or eighth day, when it contains a clear liquid, which, if the vesicle is punctured, will ooze out upon the surface sparingly. The construction of the vesicle is cellular, like that of the pustule of variola. After the eighth day, and some- times a few hours earlier, a ring of inflammation called the areola begins to form about the base, and the vesicle and areola together continue for the next two days to spread. The areola is circular, and when fully developed has a diameter of one to three inches (2| to 7 ctm.). It is often attended with considerable hardness and swell- ing of the subjacent tissues. The establishment of tlie areola demands attention as the evidence that the speci- fic effects of vaccinia have been produced. If several insertions have been made near each other, the areolae coalesce. After the tenth day the areola begins to fade, the vesi- cle begins to dry.in the centre, the lymph remaining in it becomes opaque, the pearly-colored pustule becomes yellowish, while at the centre, at the location of the orig- inal insertion of the virus, a crust has begun to form. By the fourteenth day the crust has become dry and hard, and gradually assumes a darker hue, and usually falls off from the twentieth to the twenty-fifth day. leaving a cicatrix, commonly permanent, which is usu- ally circular, slightly depressed, foveated, or indented with minute pits, and sometimes radiated. There are also constitutional symptoms more or less severe, in proportion to the intensity of the local symp- toms. There are fever, restlessness, derangement of the digestive organs, and occasionally swelling of the axil- lary glands. The constitutional symptoms are usually most severe at or a little before the time when the areola has reached its fullest development. Infants usually suffer less than older children, and these less than adults. In adults the course of primary vaccinia is apt to be more retarded than it is in infants, the areola is often more diffuse, and the swelling of the axillary glands more common. All of these phenomena may be modified by accelera- tion, by retardation, or by irregularity of development. (1) The most common form of modification is a slight delay in the development of the usual symptoms, of one or more days, so that by the ninth day the vesicle has arrived at the usual condition seen upon the seventh or eighth day. Seaton mentions cases in which a week's delay was observed, and after success had been given up ; and Bousquet mentions a case in which a dormant vaccination was revived at the end of three weeks. This delay is sometimes due to the incubation of other dis- eases. If the phenomena follow a regular course, this retardation does not necessarily imply an interference with the protective power of the vaccination. (2) Acceleration of the phenomena of vaccination is to be regarded with more suspicion than retardation. If the acceleration amounts to not more than one day in ad- vance of the usual appearances, and the vesicle and the consequent areola assume the typical form and color, the protective value of the vaccination is not necessarily impaired. (3) Vaccination may present irregular forms. The for- mation of the vesicle may be accompanied by considerable itching and irritation. Its shape may be acuminated or conoidal, and without the central depression, and the fluid contents may not be a clear serum, but a cloudy liquid. The areola may be formed early and may be irregular in shape, arriving at its height on the fifth or sixth day. A crust may form and fall off as early as the tenth or twelfth day. The local effect may have been still more accelerated, and a thin scale formed which is readily de- tached. Other irregular forms may be seen, none of which should be depended upon as protective against small- pox, nor should virus be taken from them for the pur- pose of vaccinating others. Such irregular conditions are doubtless due, either to the use of vaccine-lymph which is not sufficiently recent, and has consequently lost much of its active infective power, or it may have beeu inserted in a subject whose health is bad. So that the results of the vaccination may appear' uniform from virus employed under the first of these conditions, but not under the second. Mechanical irritation, such as may be produced by a coarse woollen sleeve, may occasionally interfere with the usual phenomena of the vesicle, by causing its rupt- ure or irregular appearance, and these phenomena may be aggravated if the garment is colored with poisonous dyes. It is a matter of necessity that proper instructions should be given to parents or guardians for the protection of the vesicles, that they may remain uninjured. The 512 Vaccination. Vaccination. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. recent instructions of the Local Government Board of England direct, that needless means of "protection," or of "dressing," to a vaccinated arm should not be em- ployed ; but if in a particular case reason is found for means of protection, the material and the method of its use should be defined. Vaccine " shields" are unfit on account of the difficulty of cleaning them, and of the liability that they may be used upon different persons. The irregular course of vaccination seldom requires treatment. If erysipelas supervenes, or the vaccination leaves an ulcer healing with difficulty, the treatment should be the same as is required for such lesions under other circumstances. With reference to the general question of irregular phenomena, it may be taken as a rule of practice that any vaccination, which presents a deviation from the perfect character of the vesicle, and the regular development of the areola, should not be relied upon as protective against small-pox, nor should lymph be taken from such a vesicle for further use in vaccination. Effect of Climate.-In temperate climates the utmost effect of season, either hot or cold, is only to accelerate or to retard (and that exceptionally and seldom beyond a few hours) the usual course of vaccination. Accord- ing to the best authorities, the excessive heat and moist- ure of certain seasons in the tropics interfere consider- ably with the regular progress of vaccination. In India vaccination is less successful after the advent of the hot season, and it is peculiarly so in the rainy season in Ben- gal, " so much so that vaccination must necessarily be suspended for a time " (Report of Small-pox Commis- sioners in 1850. Indian Government). In other parts of India these precautions are not found to be necessary. In the cooler parts of India vaccina- tion may be performed at any time, but in the hotter portions the best season for vaccination is from October to March. Another point of great importance is the difficulty of keeping vaccine-lymph in the tropics, so that arm-to-arm or calf-to-arm vaccination is almost imperative. Revaccination.-In many people the regular phe- nomena of vaccination can be produced but once in a lifetime. A subsequent introduction of vaccine-virus either fails to produce any effect whatever, or it produces a modified effect, like that of spurious vaccination. Re- vaccination is desirable in all cases of imperfect vaccina- tion, in all persons who have arrived at puberty ; and also, in case of immediate exposure to small-pox, it is advis- ble in those who have not been vaccinated within five years. It should be understood, however, that the hu- man body is not subject to mathematical rules and limi- tations, and hence, like many other principles of medi- cine, no precise limit of safety can be stated. The writer has vaccinated persons successfully, who had been suc- cessfully vaccinated within a year previous, and has also found many in whom vaccination with fresh lymph was unsuccessful after twenty years or more from the date of a previous vaccination. Under no circumstances should the lymph from a pust- ule of revaccination be employed for further use in vaccination. As revaccination is a preventive measure, like vaccina- tion, it should not be left until the occurrence of an epi- demic. In the United States, where public vaccination is carried out only in a limited degree, it is a common custom to await the outbreak of small-pox, at which time it is more likely to be done with less care, and in conse- quence of individual fear rather than according to the discretion of the physician. Since the introduction of animal vaccination, and the consequent possibility of an abundant supply, there can be no excuse for resorting to the lymph from vesicles produced by revaccination. The immediate results of revaccination may be either the development of a typical umbilicated vaccine-vesicle or of a modified vesicle, or entire failure. The claim once made by the earlier vaccinators, that a single primary vaccination was absolutely protective for life against small-pox, is no longer tenable, since expe- rience in severe epidemics in large communities has shown abundant proof to the contrary. After several years had elapsed from the date of the introduction of vaccination, it was observed that cases of small-pox oc- casionally occurred in the persons of those who had been vaccinated; such cases, however, being of a mild type and rarely fatal. It was therefore urged that the pro- tective power of vaccination was only temporary, grad- ually becoming less as the individual grows older. By some, the occurrence of such cases was attributed to an improper or an inefficient performance of the primary vaccination. Early observations in support of such be- lief were made in Copenhagen, and also in London. The number of persons attacked by modified small-pox in- creased in Copenhagen between 1809 and 1823, and in 1824 412 cases were admitted to hospitals, of whom 257 had been vaccinated and in 1825 623 cases, of whom 438 had been vaccinated. The mortality among the vac- cinated was much less than that among the unvacci- nated. By far the greater number of cases of small-pox which occurred after vaccination, were in persons who had not been vaccinated within a period of fifteen years. Dr. Gregory's observations upon the prevalence of small- pox in London confirmed the same inquiry. All of the severe cases of small-pox after vaccination, observed by him, occurred more than fifteen years after the operation. In Sweden, in 1834, out of 560 deaths from small-pox, 103 -were among those who were vaccinated in infancy, and all were more than fifteen years of age. Heim con- firms the same observation by his experience in Wiirtem- berg, and also declares that the anti-variolous power of vaccination is only temporary, and that it decreases in proportion to the length of time that has elapsed since its performance. The following table gives the results, as compiled by Dr. Gregory from the records of a small-pox hospital in London, in 1838: Ages. Unvaccinated. Vaccinated. Admitted. Died. Admitted. Died. Under 5 years 42 20 6 From 5 to 9 inclusive 37 11 5 From 10 to 14 inclusive 30 8 25 From 15 to 19 inclusive 104 32 90 6 From 20 to 24 inclusive 115 50 106 16 From 25 to 29 inclusive 45 23 55 8 From 30 to 35 inclusive 12 7 13 1 Above 35 years 11 6 4 Totals 396 157 298 31 Serres, in a report on vaccination to the French Aca- demy, stated that, in spite of the exceptions, variola spares the freshly vaccinated, and often attacks those in whom the date of the operation is more remote. Marson says, " But few patients under ten years of age have been admitted with small-pox after vaccination. After ten years the numbers begin to increase consider- ably, and the greatest number admitted are for the de- cennial period from the age of fifteen to twenty-five." Steinbrenner, on the contrary, believed in the perfect immunity secured by vaccination, and attributed the oc- currence of small-pox in the vaccinated to imperfect vac- cination. He admitted the impossibility of distinguish- ing cases in which the immunity is perfect from those in whom it is insufficient, and acknowledged that revacci- nation is the only means in our power of settling the question. Dr. Harder was the first to advocate revaccination strenuously, in 1823, and his views being promulgated extensively, found willing adherents, since the belief that vaccination had weakened by the lapse of time had be- come popular. Harder's statements were confirmed by experiment. Governments began to consider the ques- tion seriously, and revaccination was ordered in the Prussian army in 1831. This example was followed by Wiirtemberg and most of the small states of Germany. 513 Vaccination. Vaccination. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Serious epidemics which prevailed in 1831, 1832, and 1833, only hastened its further introduction. By 1838 revac- cination had become compulsory in Russia, Sweden, Denmark, and Bavaria. It was at first opposed by the Academy of Medicine in France, although it was de- fended by Louis, Bousquet, Serres, and others. It was not till 1858 that it was decreed that it should be per- formed throughout the French army. It was also demonstrated that the condition of the ci- catrices did not furnish evidence as to whether the sub- ject would or would not be attacked by the disease. In proof of the necessity of revaccination, the statis- tics of almost any epidemic of small-pox in a community where primary vaccination only had been practised, may be adduced. In Marseilles, in 1825, having a popu- lation of 40,000, three-fourths, or 30,000, had been vac- cinated. Of the latter, 2,000, or one-fifteenth of the vaccinated portion, were attacked by small-pox, and 20 died. In Wiirtemberg, between 1831 and 1836, out of the 1,677 persons attacked by small-pox, 1,055 had been vaccinated. In Boston, in 1860, out of more than 4,000 cases of small-pox among the vaccinated, there were 105 deaths. The following table was prepared by the London Board of Health, from thirty returns sent in to them without selection : to be spurious, imperfect, or irregular in character. If, however, the child's health appears to be such as to ac- count for the irregularities and imperfections, the vacci- nation should be deferred until its health is corrected. Especially should children having imperfect cicatrices be revaccinated, if there is danger of immediate exposure to infection from small-pox. Revaccination should be performed on all Persons after Puberty.-After revaccination, small-pox, even of the slightest kind, is rarely met with. In five years Heim found that there occurred, among 14,384 revaccinated soldiers, only one instance of varioloid, and among 30,000 revaccinated civilians, there were only two cases (one of which was afterward found to be chicken-pox); while during the same years small-pox had prevailed in 344 places, producing 1,674 cases of modified or unmodi- fied small-pox in a population of 363,298 people, some of whom wrere unvaccinated but most had merely not been revaccinated. Revaccination should be performed with the same care as primary vaccination, and always, when possible, with fresh lymph. It should not be left to periods when small-pox becomes epidemic, and its performance upon persons arriving at a certain age, say fifteen years, should be as systemati- cally carried out as in the primary vaccination of in- fants. From the results observed as to the performance of re- vaccination in the armies of Great Britain and of Wiir- temberg in 1831, 1835, and 1861, it was concluded that the local results obtained by the revaccination of any in- dividual give absolutely no information whatever as to the constitutional condition in which the revaccinated person was with regard to his liability to contract small- pox. The Local Government Board has issued an order,3 dated February 3, 1888, amending former regulations as to the age at which revaccination may be furnished at the public expense. The new order provides that revac- cination by a public vaccinator may be performed when the applicant has attained the age of twelve years (instead of fifteen years as heretofore), or in case of imminent danger from small-pox, at ten years (instead of twelve as heretofore), and has not before been successfully vac- cinated. The order further provides, with reference to children in public institutions, that the medical officer may re- vaccinate anyone under ten years of age, whose primary vaccination he deems to have been inadequate, and who has not before been successfully revaccinated. Dr. R. Gerstacker, in a paper entitled " The Hygienic Significance of Revaccination," 4 gives some valuable data compiled from the reports of the Imperial Board of Health, and also from the report of the Vaccination Commission. From their tables it appears that the mortality from small-pox in Prussia, formerly differing but little from that of other countries, has fallen to a minimum under the operations of the vaccination law, so that small-pox may now be considered as having disappeared, except in some frontier districts : while Austria, with her defective regulations as to vaccination, and still more so as to re- vaccination, suffers severely from small-pox. Dr. Ger- stacker presents the following table as to the mortality from small-pox in London and in Berlin, with the com- ment that, while London enforces vaccination of the chil- dren, it has not enforced revaccination. He attributes the difference in the relative mortality from small-pox in the two cities to these facts. Deaths from Small-pox, per 100,000 Inhabitants. Number of cases. Deaths. Percentage of deaths. Natural small pox in the unprotected. Small-pox after small-pox Small-pox after vaccination 1,731 58 929 361 22 32 20.85 37.92 3.44 It has been shown that the mortality from small-pox, among the vaccinated, varies from almost nothing up to 12| per cent, (the latter in the Vienna Hospital), the mean being 5| per cent. It is plain, therefore, that in every community a certain proportion of the inhabitants will take small-pox, if they rely merely on the protection which is afforded by a sin- gle vaccination. The great standing armies of Europe afford conclusive evidence as to the need of revaccination. It was intro- duced into the Russian army in 1831, and for the ensuing years from 1831 to 1857, the number of revaccinations was 733,332, of which number 391,574, or fifty-six per cent., were successful, and 228,848, or thirty-one per cent., were unsuccessful; the remainder were imper- fect. Similar results had also been obtained in the army of Wiirtemberg, and also afterward in the armies of other countries of Europe. The percentage of successful re- sults in revaccination has varied from fifty to seventy per cent. The percentage of success in revaccination varies with the age of the person vaccinated, and the time which has elapsed since the primary vaccination. Thus, in a school consisting of pupils between the ages of ten and fifteen years, who have been vaccinated in in- fancy, the percentage of successful resultsis not so great, upon revaccination, as in an army in which the ages are all above fifteen, and the consequent time since a prim- ary vaccination in infancy is greater. Seaton lays down the rule that carelessness in primary vaccination should not be excused on the ground that revacci- nation will supply its defects. " It has too often happened," he says, " that vaccination has taken, but has taken badly ; either at once or at some not distant period it has been repeated, and has perhaps been performed a third time, but ineffectually (for it will constantly happen that spurious vaccination will prevent subsequent vaccination from taking effect properly) ; then no more is thought about it, or the child is declared ' insusceptible ; ' it grows up, gets small-pox, and very likely dies. Take it at its best, an originally imperfect or incomplete vaccina- tion is a very great misfortune." Age at which Revaccination should be performed.-There are circumstances which would call for its performance in childhood, as when the primary vaccination is found 1875. ' 1876. 1877.11878. 1879. 1880. 1881. 1882. 1883. In London .... In Berlin 1.3 20.8 5.2 ; 1.8 71.0 38.8 0.4 ' 0.8 12.1 12.5 0.7 0.8 61.9 * 4.7 11.1 0.4 3.4 0.3 The percentages in the following table, for a period of six years, also present further evidence of the advantages of revaccination. 514 Vaccination. Vaccination. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Bavaria. mittee of vaccination, or collected by the vaccinator him- self, preserved in the shape of pulp, or upon points or plates, or in tubes, its efficiency is gradually weakened or lost in the desk or medicine-chest of the physician, who takes no care to renew his stock at the proper time. " The operation is quite simple, three insertions on each arm, often one only, and that is all. Usually the child escapes further notice. The parents, or even the neighbors, take upon themselves the duty of informing the physician when occasion presents itself, that the vaccination has proved successful. " More rarely . . . the child is brought, at a longer or shorter time after the operation, the visit resulting in the delivery of a certificate of vaccination, in the event of any vesicles or vaccinal scars, without regard to their number or appearance. In case of absolute failure the operation is delayed to a more favorable time. "In point of fact this delay is often indefinite, the child being, in the opinion of its parents, vaccinated, as soon as it has received the required punctures. The case is still worse when it is left to the care of midwives or nurses." The author therefore concludes that vaccination is in many cases nothing but a deceptive operation performed with a hypothetic virus. The following questions are also discussed by the same author: 1. No vesicle folloxcs a given vaccination. We are not therefore to infer that the subject is wholly insusceptible and abandon the attempt to secure a successful result. The quality of the vaccine employed, the method of op- eration, and the possibility of a temporary insusceptibility of the subject are to be borne in mind. Of vaccinations made in 1883 at Utrecht and Groningen, on subjects upon whom a primary vaccination eight days before had failed, there were respectively ninety-two and one hundred per cent, of successful results. 2. One or more vesicles are developed. Ought the sub- ject, therefore, ipso facto, to be regarded as having ac- quired immunity from small-pox ? No. In discussing the question of multiple insertions, the author affirms the impossibility of determining beforehand the required number to protect a given subject. An old regulation of the German army required twenty insertions, ten in each arm. In Holland, a modified vaccinization has been prac- tised for a long time, ten insertions being made upon each subject, and the results classified in accordance with the number of good resulting vesicles, certificates being given to such as have more than five good vesi- cles. All others are submitted to a supplementary, or an auto-vaccination. Dr. Titeca gives the results of twenty-three primary vaccinations of children of various ages from three months to five years : twelve boys and eleven girls. A second vaccination of these twenty-three children gave the following results : 7 successful equal to 30.4 per cent. 6 partially equal to 26.0 per cent. 10 unsuccessful equal to 43.4 per cent. Fifteen of these were vaccinated on the sixth or sev- enth day after the first insertion, with virus taken from the same subject (auto-inoculation). In these the results were- 6 successful equal to 40 per cent. 3 partially equal to 20 per cent. 6 unsuccessful equal to 40 per cent. In four cases vaccination was followed by a supple- mentary vaccination in from one to four months. None was successful, one partially, three unsuccessful. In four others it was practised at intervals of two, four, five, and six years, with the result that none was success- ful, two were partially so, and two were unsuccessful. A. third vaccination was made upon four subjects, six to seven days after the second vaccination. Result: None successful, two partially, two unsuccessful. The author regrets that for various reasons three cases, Averag 00 00 CD GO GO CO CO 00 00 00 CD -3 145 404 559 468 247 | 63 Cases of Small-pox. 22 58 78 71 34 1 8 Deaths from Small-pox. i 44.6 f 11 SS 99 ig Cases. Unvaccinated. tS d d o -7 Deaths. 41.1 37.0 48.2 45.5 45.4 50.0 Percentage of Deaths. 1 12.6 110 336 466 349 198 51 Cases. Vaccinated. 15 51 29 5 Deaths. 13.6 12.8 10.3 14.6 | 14.6 9.8 Percentage of Deaths. CO GO CO t-1 CflSPS 00 00 Ci -Q CD Revaccinated. O or CO or O Deaths. 0.0 12.2 8.1 5.8 0.0 12.5 Percentage of Deaths. Dr. Gerstacker further agrees with the conclusions of the earlier observers, as to the immunity against small-pox produced by primary vaccination in childhood being of limited duration, anil as to the possibility of renewing its influence by repetition. Revaccination, therefore, as he expresses it, forms an essential part of the measures of prevention against small-pox, and its hygienic impor- tance extends not only to the individual, but also to society, the relative immunity of which is warranted only by the immunity of the individual from small-pox. He reckons the protective period of primary vaccination at an average of ten years, and therefore believes the revaccination of school-children in the later years of school-life to be essential to complete immunity. Dr. Seaton sums up the purposes of revaccination as follows: 1. To repair whatever was irregular in the course of a primary vaccination. 2. To supply what was imperfect in the amount of in- fection, in cases in which the course of the disease was regular. 3. To extinguish the susceptibility to small-pox which may remain, or may rearise, in an indeterminate num- ber of persons whose primary vaccinations may have been complete as well as regular. Auto-vaccination.-By this term is meant the reinser- tion of fresh vaccine-lymph upon the same person from whom it is taken, either by the vaccinated person him- self, or by some other person, and also either intention- ally or by accident. It is not uncommon to find, among young children recently vaccinated, that in consequence of slight itching or irritation at the seat of the inser- tion, the child may scratch and rupture the vesicle with the finger-nails, and, after scratching at some other point, thus reinoculate himself, the second vaccination pre- senting the usual phenomena considerably lessened in intensity. The writer has in mind a physician of his ac- quaintance, who has upon the left side of the bridge of the nose a typical, foveated vaccine-cicatrix produced at the age of one and a half year, in the manner just cited. Vaccinization.-In a recent paper published by the Belgian Academy of Medicine, entitled "La Pratique de la Vaccine ; ce qu'elle est, ce qu'elle devrait etre " (1885), the author, Dr. Titeca, concludes that the principles of vaccination should be raised to the state of an axiom ; in other words, that it may be made perfectly protective. Dr. Warlomont has expressed a similar belief in his re- cent work.5 They have crystallized this belief under the name of the school of vaccinization (ecole vaccinisatrice), wherein they are in accord with the views of many others, both in America and in Europe. The following graphic picture of the defects of the vaccine employed, as well as of the operation itself, pre- sents some of the most common reasons for failure : " It often happens, especially in the country, that the agent intended for affording protection against variola has nothing more of vaccine than the mere name. Whether sent out by the vaccinal institute, or by a com- 515 Vaccination. Vaccination. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. which were wholly successful on the second trial, could not have been submitted to the third vaccination. From a general review of the subject the author con- cludes that vaccination, to be perfectly protective, should be practised under the following conditions : 1. The employment of a vaccine virus which has lost none of its vitality. 2. The number of inoculations should be in accord- ance with the individual vaccinal receptivity, even to the extent of the exhaustion of that condition. The first of- these conditions is fulfilled by the use of living (vivant) vaccine, collected at the time of the opera- tion ; the second by the operation to which Dr. Warlo- mont gives the name of vaccinization. Every vaccination made in default of these conditions is deceptive, and to such faulty methods the anti-vac- cination school owes its existence. Its faults and griev- ances will cease when the school of vaccinization is rec- ognized. The author recommends the following practice : 1. Vaccinization of infants within six months of birth. 2. Revaccinization every ten years, when no epidemic is prevailing, and general revaccinization in time of epidemic. Insusceptibility.-When vaccination is performed under the most favorable circumstances, with fresh lymph, from arm to arm, or from calf to arm, in primary cases, insus- ceptibility is of rare occurrence. Cases of inability to infect after repeated trials are often reported by physi- cians. Seaton says, however, that he has never met with any. Out of more than nine thousand vaccinations made at the Blackfriars Station of the National Vaccine Establishment, there was but one case in which vaccina- tion was unsuccessful on a second trial. A third attempt was made in this case, and as the child was not brought back for inspection the result was unknown. Dr. Robertson, of Edinburgh,says, in the "Twenty-fifth Report of the Registrar-General of Scotland " : " Consti- tutional insusceptibility, as expressed in the Returns, is virtually a confession from an operator that he has made three unsuccessful attempts to vaccinate a child without ascertaining the cause of his failures, and the fact that a child has a certificate of insusceptibility does not absolve its guardians from the duty of having the reality of the condition tested from time to time." Dr. Cory also says, in his report to the Local Govern- ment Board for 1885, with reference to an experience with several thousand vaccinations: "In the whole course of my vaccination experience I have never met with a case of insusceptibility in any child under ten, and with only one case above that age, although it has fallen to my lot to vaccinate many cases of repeatedly insus- ceptible children." (Dr. Cory's experience in later years has largely been concerned with bovine lymph.) The Technique of Vaccination.-Collection of Virus. -A healthy child should be selected as the vaccinifer, and one having typical umbilicated vesicles. The arm or other part upon which the vesicles are situated should be held firmly and the skin well stretched. The vesicles then stand out in relief. By means of a lancet held ob- liquely to the surface the vesicle should be opened at several points, by punctures or incisions. As the inser- tion of virus at several different points is recommended, it is therefore advisable that only such children should be employed for the collection of virus as have several vesi- cles, and that but one vesicle should be opened upon each child. If any blood should make its appearance the vesicle should not be used. Several punctures should be made, so as to open the different cells of the vesicle. The vaccine lymph will exude in small drops and may be collected upon the lancet, or upon ivory points, or other material intended for its collection. The vesicle should on no account be squeezed, or subjected to undue pressure. One vesicle will usually yield enough lymph for charging ten or a dozen ivory points, sufficient to vaccinate as many children. Direct vaccination from arm to arm, with fresh fluid lymph, is superior to any other form of humanized vac- cination, and should always be performed when it is pos- sible. Methods of Inserting Lymph.-The essential character- istics of a successful insertion are that the vaccine col- lected at the proper period of maturity should be as fresh as possible, and should penetrate the superficial layer of the skin and be brought in contact with the rete Mal- pighii, or mucous layer. For this purpose a simple puncture with a needle will usually prove successful. Bousquet states that 'small-pox was thus inoculated by Eastern nations in early periods. The part usually selected for insertion is the outer part of the arm, at or near the lower insertion of the deltoid muscle, the left arm being usually preferred. Successful vaccinations may be made upon any part of the body. Number of Insertions.-At least two insertions should be made in every case, and there can be no valid objec- tion to a greater number. Heim recommends six, three on each arm ; Martin makes six ; Bousquet, six ; and Steinbrenner ten, five on each arm. Warlomont recom- mends six, three on each arm, and that they be arranged triangularly in boys, and in a horizontal line in girls, at the distance of a thumb's-breadth apart. He adds : " If one desires to please the mothers and spare subsequent reproaches, he will ask the mothers to point out where they wish the insertions to be made ; the horizontal ar- rangement allows concealment by a short sleeve." The Age for Primary Vaccination.-In all cases vacci- nation should be performed in early infancy, health per- mitting. Young unvaccinated children are the chief sufferers from small-pox. (Statistics relative to this point will be introduced later on.) There is great risk in delaying the operation, especially in the cities and large towns. Seaton advises that plump and healthy children living in large towns should be vaccinated when they are a month or six weeks old ; and in more delicate children the operation might be postponed until they are two or three months of age, but all whose health does not offer some positive contra-indication should be vaccinated by the age of three months. The writer has, under conditions of special exposure to small-pox, vaccinated several infants within the first forty-eight hours after their birth, with perfect success, and with typical vesicles resulting. Health of the Individual to be Vaccinated.-It is not es- sential that the persons who are to be vaccinated should be in robust health. They should, however, be free from any acute disease, and also from any severe chronic disease which would be likely to interfere with the regu- lar course of the vaccine vesicle. Many diseases do not interfere at all with the progress of vaccination. While no virus should under any circumstances be taken from a child who is suffering either from scrofula or syphilis, it is quite well known that these diseases do not prevent the normal development of the vaccine vesicle. Jenner insists that herpes may interfere with the regular course of vaccination, and other cutaneous dis- eases of the vesicular type may also constitute a bar to its immediate performance. In many countries, and also in some of the United States, vaccination is made a statutory prerequisite to school attendance, and the important question occasion- ally arises, " Shall exception be made in the case of schol- ars suffering from ill-health V' From the stand-point of public hygiene, it must be urged that such scholars con- stitute a public danger, and a constant menace to the community, and it may also be added that a scholar whose health is not sufficiently good to permit of vacci- nation, is not, as a general rule, in a condition of health to endure the routine of school-attendance, and should remain out of school until recovery will permit of both school-attendance and vaccination. In laying down rules, however, in a positive manner, Dr. Seaton adds: " As to the health of the person to be vaccinated, it is assumed that there is no immediate risk from small-pox, for under such circumstances it would be extremely foolish to hesitate or to delay, and nothing but the actual presence of serious acute febrile disease should then be a sufficient contra-indication. 516 Vaccination. Vaccination. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Methods of Insertion.-1. One of the best methods, and also one most commonly employed, is the method of scari- fication. The arm of the person to be vaccinated should be grasped by one hand of the vaccinator, so as to put the skin upon the stretch. With a sharp lancet several fine parallel scratches, or incisions and cross-incisions, should then be made upon the skin in the following manner: These incisions should only be carried to such a depth that the surface be- comes slightly reddened by the appearance of blood. They may often be made upon sleeping children by means of a sharp lan- cet, without awaking them. Several such scarifications should be made, never less than two, at a distance of about one inch (2 to 3 ctm.) apart. Upon these should be applied the fresh lymph, rubbed lightly into the scarifications from the point of a lancet, and if preserved lymph is used, the ivory points, or other appliances upon which it is stored should be wiped upon the scarifications, after first moistening the surface of the preserved lymph with a little pure water. If there is a free oozing of blood or serum, it is not necessary to moisten the dried lymph. Gregory, Marson, and Bousquet all agree in stating that a deep insertion, with consequent free flow7 of blood, does not interfere with the success of a vaccination. 2. By Puncture.-By this method a sharp lancet is in- serted obliquely to a depth of about one-eighth of an inch (2 to 3 mm.) or more. From two to five such punctures should be made at a distance of at least three- fourths of an inch apart. A common sharp-pointed lan- cet is best adapted to the purpose. The fresh lymph may be introduced into these punctures. 3. The method by puncture may be modi- fied by making a considerable number of small punctures close together, or, in other words, a tattooing in several spots, the lymph being spread upon these spots. The instructions of the Local Government Board of England, recently revised (from the " Sixteenth Annual Report, 1886-1887"), contain so much practical advice upon the subject that they are quoted herewith. The re- port makes the following comments upon them : " By due observation of these instructions, the minute dangers at- taching to the use of humanized lymph will be reduced within such small limits that the advantage of the vacci- nation shall infinitely outweigh any possible harm from it." " Instructions for Vaccinators under Contract. -1. Except so far as any immediate danger of small-pox may require, vaccinate only subjects who are in good health. As regards infants, ascertain that there is not any febrile state, nor any irritation of the bowels, nor any unhealthy state of the skin, especially no chafing or eczema behind the ears, or in the groin, or elsewhere in folds of skin. Do not, except of necessity, vaccinate in cases where there has been recent exposure to the in- fection of measles or scarlatina, nor where erysipelas is prevailing in or about the place of residence. " 2. In all ordinary cases of primary vaccination make such insertions of lymph as wTill produce at least four separate, good-sized vesicles, or groups of vesicles, not less than half-an-inch from one another. The total area of vesiculation on the same day in the week following the vaccination should be not less than half a square inch. " 3. Direct that care be taken for keeping the vesicles uninjured during their progress, and for avoiding after- ward the premature removal of the crusts. Do not use any needless means of " protection," or of " dressing," to a vaccinated arm ; but if in a particular case you find reason for means of " protection " or of " dressing," define the material and the manner of use of the appli- ance best adapted to the case, avoiding all such as can- not readily be destroyed and replaced whenever they become soiled. " 4. Enter all cases in your register on the day when you vaccinate them, and with all other particulars re- quired in the register up to and including the column headed " Initials of persons performing the operation." Enter the results on the day of inspection. Each of these entries must be attested by the initials of the person who inspects the case. In cases of primary vaccination register as " successful " only those cases in which the normal vaccine vesicle has been produced ; in cases of re- vaccination register as " successful " only those cases in which either vesicles, normal or modified, or papules surrounded by areolae have resulted. When any oper- ation (whether vaccination or revaccination) has to be repeated, owing to want of success in the first instance, it should be entered as a fresh case in the register. " 5. Endeavor to maintain in your district such a suc- cession of cases as will enable you to vaccinate with liquid lymph directly from arm to arm at each of your contract attendances, and do not, under ordinary circtim- stances, adopt any other method of vaccinating. To provide against emergencies, always have in reserve some stored lymph, either dry on ivory points, thickly charged, and constantly well protected from damp, or liquid-in fine, short, uniformly capillary (not bulbed) tubes, hermetically sealed at both extremities. Lymph, successfully preserved by either of these methods may be used without definite restrictions as to time. With all stored lymph caution is necessary, lest in time it may have become inert or otherwise unfit for use. "6. Consider yourself strictly responsible for the quality of whatever lymph you use or furnish for vaccination. Never either use or furnish lymph which has in it any, even the slightest, admixture of blood. In storing lymph, be careful to keep separate the charges obtained from different subjects, and to affix to each set of charges the name or the number, in your register, of the subject from whom the lymph was derived. Keep such note of all supplies of lymph which you use or furnish as will always enable you to identify the origin of the lymph. Do not employ lymph supplied by any person who does not keep exact record of its source. "7. Never take lymph from cases of revaccination. Take lymph only from subjects who are in good health, and, as far as you can ascertain, of healthy parentage ; preferring children whose families are known to you, and who have elder brothers or sisters of undoubted healthiness. Always carefully examine the subject as to any signs of hereditary syphilis. Do not take lymph from children who have any sort of sore at or about the anus. Take lymph only from well-characterized unin- jured vesicles. Take it at the stage when the vesicles are fully formed and plump. Do not take it from a vesicle around which there is any conspicuous com- mencement of areola. Open the vesicles with scrupulous care, to avoid drawing blood. Take no lymph which, as it issues from the vesicle, is not perfectly clear and transparent, or which is thin and watery. From a well- formed vesicle of ordinary size do not, except under circumstances of necessity, take more lymph than will suffice for the immediate vaccination of five subjects, or for the charging of seven ivory points, or for the filling of three capillary tubes, and from larger or smaller vesicles take only in proportion to their size. Never squeeze, or scrape, or drain any vesicle, and do not use lymph that has run down the skin. Be careful never to transfer blood from the subject you vaccinate to the subject from whom you take lymph. "8. Scrupulously observe in your inspections every sign which tests the efficiency and purity of your lymph. Note any case wherein the vaccine vesicle is unduly hastened or otherwise irregular in its development, or wherein any undue local irritation arises ; and if similar results ensue in other cases vaccinated with the same lymph, desist at once from employing it. Consider that your lymph ought to be changed if your cases, at the usual time of inspection, on the day week after vaccina- tion, show any conspicuous areolae round their vesicles. " 9. Keep in good condition the lancets or other instru- ments which you use for vaccinating, and do not use them for any other purpose whatever. When you vac- Fig. 4430. Fig. 4131. 517 Vaccination. Vaccination. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. cinate, have water and a napkin at your side, with which invariably to cleanse your instrument after one opera- tion before proceeding to another. Never use an ivory point or capillary tube a second time, either for the con- veyance ox- for the storage of lymph ; but when points or tubes have once been charged with lymph, and put to their proper use, do not fail to break or otherwise destroy them." (" Sixteenth Local Government Report, 1884." Supplement, p. 39). Instruments Employed.-1. The common lancet, with a sharp point and edge, is undoubtedly the best instru- ment that has been devised for vaccination. It is simple, easily cleaned, easily sharpened, and may be used either for puncture or for scarification, the point being used for the former, and the edge for scarification. 2. Another instrument which proves quite efficient for scarification has the following shape. The only ob- erates the point by a spring, punctures the skin, and de- posits the bit of dried lymph beneath the surface of the skin. 7. Burg's vaccinators consist of boxes or small cases of sharp needles intended for the storage of vaccine, each needle being charged with a minute quantity of lymph and then dried. In the larger case the needles Fig. 4432.-Vaccine-scarifier. jection to this instrument is the greater difficulty in cleaning the spaces between the points. 3. Ivory-points.-One of the advantages claimed for ivory- or bone-points is that they may serve two purposes: first, for the storage of lymph ; and second for use in scarifi- cation, the edges near the point being sharpened or chamfered for the purpose. They are illy adapted for such use, it being impossible to give them a hard cutting edge as sharp as that of a lancet. The ivory-point is, however, admirably adapted for the storage of dry lymph. Various other instruments have been devised, many of them more or less complicated, and therefore not so well adapted for vaccination, in con- sequence of the greater difficulty in cleaning them, a point which deserves very careful attention in a matter of such great impor- tance as that of vaccination. The two following instru- ments are figured from Warlo- mont's " Traite de la Vaccine." 4. Ume's vaccine - scarificator consists of four blades fixed upon a horizontal axis, to which may be given an alternating rotating movement by means of a toothed wheel controlled by a rack. The depth to which the blades pene- trate is at the choice of the op- erator by means of a screw-cap fitting over the lower end, after the usual manner adopted in the larger forms of scarificators used for other purposes. Slight press- ure on the knob at the top frees a catch, and the stem rises quick- ly by means of a spring, rotating the blades and providing the required scarification. 5. Warlomont's vaccinator - trephine is a lighter, sim- pler form of apparatus, consisting of a circular biade 2 mm. in diameter enclosed in a circular sheath. A rotatory motion is given to the blade by the play of an internal spiral, a circular furrow being traced upon the skin of a depth measured by the projection given to the blade. The lymph is applied as in the ordinary form of scarifi- cation. 6. Whittemore's Vaccinator.-Thig instrument is usu- ally employed for vaccinating with the dried crust, which may be placed upon the point or perforator. A single motion only is required ; the handle being depressed lib- Fig. 4433.-Ivory-point for Vaccine. Fig. 4435.-Warlomont's Vaccinator. are arranged around a central space where they may all (200 needles) be charged at once with a small quantity of vaccine lymph. The smaller instrument and another of very large size are constructed upon a similar principle. This instrument was confessedly devised for the purpose of defeating the ends oT bovine vaccination in France, as stated in the description given in the fourth volume of the " Revue d'Hygi&ne, 1882," p. 355. This statement is ex- plained by the fact that in France custom allows a liberal fee to mothers for the use of the lymph from the vesicles of their infants, and such an instrument would prove very economical. There is no reason, how'ever, why, if practi- cable at all, it could not be used in tjie same manner in connection with bovine vaccination. The same objec- Fig. 4434.-lime's Vaccine- scarificator. Fig. 4436.-Whittemore's Vaccinator. tion is pertinent as in the case of other instruments : difficulty of keeping all the needles clean. It is much better to employ materials for storage which can be destroyed after their use. Other instruments mentioned in the "Transactions of the Royal Health Office of Germany " are the following : Kirstein's vaccination lancet. Dreyer's vaccination needle, shaped somewhat like a 518 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vaccination. Vaccination. draughtsman's pen. It holds the lymph between the blades and makes two superficial cuts. Since it is dif- ficult to cleanse it has not been commended by the Min- ister of Medical Affairs. The Giintze-Lowenhardt instrument, having a limited use. A lancet invented by Maurer, of Vienna, whose excel- lence consisted in a detachable handle and facility of transportation. The handle is long, and is held firmly like a penholder ; the blade is rounder and with scrupulous regard to cleanliness. 1 he instruments employed should be used for no other purpose, and if lancets are used, they should be cleaned with the great- est care after each use, and when several persons are to be vaccinated at once, the instrument employed should be cleaned after each operation. The use of a disin- fecting solution for such purpose is desirable, such as a five per cent, solution of carbolic acid, or a solu- tion of bichloride of mercury, 1 part to 500 of water. Circumstances Calling for the Immediate Perfor- mance of Vaccination.-Under certain conditions it may be prudent to vaccinate at a very early age. When small-pox is prevalent in any locality, and especially when it exists in the same house where unvaccinated persons or such as have not been re- cently vaccinated are living, vaccination should be immediately performed. Repeatedly, for want of such precaution, have the lives of infants been sacrificed. The loss of a single day may sometimes prove to be the loss of a life. Since the incubative period of vaccinia is shorter than that of small-pox by about three days, it is found that if vaccination is performed at any time within the first three days of exposure the vacci- nation will cause a certain degree of modification of the small-pox, and consequent protection. If it is postponed to a later day no protection is af- forded. An illustration of the latter condition has just come under the writer's observation. An un- vaccinated child was exposed to small-pox on a certain day. Vaccination was delayed until ten days afterward. On the third day after the vac- cination was performed, a well-marked eruption of small-pox appeared and the child died. Singularly enough the appearance of small-pox was attributed by some to the vaccine virus employed but two days pre- viously. Marson states the case still more definitely as follows : " Suppose an unvaccinated person to be exposed to small-pox on Monday : if he be vaccinated as late as the following Wednesday, the vaccination will be in time to prevent small-pox being developed ; if it be put off until Thursday, the small-pox will appear, but will be modi- fied ; if the vaccination be delayed till Friday, it will be of no use, it will not have had time to reach the stage of areola, the index of safety, before the illness of small- pox begins" (Marson, in "Reynolds' System of Medi- cine," vol. i., p. 268). The only safe rule under all such circumstances is to vaccinate immediately. In all such cases it is of the utmost importance that accurate observations should be made and recorded as to the date of exposure, the date of vaccination, and also the date of first symptoms of small-pox, should they oc- cur. Seaton also urges with propriety that the word " vac- cinated " should not be used in certificates of death in which vaccination was merely attempted, but without any result. He also condemns in the strongest terms the practice of vaccinating after symptoms of small-pox have actually appeared in any given case presented for vacci- nation. Extent to which Vaccination is now Prac- tised.-Jenner stated in 1801, that about six thousand persons had been inoculated with cow-pox in England. In the previous year the practice of vaccination had been introduced into several other countries, and gradually won its way into public favor. At the present day a fair estimate of the annual number of vaccinations performed throughout the world (including revaccinations) may be stated to be at least 20,000,000, which would amount to forty per cent, of an estimated annual number of births of 50,000,000. The following statistics are compiled chiefly from the excellent summary published by the Italian Government, entitled " Risultate dell' Inchiesta sulle Condizione igien- iche e sanitarie nei Comuni del Regno," to which have been added other data compiled from the official publi- cations of different countries. Fig. 4437.-Burq's Vaccinator. thicker than the ordinary lancet, so that shallow in- cisions only are possible. A three-tongued instrument, used in Eberbach. Grafe's cataract knife. Detert's vaccination knife. Friedinger's spring vaccinator. Needles shaped like cataract needles. Hamburg lancets, made of a simple piece of steel, easi- ly cleaned with hot water. " In the Berliner Klin. Wochenschrift for May 24, 1886, Drs. Schmidt and Wolff berg describe an aseptic vac- cinating case which contains a lancet, glass watch-crys- tals, tubes holding dry vapcine powder, a file to open them, and vials containing sterilized distilled water to mix the powder. It con- tains also some solutions of carbolic acid and bi- chloride of mercury, which are intended for use in cleaning the lan- cet, and finally a few glass watch - crystals which are intended to hold the vaccine paste. Dr. Burdon Sanderson employs a gauge for measuring vaccine vesi- cles (which is of the fol- lowing shape), and esti- mates their protective value by the aggregate area of surface foveated in a characteristic man- ner. (Sixth Report of the Privy Council of England, p. 205.) The writer has occa- sionally noticed that lymph which has been stored upon points for a week or more will often produce small vesicles, not more than 4 to 6 mm. (| to A- inch) in diameter, with very slight areola, but otherwise characteristic. The protec- tive power of such a vaccination would presumably be but slight, and the vaccination should be repeated with fresh lymph. Care of Instruments.-In consequence of the impor- tance of this operation, it should invariably be performed Fig. 4438.-Burdon Sanderson's Gauge for Measuring Vaccine Vesicles. 519 Vaccination. Vaccination. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Countries. Period. Living births. Number vaccinated. Per cent, vaccinated. Italy 1880-84 5,214,098 3,829,589 73 Germany. 1880-82 5,080,072 3,625,839 71 Prussia 1880-82 3,077,742 2,278,004 74 Bavaria.- 1880-82 608,925 378.945 62 Saxony 1880-82 374.979 251,527 154,412 67 Wurtemberg 1880-82 230,776 67 Baden 1880-82 165,784 94,629 57 Other States 1880-82 622.466 468,322 2,641,080 1,547,406 1.194,796 2,291,352 1.525.605 75 Austria 1880-83 3,393,810 1,794,900 1,853,250 2,668,074 1,779.862 7'8 Hungary 1880-83 86 France 1883-84 64 England and Wales -j 1875-77 1882-83 86 86 Scotland 1873-84 1,504,319 475 637 1,320,188 422.311 88 Ireland 1882-85 89 Holland 1880-83 577,380 475.533 82 Norway 1880-82 176.640 153,909 320.253 87 Sweden 1881-83 401,366 80 European Russia 1883 3,880,857 2,185,274 56 Vaccinations in the Principal Countries of Europe. Countries. Period. Living births. Number . Per cent, vaccinated, vaccinated Japan .. British India y 1875-79 1880-81 1881-82 1882-83 5,692.083 4,181,722 4.571,1(56 4,408,142 Vaccinations in Other Countries. Vaccination is also making rapid progress in other lands where European, and especially English-speaking, colo- nies have begun to form a considerable portion of the population. In the following tables are presented in greater detail the data from official sources of recent years of some of the principal countries of Europe, including the number of vaccinations, and also the number of successful re- sults. Number of Vaccinations male in the German Empire, compiled from " Arbeiten aus dem Kaiserlichen Gesundheits- amte," Berlin, 1886. Year. Vaccinated. Remaining unvaccinated. Kind of lymph used. Successfully. Unsuccessfully. Total. Humanized. Bovine. 1879 1,215,391 24,318 1,247.864 137,622 1,196,478 37,641 1880 1,201304 25.144 1,233.010 140,601 13 84,438 46.122 1881 1364,164 26.665 1,196.919 136.360 1,139^549 57,136 1882 13 58,696 31,441 1,195,910 142,507 1,103,462 91/Ml Total population in 1880 45,234.061 Year. Number of young persons subject to revaccination. Number of those revaccinated. Number avoiding vaccination. Kind of lymph used. With success. Without success. Unknown. Total. Humanized. Animal. Not stated. 1880 1,049,877 862,268 135,274 6,961 1.004.503 45.334 971,080 27,110 6 323 1881 1,083.889 910,817 121,280 6.260 1,038,357 45,491 1.001,744 33J07 3,506 1882 1,068,830 898,601 119,872 6,247 1,024,720 44,053 954.915 66,514 3,291 Revaccinations. Austria. Year. Number of children subject to vacci- nation. Number Vaccinated. With good result. With poor result. Result not determined. Total. 1880 815,067 608,401 13,326 44,704 666 431 1881 774'. 490 572.581 13.768 39,281 625.630 1882 829,877 610,977 17,395 47,013 675.388 1883 834.715 614,957 14,734 43,939 673,630 The following is a summary of the statistics of vacci- nation in England and Wales for the period 1852 to 1886 at the expense of the poor-rates. These comprise about two-thirds of the whole number vaccinated, the remain- ing third being performed by private practitioners. Number of Successful Primary Vaccinations from 1873 to 1886, and Revaccinations from 1884 to 1886, performed in England and Wales at the Expense of the Poor-rates. Year. Number of registered births. Number of persons successfully vacci- nated at expense of poor-rates. Rate per cent, of births. 1853 601,839 397.128 66.0 1853 601,333 366,593 61.0 1854 623,699 677.886 108.7 1855 623,181 448,519 72.0 1856 640,840 422,281 65.9 1857 649,963 411,268 63.3 1858 654,914 455,004 69.5 1859 669,834 445,020 66.4 1860 689,060 485,927 70.5 1861 685.646 425,739 62 1 1863 702.181 437,69.3 62.3 1863 720,660 646,464 89.7 1864 739,236 529,479 71.6 1865 742.680 578,583 77.9 1866 743,859 454,885 61.0 1867 766.635 490,598 64 0 1868 771,905 513,042 66.5 1869 779.039 524,143 67.3 1870 785,775 472,881 60.0 1871 792.663 693,104 87.4 1873 810,291 669,320 82.6 Year. Number of reg- istered births. Number of success- ful primary public vaccinations at ex- penseof poor-rates. ber of sue- 1 sful revac- ations. Rates per cent, of successful primary public vaccinations to births. At all ages. Under one year. At all ages. Under oneyear. Num ces 2 Q 1873. 832 255 501,189 469.538 60 2 56 4 1874 845.286 493,285 470,256 58.4 55 6 1875 853,049 498,952 475.539 58.5 55 7 1876 881,518 506.587 486.031 57 5 55 1 1877 881,897 529,376 498.577 60 0 56 5 1878 892,823 513,575 494,028 57 5 55 3 1879 884,995 519,715 500.646 58 7 56 6 1880 889.893 513,283 494,942 57 7 55 6 1881 874,474 533,005 501,125 61 0 57 3 1882 880,026 516.340 495.374 58 1 55.8 1883 892.524 511,544 495.056 57.3 55.5 1884 896,179 504,335 483,742 29,2 73 56.3 54.0 1885 899,776 510,719 489,815 35.450 56.8 54 4 1886 906.819 498,039 480,306 14,166 54.9 53.0 520 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES Vaccination. Vaccination. The following data relate to the vaccination of chil- dren whose births were registered in 1884 in England and Waies, showing that 764,975, children, or 84.4 per cent., were successfully vaccinated ; 90,134, or 9.9 per cent., died unvaccinated, and a small portion (0.009 per cent.) remained unvaccinated in consequence of having had small-pox ; 1,363 cases, or 0.15 per cent, of the whole, were certified as insusceptible of vaccination, the opera- tion having been performed three times without suc- cess. In about one per cent, of the cases the vaccination was postponed on account of the children's state of health, and those wholly unaccounted for amounted to 4.6 per cent. Births. cessfully vac- cinated. usceptible to iccination. 1 small-pox. d unvacci- nated. jcination stponed. naining. Children not final- ly accounted for (including cases postponed), per cent, of births. c 1-I M <D 5 > a Q 1884 1883 906,581 764,975* 1,363 81 90.134 8.69.3 41,335 5.5 5.1 * 1882, 763,525; 1883, 762,080. The following table show's the number of vaccinations in Scotland for a period of ten years ending 1884, and also for the year 1885, and the proportion both to all births and to surviving births in each year. Scotland. Number of Cases. 1 Percentage to surviving births, 1885 X Percentage to surviving births ? ro I 02 V D 1 § 1 X X 1 I X 3 X 3 X Percentag 1875 Ten years average 1885 1 1 1 1 3 X X 3 X ■3 3 Years. 87.09 1.64 95.30 1.80 I 7 87.46 ' 86.83 87 81 108,096 111.815 112,229 111,694 111,469 109,381 111.208 110.263 10S, 906 112,122 110,698 109,886* es to Tot 87.42 88.25 88.44 88.05 88.62 87.73 87.91 87 40 Successfully vaccinated. 1.51 1.52 1.16 1.27 1,884 1,964 1,458 2,073 al Birt 0.98 0.82 1.03 0.94 i 1.03 1 1.13 1.26 1 36 1.713 192 1,211 1,034 1,304 1,196 1,290 1,404 1.586 Vaccination postponed. 194 242 185 225 US. 0.15 0.14 0.14 0.15 0.14 0.12 0.12 0.15 0.16 0.19 0.15 0.16 0.18 0.19 ggggg^g From constitutional insusceptibility. Insusceptible cination 0.002 0.002 0.003 0.002 i 5 4 3 3 0 0 4 2 0 2 0 0.001 0.003 0.003 0.002 0.003 From having had small-pox. 0.20 0.20 0.27 0.38 0.32 0.28 0.29 0.28 0.22 0.29 0 20 0.27 0.30 0 18 252 348 480 406 349 359 352 280 365 265 346 228 From previous vac- cination. ° p o 8.62 8.49 8.17 8.60 7.95 8.84 8.38 8.78 8.60 9.06 8.60 11,326 10,760 10,374 10,905 9,999 11,016 10,587 11,073 10,713 11,694 10,845 10,872 9 16 Died before vaccination. - 2.50 2,575 2,567 2,329 2,460 2,492 2.359 2,594 2,637 2.452 2,836 2.530 2,888 2.08 2.02 1.84 j 1.94 1.98 1.89 2.05 2.09 1.97 2.19 1 2.01 I 2.20 2 29 Removed from district be- fore vaccination, or other- wise accounted for. 5 123,651 126.706 126,900 126.854 125,782 124,674 126,277 126,162 124,516 129,123 126.064 126,152 100.00 100.00 100.00 100.00 1(0.00 loo.oo 100.00 100.00 100.00 100.00 100.00 Total births. 00'001 100.00 ooeooSSSoo S' 7 Spy*Surviving births. JO (UaOSa-ISOtSW gggggggggg g i Bgssgslsss 1882 1883 1884 1885 Year. 122,648 118,163 118,875 115,951 Living births. 107,613 106,997 105,021 102,680 N u mber success- fully vaccinated. 471 365 383 278 Not susceptible to vaccination. 2,781 2,866 2,990 3,124 Vaccination post- poned. 6,575 6,713 6.558 6,460 Died before vac- cination. Ireland. Paly. Ratio of Vaccinations to 100 Births. Five Years-1880 to 1884. Sardinia 113 Piedmont 79 Calabria 78 Lombardy 77 Umbria 77 Campania 76 Tuscany 73 Abruzzi 72 Venetia 72 Emilia 70 Latium 70 Sicily (18 Liguria 67 Apulia 67 Basilicata 65 Marches 64 Italy 73 Annual Ratio of Revaccinations per 1,000 of the Population. Year. Number vaccinated. 1S83 600,733 594,063 1884 France. Lombardy 11 Sardinia 10 Venetia 7 Piedmont 7 Marches 4 Rome 2 Tuscany 2 Basilicata 2 Calabria 2 Sicily 2 Abruzzi 2 Emilia 2 Liguria 1 Campania 1 Apulia 1 Umbria 0.3 Italy 4 521 Vaccination. Vaccination. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. In many of the United States, in consequence either of the entire absence of laws relative to vaccination, or on account of the lax enforcement of such as exist, it is probable that the ratio of vaccinations to births is less than that of any of the countries of Europe, unless a few cities of the former may be excepted in which effi- cient Boards of Health have enforced annual vaccina- tions and revaccinations. The most thorough vaccination performed by any State authority in recent years, was that which was made by the State Board of Health of Illinois, in 1882, in which 233,340 vaccinations were performed in a pop- ulation of over three million people. Of these 153,936 were primary vaccinations, and 79,404 were revaccina- tions ; the former being about double the annual number of births, the latter being estimated at 25 per 1,000 of the population. The following table gives the statistics of vaccination in Japan for four years (1875-79), as compiled from the official reports of that government. . Years. Successfully vaccinated. Not suscep- tible to vaccina- tion. Vaccinated a second o r third time. Total. Population. Per cent, to population. Per cent, of successful p r i m a ry vaccina tions. Per cent of successful revaccina- tions. Calves vac- cinated. July 1 to June 30. 1875 - 1876 1876 - 1877 685,145 785,757 904,931 793,212 26 710 27,442 41.833 24,842 299,460 846,099 774,838 481,214 1,011,915 1,659,298 1,721,602 1,299,268 30,990,617 30,990,617 30,990,617 30,990,617 3.26 5.48 4.96 4.19 96.2 96.6 95.6 96.9 32.5 34.6 27.9 40 19 19 1877 - 1878 1878 - 1879 Estimating the birth-rate at 30 per 1,000, the percent- age of primary vaccinations in Japan would compare quite favorably with the better vaccinated European countries. The Protective Power of Vaccination.-In order to consider this phase of the question intelligently, and to determine satisfactorily the protective value of vacci- nation and of revaccination against small-pox, it will be necessary to consider the subject : first, by a comparison of the period before, with the period following, the in- troduction of vaccination ; and, second (since it may with reason be urged that epidemics of several infectious dis- eases have become less severe within a century or more), a comparison of different populations living under simi- lar conditions, except that of vaccination. 1. The Period Before and the Period After the Intro- duction of Vaccination. It will be necessary in this connection to review the history of small-pox, for a century or more, in different countries. " At the present day," says Simon, " the very success of vaccination may have blinded people to its impor- tance. It is very easy to be bold against an absent dan- ger, to despise the antidote while one has no painful ex- perience of the bane." Small-pox is fatal to a very large proportion of those whom it attacks ; it is eminently infectious from person to person ; it seizes, with very few exceptions, upon all who for the first time come within its range. Although small-pox has been described with accuracy by early writers, notably by the Arabian physician Rhazes, its history previous to the eighteenth century must be regarded as in a great measure defective, in con- sequence of being confounded with measles and with other diseases. It is known that not a decade passed in the seventeenth and eighteenth centuries without the occurrence of dev- astating epidemics of small-pox in Europe. In England from seven to nine per cent, of all deaths were attributa- ble to small-pox. In London it averaged from four to eight per cent, of the total deaths. Captain John Graunt, in his observations on the Bills of Mortality of London (published in 1665), gives the number of deaths from small-pox for twenty years (1629 to 1636, 1647 to 1658), as 10,576, out of a total mortality of 229,250. It was also the seventh in the order of destructiveness upon the pop- ulation, consumption being first. In Berlin, from 1783 to 1797, one-twelfth of all deaths, according to Casper, were from small-pox. M. de la Condamine estimates that one-tenth of all deaths in France, amounting to 30,000 annually, were from small- pox. Three and a half millions perished from it in Mex- ico in the sixteenth century. In 1734 nearly two-thirds of the population of Greenland were swept away by it. In Iceland 18,000, out of a population of 50,000, died of small-pox. Catlin, in his "Letters and Notes on the Manners and Customs of the North American Indians " says : " I would venture the assertion, from books that I have read and from other evidence, that of the numerous tribes that have already disappeared, and of those that have been traded with, quite to the Rocky Mountains, each one has had this exotic disease in their turn, and in a few months have lost one-half or more of their num- bers." Washington Irving, in "Astoria," mentions dreadful outbreaks in which " almost entire tribes" have been destroyed. These statements are also corroborated in Prince Maximilian's " Travels in North America," in which are detailed the facts relative to epidemics among the Mandans and Assiniboins. Pits were dug to receive the corpses of those who died-50 to 100 daily-until the ground froze, and they were then thrown into the river in large numbers. One tribe, which had been reduced by other disasters to 1,500 persons, was nearly extermi- nated by small-pox, 30 persons only being left. Among the Blackfeet the inmates of more than one thousand tents were swept away. He estimates the mortality from small-pox in that epidemic among the Indians at 60,000. Wernher says, in his recent work, " Zur Impffrage:" " Before the introduction of vaccination small-pox had become a permanent disease which never entirely ceased in one year, and every three or five years became a great epidemic. " In non-epidemic years one-tenth of all mortality was from variola, in epidemic years one-half. Very few men escaped small-pox till old age ; almost everyone sickened at least once in his life of this horrible, murderous dis- ease. " Countless mortals who escaped death were maimed by loss of sight. Of new-born children, one-third died of small-pox before their first year; one-half before their fifth year of life. There was no family which had not heavy losses to deplore. In the country the mortality was greater than it was in the city. ' ' Physicians and government possessed no means against this abominable evil. Isolation was impracticable from the general, wide-spread nature of the disease. Men ac- cepted the pest as an unavoidable fate. " The loss which Europe suffered from this one disease amounted to many millions. It was a principal factor which deterred or kept the population from progress ; and to lead us back to these conditions are the efforts of many ignorant mortals directed." Comparing the present conditions with those just stated the author goes on to say : "We now find no child mortality from small-pox among vaccinated children. " The assertion that, by means of vaccination, mortality from small-pox among children has been increased is a falsehood. Every one can see for himself in his own town whether children become sick of small-pox or not. The mortality from small-pox among children in Paris and New York was on account of the neglect of primary vaccination. 522 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vaccination. Vaccination. "Also, among adults, whenever vaccination and revac- cination are maintained, mortality from small-pox is at an end." The same writer gives testimony to the benefits accruing to the German Empire from vaccination and re- vaccination during the ten years in which they had been systematically and generally practised, the results com- paring very favorably with those of neighboring nations where the practice was less rigorously enforced. The following familiar table is herewith quoted from the " Report of the Epidemiological Society of London," and contains very conclusive evidence of the decline of small-pox in different countries after the introduction of vaccination. Two series of facts are presented. 1. The number of persons per million of the population who died of small-pox annually before the introduction of vac- cination ; and 2, the number per million who died an- nually of the same disease after its introduction. The periods are not in all cases the same, but the statistics are those which it was possible to collect for the periods named. In the accompanying chart are also presented the data relative to the mortality from small-pox in Sweden be- fore and after the introduction of vaccination, by which it appears that in the twenty-four years before the intro- duction of vaccination in 1801, the mortality from small- pox counted 2,050 victims annually out of each mill- ion of the population, and after the introduction of vaccination this mortality was reduced to 158 per million annually. The period anterior to 1773, included in the original, has been omitted, since the deaths from small- pox previous to that year were not separated from those from measles. Approximate .average annu- al death-rate by small-pox per million in- Period relative to which Country or city. habitants. data are given. Before intro- duction of vaccination. After intro- duction of vaccination. 1777-1800 and 1807-1850.. Lower Austria 2,484 310 1777-1806 and 1807-1850.. Upper Austria, and Salzburg 1,421 501 1777-1806 and 1807-1850.. Styria 1,052 446 1777-1806 and 1807-1850.. Illyria 518 244 1777-1806 and 1838-1850.. Priest 14,046 182 1777-1803 and 1807-1850.. Tyrol and Voralberg 911 179 1777-1806 and 1807-1850.. Bohemia 2,174 215 1777-1806 and 1807-1850 . Moravia 5,402 255 1177-1806 and 1807-1850.. Silesia (Austrian) 5,812 198 1810-1850.. Silesia (Prussian) ... 310 1777-1806 and 1807-1850.. Galicia 1,194 676 1787-1806 and 1807-1850.. Birkowina 3,527 516 1817-1850.. Dalmatia 86 1817-1850.. Lombardy 87 1817-1850.. Venice 70 1776-1780 and 1810-1850.. Prussia (Eastern) 3,321 56 1780 and 1810-1850.. Prussia (Western) 2.272 356 1780 and 1816-1850.. Posen 1,911 743 1776-1780 and 1810-1850.. Brandenburg 2,181 181 1776-1780 and 1816-1850., Westphalia 2,643 114 1776-1780 and 1816-1850.. Rhenish Provinces 908 90 1781-1805 and 1810-1850.. Berlin 3,422 176 1776-1780 and 1816-1850.. Saxony (Prussian) 719 170 1780 and 1810-1850.. Pomerania 1,774 130 1771-1801 and 1810-1850.. Sweden 2,050 158 1751-1800 and 1801-1850.. Copenhagen 3.128 286 Death-rates from Small-Pox in Sweden, 1773-1855 Fig. 4439. 523 Vaccination. Vaccination. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Year. Population. Deaths from small-pox. Year. Population. Deaths from small-pox. 1749* 4,453 1803 1,464 1750 6,180 5.546 1804 1,460 1,090 1,482 1751 1,785,727 1805 1752 10,302 8,000 6,862 4,705 1806 1753 1807 2,129 1,814 2,404 1754 1808 1755 1809 1756 7,858 10,241 7,104 3,910 3,568 5,731 9,389 11.662 1810 2,377,851 824 1757 1811 698 1758 1812 404 1759 1813 547 1760 1,893,248 1814 308 1761 1815 472 1762 1816 690 1763 1817 242 1764 4,562 4,697 4,092 4,189 10,650 1818 305 1765 1819 161 1766 1820 2,584.690 143 1767 1821 37 1768 1822 11 1769 2,015,127 10,215 5,215 4,361 5,435 12,130 2,065 1,275 1,503 1,943 1823 39 1770 1824 618 1771 1825 1,243 625 1772 1826 1773 1827 600 1774 1828 257 1775 1829 53 1776 1830 2,888,082 104 1777 1831 612 1778 6,607 15,102 3,374 1,485 1832 622 1779 1833 1,145 1,049 * 445 1780 2,118,281 1834 1781 1835 1782 2,482 3,915 1836 138 1783 1837 361 1784 12,453 5,077 671 1838 1,805 1,934 1785 1839 1786 1840 3,138,887 650 1787 1,771 5,462 6,764 5,893 3,101 1,939 2,103 3,964 6,740 4,503 1,733 1841 237 1788 1842 58 1789 1843 9 1790 2,158,232 1844 6 1791 1845 6 1792 1846 2 1793 1847 13 1794 1848 71 1795 1849 341 1796 1850 3,482,541 1,376 1797 1851 2,488 1,534 279 1798 i;357 3,756 12,032 6,057 1,533 1852 1799 1853 1800 2,347,303 1854 204 1801 1855 3,639,332 41 1802 * From 1749 to 1773 the figures embrace the mortality from small-pox and measles, because the two diseases were not separated in the data given. After 1773 the figures are for small-pox only. Mortality from Small-pox in Sweden. In Berlin the death-rate from small-pox was 3,422 per million in the twenty-four years before the introduction of vaccination, and 176 per million in the forty years af- ter that date. In other words, the mortality from small- pox in Copenhagen after the introduction of vaccination, was only one eleventh of what it was before its introduc- tion ; in Berlin it was but one-twentieth ; in Sweden, one- thirteenth, and in Westphalia, one-twenty-fifth. The following tables will illustrate the decline in small- pox mortality which followed the introduction of vacci- nation in Berlin and also in Bohemia : Small-pox in Berlin before and after the Introduction of Vaccination. * (The statistics for the period from 1773 to 1778 are missing.) Before the Introduction of Vaccination. ihiOOim HWiiiii H H = U H ; sjagsssassgs J SWW i HM§§H§§S!| §§MMsS§ H g Population. .^£5®-."..®^ a .-'?P'?o'*'.o'*? Total deaths. io co bi co os iu co o to io or £? io co U co cn bv -c »-* w Death-rate per 1,000. B | ITO^Sn^X Deaths from small-pox. | SSSS^Sgpg ►U CO 00 CH »U 05 CO O Or 05 CH rfi. »U 05 00 IO CO tU »-* C3 O CO Ratio of deaths from small-pox to deaths from all causes, per 1,000. ppppp ppppppppp gggg§SK£55£SS Ratio of deaths from small-pox to popula- tion, per 1,000. Small-pox in Europe, 1879-1885. Countries. Period. Popula- tion. Deaths from small-pox. Ratio per 10,000. Italy (284 chief places) 1881-84 7,149,256 4,673 1.63 England and Wales 1880-84 26,413; 861 8,823 0.67 Scotland 1880-83 3,745,485 43 0.03 Scotland (8 cities) 1881-84 1,253,087 26 0.05 Ireland 1880-85 5,174.836 628 0.20 German Empire (148 cities)... 1881-84 8,790,783 793 0.23 Prussia 1880-83 27,807,012 3,254 0.29 Austria 1879-83 22,134,454 77,988 7.05 Austria (15 chief cities) 1879-82 1.543,656 5,205 8.43 Switzerland (12-15 cantons).. 1880-83 1,749.601 238 0.33 Switzerland (17 cities) 1881-83 439,843 105 0.80 Belgium 1880-84 5,655,197 11,577 4.09 Belgium (70 cities) 1880-84 1,731,269 2,182 3.15 Holland 1881-84 4,225,065 963 0.57 Sweden 1880 83 4,579,115 758 0.41 Sweden (89 cities) 1880-82 690,309 143 0.69 Denmark (chief cities) 1880-82 564,914 20 0.12 Spain 1881-84 16,858,721 57,032 8 46 Spain (70 cities) 1881 -84 2,828,977 14,793 13.07 European Russia 1882 78,590,594 23,236 2.96 In Westphalia the mortality was reduced from 2,643 per million in the earlier period to 114 in the latter. Comparing cities, we find that in Copenhagen, in the fifty years previous to vaccination the mortality was 3,128 per million, and in the succeeding fifty years it was but 286 per million. Fig. 4440. 524 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vaccination. Vaccination. Epidemic Years in Berlin before and after the Introduction of Vaccination. 00 X z s 3 Year. 94,433 125,878 133.520 147,338 119,717 176,709 632.719 826,341 Population. 4,469 4,653 5,123 5,077 5,990 7,681 17,818 32,362 28,763 Total mortality. CO 00 iO jU CO Q0 oo ko 52.6 36.0 38.3 34.4 50.0 43.4 Death-rate. 600 1,060 987 1,077 911 1,626 617 5,084 1,100 Deaths from small-pox. 133.0 220.7 192.6 212.1 152.5 211.7 34.6 157.0 38.2 Ratio per 1,000 deaths. 6.35 8.42 7.39 7.30 7.61 9.20 0.97 6.15 1.33 Ratio of deaths from small-pox to popula- tion, per 1,000. Population and Deaths from all Causes and from Small- pox in Bohemia* Before the Introduction of Vaccination. Year. Population. Deaths. -rate tage. From Remarks. Total. s m a 11- c! 2 pox. o & - - - - 1796 3,003,482 92,242 6.686 2.23 General death-rate, 1797 2,991,346 86,885 1,988 0.66 1 to 32, or 30.9 per 1798 3,045,926 84,743 3,105 1.02 1,000 of the living 1799 3,041,608 99,079 17,587 5.78 population. 1800 3,047,740 110,730 17,077 5.60 Death - rate from 1801 3,036,481 105,576 3,169 1.04 small-pox,1 to 396, 1802 3,111.472 85,460 4.029 1.29 or, 2.5 per 1,000 of - - - the population. Ratio of deaths Total.. 21,278,055 664,715 53,641 from small-pox to total deaths, 1 to 12.5, or 80.3 per Average. 3,039,722 94,959 7,663 1,000. After the Introduction of Vaccination (24 years). 1832 1833 3,888,828 139,061 121,697 807 533 0.21 0.14 1834 1835 1836 1837 1838 - 3,945,875 4,027,581 122,171 122,952 124,015 141,982 108,419 285 337 291 104 62 0.07 0.08 0.07 0.03 0.02 General death-rate, 1 to 32.5, or 30.8 per 1,000 of the living population. 1839 121,400 128 0.03 1840. ... 118,471 699 0.17 1841 - 4,145,715 116,575 697 0.17 1842 124,019 339 0.08 1843 1844 1845 1846 1847 - 4,285,730 - - 4,480,661 - 142,876 113,184 178,826 132.379 134,490 332 150 62 59 9 0.08 0.04 0.01 0.01 0.002 Death-rate from small-pox. 1 to 14,741, or .068 per 1,000 of the popu- lation. 1848 141,409 115 0.03 1849 131,403 383 0.08 1850 1851 - 4.613,080 176,211 133,245 478 508 0.10 0.11 1852 134,921 343 0.07 1853 1854 1855 - 4,593,770 - 124,617 124,746 124,746 43 68 64 0.009 0.014 0.013 Ratio of deaths from small-pox to the total mortal- Total.. 33,981,240 3,153,815 6,896 ity, 1 to 457.5, or 2.18 per 1,000. Average. 4,247,655 131,409 287 ♦Gutachten des Doctoren Collegiums in Prag (Wernher.) Fro. 4441. about 4.4 per cent, of the population). In 1721, with a population of 11,000, there were in Boston 5,989 cases of small-pox, more than half the population taking the dis- ease, of which number 850 died. In the words of the historian, "The disease ran riot over the town, feasting on all who were susceptible to its poison."-Dr. Toner, in publications of Mass. Med. Soc., 1866, vol. ii. In 1730, with a population of 15,000 people, 4,000 were sick, and about 500 died. A vessel from London, with small-pox on board, was wrecked in 1751 near Nahant, and spread the disease again, and there were 7,653 cases, and 545 deaths. It broke out in the American army at Cambridge in 1776, and Dr. Waterhouse wrote, "There were scarcely enough men free from it, or not liable to take it, to keep guard at the different hospitals." After the introduction of vaccination the mortality from small-pox in Boston was as follows, so far as the records can be obtained : Deaths. From 1811 to 1820 6 From 1821 to 1830 8 From 1831 to 1840 214 From 1841 to 1850 534 Deaths. From 1851 to 1860 732 From 1861 to 1870 500 From 1871 to 1880 1,094 From 1881 to 1887 18 Small-pox in Boston before the Introduction of Vaccination. Epidemic Years Only. Year. 1 Population. Cases of small- pox. Deaths from small- pox. Death-rate from small-pox per 1,000 in ha bi- tants. Remarks. 1631 ».. Very many 1633 1639 3.. 150 Very many Very many 1677 4.. 4,000 Very many 1678 6.. 4,000 Very many 700-800 died in Mas- 1702«.. 6,750 213 31.5 sachusetts, exclu- sive of blacks. 1721 ... 11,000 6.006 850 77 3 Inoculation intro- 1730 ... 15,000 4,000 500 33 3 duced. 1752 ... 15,731 7.669 569 36.2 1764 ... 15.520 5,646 170 10.9 1776 . 5.750 5.292 57 10.0 1778 ».. 10,000 2,243 61 6.1 1792 ... 20,000 8,346 198 9.9 1 Increase Mather. 2 Report of Sanitary Commission, 1850. 3 Webster's History of Pestilence. 4 Charlestown Records. 3 Felt, Annals of Salem. 8 Population changeable: years of war. No complete statistics of American cities for the pe- riod before the introduction of vaccination can be ob- tained. The data contained in the accompanying table are compiled from the most reliable historical sources, with reference to the prevalence of small-pox in Boston. After the settlement of the colony at Plymouth, in 1620, small-pox appeared frequently in Massachusetts, among both the Indian tribes and the English settlers. Such epidemics occurred in 1631, 1633, 1639, 1677, 1678 (from 700 to 800 died in this year), 1702 (213 died, which was 525 Vaccination. Vaccination. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Small-pox in Boston after Introduction of Vaccination. The average population for the period was 167,700, and the average number of deaths from small-pox per year was 40. The causes of the increase of small-pox in Boston after 1839 are mentioned in the "Report of the Sanitary Commission of Massachusetts (1850)." It appears from that report that vaccination was very generally practised in the towns of Massachusetts after its introduction, in 1800, by Dr. Waterhouse, whose son was the first person who was vaccinated in America. The State Law of 1810 made it obligatory, and from that date until 1836 there were but thirty-seven deaths in Boston, most of which occurred at Rainsford's Island. The law was repealed in 1836, and vaccination was made optional instead of obligatory. For- the following twelve years after the re- peal of the law, 533 people died of small-pox in Boston. The report closes with these words: "Under existing circumstances it becomes the special duty of every per- son to protect himself against the disease. Anyone who permits himself to be sick with it, is as justly chargeable with ignorance, negligence, or guilt, as he who leaves his house open to be entered and pillaged by robbers, known to be in the neighborhood. And upon that State, city, or town, which does not interpose its legal author- ity to exterminate the disease, should rest the respon- sibility, as must rest the consequences, of permitting the destruction of the lives and the health of its citi- zens." By reference to the tables relative to the prevalence of small-pox, which for the last century present only the data of epidemic years, since other data are not to be had, it will be seen that the highest ratio of deaths from small- pox, in any epidemic year since the introduction of vac- cination (2.73 per 1,000 of the living population), was much less than that of the lowest epidemic year before its introduction. Among the few records as to the prevalence of small- pox before the general introduction of vaccination, one of the best is found in a recent paper by Dr. John C. McVail, of Kilmarnock, Scotland, published in 1882. It presents a most graphic picture of the prevalence of small-pox at that time. It appears that a schoolmaster of Kilmarnock, who was considerably in advance of his times, kept a record of the mortality of his parish in a beautifully written volume. This schoolmaster, Robert Montgomerie, was also the session-clerk. The record contains a statement of the name, date, age, and cause of death of all who died in the parish of Kilmarnock for the thirty-six years from March 1, 1728, to March 1, 1764. The population of the town in question is estimated to have averaged 4,200 for the period under consideration. The total deaths for the thirty-six years were 3,860, which would indicate a death-rate of 24.36 per 1,000 per annum. In the careful record of the schoolmaster, which is divided into groups of six years each, four causes are credited with fully two-thirds of the total deaths. These were decay, age, small-pox, and fevers. What is meant by decay it is not easy to state ; that old age is not a necessary element is evident from the fact that deaths at the ages of one and two years are attrib- uted to it. The term embraces nearly all chronic dis- eases causing emaciation and debility, among which,eof course, consumption is chief. From such cause or causes there were 915 deaths. The second disease was age, with 625 deaths, which appears to have formed a con- venient class for all persons who lived beyond seventy years, and for many between sixty and seventy years. Omitting small-pox, fevers were credited with 545 deaths. This term probably included scarlet fever, which is not mentioned elsewhere, and also, perhaps, pneumonia and other acute febrile diseases. There can be no doubt, says Dr. McVail, that small- pox caused more deaths, by a long way, than any other disease in old Kilmarnock. The entire number of deaths from small-pox in this little parish for the thirty-six years was 622. There were in all nine epidemics in the thirty-six years, the average time between the epidemics being four years. They came with terrible regular- ity. 1811. 1812. 1813. 1814. 1815. 1816. 1817. 1818. 1819. 1820. 1821. 1822, 1823. 1824. 1825. 1826. 1827. 1828. 1829. 1830 1831. 1832. 1833. 1834. 1835. 1836. 1837. 1838. 1839. 1840. 1841. 1842. 1843. 1844. 1845. 1846. 1847 1848 1849. Year. 33,000 43,298 58,277 61,392 : 78,653 93,383 114,366 Population. No record. Cases of small-pox. 2 "4 :::. " 1 1 "3 2 ' 4 2 "4 7 6 13 3 60 115 57 42 55 ' 81 92 23 21 21 Deaths from small-pox. 0.06 0.12 0.02 0.017 6.05 0.03 0.06 0.03 0.05 0.10 0.09 0.16 0.04 0.09 1.23 0.61 0.45 0.06 0.27 0.81 1 0.20 0.19 i 0.19 Deathrate per 1,000 in- habitants. ' 1 1850. 1851. 1852. 1853. 1854. 1855. 1856. 1857. 1858. 1859. 1860. 1861. 1862. 1863. 1864. 1865. 1866. 1867. 1868. 1869. 1870. 1871. 1872. 1873. 1874. 1875. 1876. 1877. 1878. 1879. 1880. 1881. 1882. 1883. 1884. 1885. 1886. 1887. Year. 136,881 160,490 177,840 192,318 250,526 :::::: 341,919 362,839 390,393 Population. . . . . 2^3^ * Qt * * * • • * • • : 0 h-* >-1 00 X- X- ' l-1 •'I X AD ' 1 Cases of small-pox. 192 63 12 6 118 132 78 2 3 156 162 7 13 11 113 115 51 144 8 6 32 28 738 302 2 1 2 4 "1 6 8 1 1 2 Deaths from small-pox. 1.40 0.46 0.09 0.04 0.86 0.80 0.49 0.01 0.02 0.97 0.92 0.04 0.07 0 06 0.63 0.60 0.26 0.75 0.04 0.03 0,13 0.11 2.95 1.21 0.008 0.003 0.006 0.012 6'603 0.017 0.022 0.003 0.003 0.005 Death-rate per 1,000 in- habitants. Fia. 4442. 526 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vaccination. Vaccination. an annual epidemic equal to that of 1873-74 would do lit- tle more than represent the condition of matters in the last century. Wolff berg classifies the mortality from small-pox in the prevaccinal period as follows : Small-pox, which before the days of Jenner deci- mated the infant population of Europe, carried off from 11 to 12 out of every 100 who were sick with the dis- ease. Out of 100 sick, about 12 suffered with malignant confluent small-pox, and of these seventy-five per cent, were fatal ; 25 more had the disease severely, and of these ten per cent. died. About 33 out of 100 were af- fected lightly, of which number two per cent, die'd ; and finally, 30 were so lightly affected as to be about on their feet (ambulant cases), of which number none, as a rule, were fatal. 2. Comparison of the Vaccinated with the Unvacci- nated in like Periods of Time.-If, now, it shall be urged, as it is occasionally, with some degree of reason, that certain malignant diseases have almost disappeared, at least from among civilized nations, as, for example, the plague, and that the disappearance, or comparative rarity of small-pox is not a necessary consequence of vaccination, let us then examine the condition of the vaccinated, as compared with that of the unvaccinated, with reference to their immunity from small-pox, while living in a similar environment and at the same period of time. Wherever extensive parallel observations are made upon large populations of the vaccinated and of the unvaccinated, as exposed to epidemics of small-pox, the protective power of vaccination is especially mani- fest. ' In the accompanying tables are given the statistics of different populations in which observations are made upon the comparative immunity from small-pox of the vaccinated and the unvaccinated. It will be noticed that in the majority of the instances noted, the mortality among the vaccinated was but one-fifth or one-sixth of that of the unvaccinated, and that the highest mortality among the vaccinated was less than the lowest among the unvaccinated. The following table presents the data of these epi- demics of small-pox by ages : Year. Total deaths. Age in years at death. Age not stated. Under 1 2 3 4 6 and over. 1728 ( 66 7 14 12 14 9 5 4 1729 ( 1730 1731 1732 1 1733 45 i2 9 13 6 4 1 1734 1735 1736 66 12 20 20 8 i i 4 1737 1738 1739 1740 66 15 21 9 14 2 'i 2 i 1741 1742 1743 1744 l 74 15 13 19 11 10 2 3 i 1746 1747 1748 8 2 3 2 1 i 1 i 1 1749 ( 84 12 17 22 15 12 5 i 1751 1752 1753 1754 1755 1 •• 1 95 .. i 23 25 15 1 15 io :: 5 :: 2 7 1756 1757 | 46 11 11 13 6 4 1 2 1759 1760 1761 1762 1763 66 2 f 7 10 1 9 io 8 4 1 3 Totals 622 118 136 101 • 24 27 9 In seven of these nine epidemics the death-rate for the year was higher than the birth-rate, in one year to the extent of seventy-two per cent. The statistics of these years are summed up in the following table : Epidemic Tears in which the Total Deaths exceeded the Total Births. Places and dates of observation. Total number of cases observed. 1 • Death-rate per 100 cases. Among the unvao- cinated. Among the vaccinated. France,* 1816-41 Quebec,1 1819-20 16,397 16.1 1.0 27.0 1.7 Philadelphia,11 1825 140 60.0 Canton Vaud,2 1825-29 5,838 24.0 2.2 Darkehmen,2 1828-29 134 18.8 Verona,3 1828-39 Milan,4 1830-51 909 46.6 5.6 10.240 38.5 7.6 Breslau,2 1831-33 220 53.8 2.1 Wirtemberg,5 1831^-35^ 1,442 27.3 7.1 Camiola,6 1834-35 442 16.2 4.4 Vienna Hospital,2 1834 360 51.2 12.5 Carinthia,6 1834-35 1,626 14.5 0.5 Adriatic,2 1835 1,002 15.2 2.8 Lower Austria,2 1835 2,287 25.8 11.5 Bohemia,' 1835-55 15.640 29.8 5.2 Galicia,2 1 836 1.059 23.5 5.1 Dalmatia,2 1836 723 19.6 8.2 London Small-pox Hospital,7 1836-56 9,000 35.0 7.0 Vienna Hospital,7 1837-56 6,213 30.0 5.0 Kiel,7 1852-53 218 32.0 6.0 Wiirtemberg* 6.258 38,9 3.5 Malta,6 7.570 21 1 4.2 Epidemiological Society Returns 8 4.624 23.0 2.9 Illinois,9 1,931 48.6 6 1 * Wunderlich's Handbook, iv., 201. 1 Thompson: Small-pox, p. 376 2 Steinbrenner. 3 Rigoni Stern : Die Vaccination und ihre Neuesten Gegner. 1854. 4 Canstatt's Jahresbericht, 1852. 6 Heim. 6 Med. Jahrb. d. Oesterr. Staates, 1838. 7 Report of Coll, of Surgeons, and Statement of Professor Hebra. 8 Seaton. " Fifth Report of State Board of Health. 1882. 4 o £ re g 5 X O' r g >9 B -q e ?> e X Year. 00 00 111 135 95 134 146 125 132 Biiths. 203 132 173 1 147 1 66 1 164 : 65 149 1 79 I-*.. S3 Deaths from all causes. 95 37 66 g Deaths from small-pox. « 51 12 69 15 1 57 41 Excess of deaths over births. It will prove instructive to compare the greatest epi- demic of modern times, in the same town, with the greatest to be found in the old records. In the year 1874 there were 141 deaths from small-pox in Kilmar- nock, which then had 24,000 inhabitants, or at the rate of 5.8 per 1,000 living. The old epidemic was, there- fore, fonr times as severe as the modern one, and it should be remembered that while the former epidemic had only a period of four and a half years in which to collect its victims, no serious epidemic had occurred for more than thirty years previous to 1874. One can hardly conceive what would be said at the present day about an ordinary annual death-rate as great as that of what we have learned to look upon as a terrible epidemic, and yet 527 Vaccination. Vaccination* REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. people from small-pox. On the other hand, among the European troops in the same country (120,000), there were only two deaths from small-pox. The immunity of the troops was attributed solely to the thorough and rigorous enforcement of vaccination." (Wernher, p. 263.) The contested points in regard to vaccination may be reduced to three: 1. Whether, in an equal number of vaccinated and un- vaccinated, fewer of the former are attacked by small-pox than of the latter (a question of morbidity). 2. Whether, in an equal number of vaccinated and unvaccinated, fewer of the former die of small-pox (a question of mortality). To the question as to the ratio of the deaths from small-pox to the number of those taken sick with the disease, Dr. Korosi applies the term lethal- ity. 3. Whether or not vaccination is of itself innocuous, and whether or not other diseases may not be introduced by vaccination. (Korosi: Neue Beobachtungen uber den Einfluss Schutz-pockenimpfung auf Morbiditat und Mor- talitat.) In summing up his observations upon the influence of vaccination upon the population of Budapest, Dr. Korosi collected the data of 20,574 cases of illness in four hos- pitals in Budapest and fifteen provincial hospitals of Hungary, subsequent to April 1, 1886. Excluding 223 children under one year of age, because many are not vaccinated in their first year, he found that out of 18,572 persons sick with different diseases, exclu- sive of small-pox, 16,135 were vaccinated, and 2,437 were not vaccinated. Of the 16,135 vaccinated, 1,306 died, or 8.1 per cent.; of 2,437 unvaccinated, 321 died, or 13.2 per cent. So that the lethality of the unvaccinated was sixty per cent, greater than that of the vaccinated. With reference to the effect of vaccination on the mor- tality from small-pox, he found that there were treated in all 1,113 persons over one year of age ill with small- pox. Of these 631 were vaccinated, of which number 42 died, or 6.66 per cent.; 468 were not vaccinated, of which number 231 died, or 49.68 per cent. There were 17 doubtful cases, of which number 3 died. So that, with reference to small-pox, the lethality of the unvaccinated was eight hundred per cent, greater than that of the vaccinated. Dr. Korosi admits fairly that not quite the whole of this difference can be attributed to neglect of vaccination, since from all other diseases upon which neglect of vaccination has no effect there died 160 unvaccinated to 100 vaccinated. Taking this into ac- count, we may still predict that under like conditions the unvaccinated will have nearly a sixfold greater liability to death when stricken with small-pox than the vacci- nated. Dr. Buchanan, the medical officer of the Local Gov- ernment Board, gives the following summary of death- rates from small-pox among the vaccinated and the un- vaccinated for the year ending May 29, 1881 : Fig. 4443. In Marseilles, in 1828, a severe epidemic of small-pox prevailed, in which the following data were collected, relative to the mortality of these two classes of the popu- lation. The populations given in the first column are necessarily approximate only. Number. Cases of small-pox. Deaths by | small-pox. 1 1. Protected by small-pox 2,000 20 4 2. Protected by vaccination 80, (MIO 2,000 20 3. Unprotected 8,000 4,000 1,000 Total number of persons at ages 0-30 years who were almost exclusively susceptible.. 40,000 6,020 1,024 Death-rate of people of subjoined ages. Per million of each age of the vacci- nated class. Per million of each age of the unvac- cinated class. All ages 90 8, SEO Under twenty years 61 4,520 Under five years 40# 5,950 A severe epidemic of small-pox broke out in Montreal, in 1855, principally in the last half of the year, and de- stroyed 3,164, out of a population of 167,501. In the re- port of the local Board of Health for that year these are classified as follows : Population. Deaths from small- pox. Ratio per 1,000 of the population. French Canadians 93,641 2,887 30.8 Other Catholics 29,627 181 6.1 Protestants 44,233 96 2.1 At the date of the British census of 1881 the number of children under ten years of age in London was 916,784, which was divided into about 55,000 unvaccinated and 861,000 vaccinated. In the same year the deaths from small-pox were as follows : 782 among the 55,000 unvac- cinated, and 125 among the 861,000 vaccinated, or 1 in 70 of the former to 1 in 6,968 of the latter, a difference of nearly one hundredfold in favor of the vaccinated class. The difference in these two methods of inquiry should be noticed, since Dr. Buchanan considers the effect of vaccination upon the population at large, while Dr. K6- This classification was a fair index of the condition of the population of Montreal at the breaking out of the epidemic, the French Canadians being chiefly the unvac- cinated portion, and the remainder the vaccinated. " In the years 1873 and 1874, there died in the East In- dies about 500,000, and in 1875 and in 1876 about 200,000, 528 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vaccination. Vaccination. rbsi considers the effect of vaccination upon the mortality from small-pox as compared with the number of cases. The medical officer further comments upon these fig- ures as follows : " If the London children under ten who were unvac- cinated had had the protection which the current vac- cination gives, not 782 of them, but, at the outside, nine would have died of small-pox during the year. "If the 861,000 vaccinated children had died at the rate of the 55,000 unvaccinated, we should not now be considering 125 small-pox deaths, and how they can be reduced, but we should be confronted with an additional 12,000 and more deaths from small-pox occurring dur- ing the year in the London population under ten years of age. " This saving of life was essentially the effect of vac- cination. If anyone should advance the opinion that the vaccinated may have owed their escape from death by small-pox, not to their vaccination, but to their be- longing to that richer class of the community which, through being better lodged and guarded, is less exposed to the infection of small-pox, the reply is at hand. Let us consider separately the class of the population which has its children vaccinated at the public expense. We know that it is not less than half the population, and that almost the whole of the poorer population is in- cluded in this class. No one will say that this half is the better housed, or its children more out of the way of in- fection, or that its children can command better aids to recovery if they should be attacked. " The children under ten living in London, and hav- ing been vaccinated at the public expense, number about four hundred and thirty thousand. If the rate of death which had prevailed among the unvaccinated children of London had prevailed also among this section of the vaccinated, then, among these vaccinated children, there would have been more than six thousand deaths from small-pox last year. But out of these children, being in chief part children of the poorer class, what was the num- ber of deaths that actually did occur from small-pox ? Not 6,000, nor 1,000, but at the outside 35, more truly 23, for 12 of them were not vaccinated till small-pox had actually taken hold on their bodies.* " In spite, therefore, of any greater exposure to small- pox undergone by the poorer half of the vaccinated com- munity, it is seen that the poorer half had actually less mortality from small-pox among the children than the richer half ; and the opinion that the escape of the vac- cinated from death by small-pox was due to any smaller risk of small-pox infection encountered by the vaccinated as compared with the unvaccinated may be confidently set aside. It is not to be disputed that this saving of life by vaccination among children under ten years of age is, in a great measure, due to the operation of the Vaccina- tion Acts of 1867 and 1871." The accompanying table also gives the statistics of Bohemia with reference to the mortality from small-pox among the vaccinated and the unvaccinated. From all these observations, and from many more of the same character which might be quoted, we find that the mortality among the unvaccinated (without reference to the question of age-distribution, or to the quality of the vaccination performed) is from five to seven times as great as it is among the vaccinated. When, however, the conditions of the latter class are more carefully examined, it is found that among vac- cinated persons infected with small-pox the danger of the disease is chiefly determined by the character or quality of the vaccination. Mr. Marson, who first observed and made known the value of this principle, stated that, if the vaccinated are divided into two classes-(1) those who have been vac- cinated in the best known manner, and (2) those who have been badly vaccinated-the fatality from small-pox, if it infects the former, is but 5 per 1,000, and among the Cases of Small-pox, and Deaths, among the Vaccinated and the Unvaccinated in Bohemia. Official Reports for twenty-one years.1 Year. Vaccinated. ng Unvac- ated. From small-pox. Sick. Deaths. Vacci- nated. Un vacci- nated. Vacci- nated. Un vacci- nated. a 1835.. 132,727 4,029 505 430 20 136 1836.. 136,194 3,319 374 215 26 64 1837.. 126.123 3,971 57 123 4 52 1838.. 133.527 3.967 101 96 15 32 1839.. 132,523 3,906 160 168 20 70 1840.. 190,898 3,585 1,138 966 89 351 1841. 139.474 3,482 1,583 1,522 83 382 1842.. 142,970 3.180 681 703 30 208 1843.. 142,314 2,874 627 714 21 *29 1844.. 126,647 6,109 61 148 1 43 1845.. 149,612 6,410 55 63 2 25 1846.. 146,467 5,474 6 50 0 7 1847.. 141,268 5,301 19 25 0 4 1848.. 132,320 5,718 227 109 17 49 1849.. 139,532 5,704 575 645 63 177 1850.. 156,561 6,375 568 374 14 131 1851.. 152,294 4,694 16 293 3 42 1852.. 161,364 3,689 252 2-31 13 65 1853.. 145,038 3,067 327 168 3 39 1854.. 161,313 2,927 457 203 3 31 1855.. 136,424 2,049 389 156 7 56 Total 3,025,590 90,130 8,178 7,402 434 2,193 Average 143,122 4,221 389 355 20 105 Ilatic^of deaths to cases, per cent... 5.5 29.6 Gutachten des Doctoren Collegiums in Prag (Wernher. J latter 150 per 1,000 ; i.e., the risk in the one class will be live times as great as that in the other. Mr. Marson's observations further established the fact that the degree of modifying power is in the exact ratio of the excellence and completeness of the vaccination as shown by the cicatrices. This principle was shown by observations upon 15,000 cases of small-pox which came under his ob- servation in the course of thirty years. The following well-known table is introduced in sup- port of the statement. Classification of cases according to character of vaccination. Mortality-rate in each class. Per cent. 1. Un vaccinated 35 00 2. Said to have been vaccinated, but having no cicatrix 23.57 3. Vaccinated : (a) I laving one vaccine cicatrix 6.80 (b) Having two vaccine cicatrices 4.70 (c) Having three vaccine cicatrices... 1.95 (d) Having four or more cicatrices 0.55 (e) Having well-marked cicatrices..... 2.52 (/) Having badly-marked cicatrices 8.82 4. Having previously had small-pox 19.00 From these observations it appears that the average of vaccinated persons, if they contract small-pox, have about one-sixth of the chance of dying from this disease which is incurred by those who have never been vacci- nated ; some of them, on account of the poor quality of the vaccination, incur one-third of that risk, while, on the other hand, others, thoroughly vaccinated, incur less than one-seventieth part of it. As to the prognosis of any case of small-pox, then, the question is not merely whether the patient has been vaccinated or not, but also how he has been vaccinated. (Seaton, in " Reynolds's System," vol. i.) Wolff berg, in a further discussion of Gerstacker's views, also regards the duration of the protection af- forded by revaccination as an unsettled question. In addition to the effect upon the fatality from small- pox, further observations have also been made by Drs. Buchanan and Seaton upon 50,000 children, with refer- ence to the quality and amount of vaccination in esti- mating its protective value. Some of this number had * It would seem fair that these 12 should have been classed with the unvaccinated rather than with the vaccinated, and thus the difference between the mortality-rate of the two classes would have been more than a hundredfold. 529 Vaccination. Vaccination. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. never been vaccinated. The majority had been vacci- nated in various ways. Of every 1,000 children without any marks of vaccination, there were not less than 360 who had scars of small-pox, while of those who had evi- dences of vaccination, only 1.78 per 1,000 had any such traces. On further classification as to the kind of vac- cination, the following results were presented : produce ; and (4) the great and unnecessary extent to which the use of preserved and conveyed lymph was substituted for the vaccination direct from the arm, which should be the rule of all vaccinators. These observations were made upon children, most of whom had been vaccinated by public vaccinators, but a large number of whom had been vaccinated by private practitioners; and it was the impression of the observer that the latter were not so well vaccinated as the former. This observation has been substantiated by more recent inquiries (Report of the Local Government Board, 1884). This report, in commenting upon the variable quality of vaccination, and upon the inquiries of Dr. Stevens upon this subject, says : " The 125 children un- der ten years of age who died of small-pox after an al- leged vaccination, must be reduced to 117 by deduction of those who were discovered, on his personal inquiry, not to have been vaccinated at all, or to have been ' un- successfully ' vaccinated ; and this number 117 divides into 82 vaccinated by private practitioners, and 35 by public vaccinators. Now, the number of vaccinated children under ten years of age, in London, is made up in about equal numbers of those vaccinated by private practitioners, and of those vaccinated at the public ex- pense. Among the privately vaccinated there were 82 deaths, and among the publicly vaccinated there were but 35. " From these figures we may deduce the fact that pub- lic vaccination in London protects against small-pox much more than private vaccination. " Children privately vaccinated comprise most of' the children of the upper classes, who certainly run less risk of small-pox infection than those of the poor. The comparatively large mortality among those privately vac- cinated, therefore, becomes the more striking. There is a form of private vaccination which offers itself in competition with public vaccination, and which parades its inefficiency as a reason for its acceptance by ignorant people. Its professors say to young mothers, ' Do you come to me, and I won't hurt the baby ; I'll make only one place on its arm, not four, as those public vaccina- tors do.' And undoubtedly, there are medical men to be found who, having formed some opinion of their own about the sufficiency of one vesicle, cannot be in- duced to set aside that opinion in deference to the indis- putable evidence to the contrary that every small-pox hospital holds up to them." The following table is from Dr. Korosi's admirable paper, read before the International Medical Congress at Washington, 1887, entitled " A Critical Review of Vac- cination Statistics, with New Contributions as to its Pro- tective Power." Classification of children examined. Proportion marked with small-pox per 1,000 children in each tivelj class, respec- r. 1. Having no vaccine marks 360.00 2. Vaccinated : a. Having one vaccine cicatrix 6.80 b. Having two cicatrices 2.49 c. Having three cicatrices 1.42 d. Having four or more cicatrices e. Having cicatrix or cicatrices of bad 0.67 quality /. Having cicatrix or cicatrices of tolerable 7.60 quality g. Having cicatrix or cicatrices of excellent 2.35 quality 1.22 Taking the extremes, it appeared that, of the children having four or more perfect vaccine marks, only 0.62 per 1,000 had any trace of small-pox, while of those who had a single bad mark of vaccination only 19 per 1,000 were scarred with small-pox. As against small-pox, therefore, of such extent as to leave any traces, the best vaccination was more than thirty times as protective as the worst. This numerical statement is far from ex- pressing the real difference, for the marks which small- pox had left on the vaccinated, and especially on the well vaccinated, were usually very slight, and left scarcely any disfigurement ; while of the unvaccinated a very large proportion were seriously disfigured. Many were hideous to look at, and in several the disease had produced permanent blindness and deafness. In the examination of nearly a half-million children in England, with reference to the quality of the vaccina- tion, the following causes of imperfection were noticed : (1) The frequency with which practitioners, instead of attempting fully to infect the system, had been satis- fied with insertions of lymph sufficient to produce only one, two, or three ordinary vesicles. (2) The want of due attention to the selection of the lymph used in vac- cinating. (3) Carelessness and clumsiness in the per- formance of the vaccination, so that, if the operation did not wholly fail, it very frequently resulted in a less de- .gree of effect than it had been the aim of the operator to The Morbidity, Mortality, and Lethality from Small-pox in the Prussian, Austro-Hungarian, and French Armies, from 1867 to 1882. Years. Morbidity. Mortality. Lethality. Sick per 100.600 men. Deaths per 100,000 men. Deaths per 100,000 sick. Prussian. Austro- Hungarian. French. Prussian. Austro- Hungarian. French. Prussian. Austro- Hungarian. French. 1867 74.24 ? 231.14 0.79 ? 18.22 1.06 ? 7.88 1868 38.74 ? 632.99 0.40 ? 42.82 1.04 ? 6.76 I860 43.42 ? 372.79 0.40 ? 22.75 0.92 ? 6.10 1870 I 1871 f 1,280.44 687.02 815.08 ? ? [- 60.90 17.28 40.01 ? J- 4.76 2.51 4.91 ? 1872 161.35 1798.00 60.00 5.65 104.04 10.07 5.50 5.64 17.83 1873 43.52 1658.00 27.05 3.01 109.00 4.00 6.92 6.57 14.55 1874 1875 8.34 6.42 1003.00 336.05 39.07 141.83 67.00 21.05 3.03 17.82 6.68 6.39 8.31 12.56 1876 6.35 274.07 230.47 10.04 28.23 ..... 3.78 12.25 1877 4.89 412.00 222.26 25.05 19.62 ...... 6.19 8.83 1878 4.58 344.00 213.09 15.04 20.14 4.48 9.45 1879 2.12 303.08 115.06 22.07 18.09 ...... 7.47 7.69 1880 6.93 475.03 153.06 25.02 14.09 ...... 5.29 9.70 1881 4.05 434.02 111.02 29.00 7.09 •••••• 6.70 7.10 18S2 2.02 423.00 ? 27.06 ? 6.54 9 Yearly average for the whole period 105.50 689.65 196.32 4.45 38.62 16.87 4.22 5.60 8.58 Average for the period 1872 to 1881 24.85 703.07 131.52 0.86 42.71 13.55 3.46 6.07 10.03 530 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vaccination. Vaccination. Still more conclusive are the charts of the German vaccination commission, in which are shown the small- pox deaths and numbers of cases in Prussia as compared with Austria, and also in the armies of those countries for a series of years. The general resemblance of these charts from 1836 to 1874 is noticeable, but from that date onward there is a great difference. In Austria small-pox continued to prevail, while in Prussia there was a sudden and remarkable decrease under the operation of the law of 1874. In Prussia the deaths per 100,000 of the living popu- lation for the years 1875-1881, were 3.6, 3.1, 0.3, 0.7, 1.2, 2.6, and 3.6, while in Austria the corresponding figures were 57, 39, 53, 60, 50, 64, and 82. In the Prussian army there has not been a single death from small-pox since 1874. In Germany small-pox has diminished, since the enact- ment of the law of 1874, to a degree never before known, so far as records reach, while in the neighboring coun- tries it prevails. Under the title of " the balance of vaccination," Korosi discusses the advantage secured as contrasted with the infinitesimal dangers of the practice. He says : "There died in Buda-Pesth 153 children from skin diseases in six years, of wliich number 30 had been vaccinated. If the chances of death increased thirteen per cent, with the chances of disease, then instead of these 30 cases in the course of six years, there would have been 34 cases ; ac- cordingly 4 cases would have been charged to vaccina- tion ; in other words, for each year 4 to 6 cases, in a population of about 350,000, and for 100,000 inhabitants and one year, about i of a case. Therefore, in a city of one million inhabitants there would die, of skin diseases as a result of vaccination, at most two children more, while, on the other hand, 2,000 would be saved from the small-pox. The balance gives a gain of 1,998 lives. In whatever light the case may be considered, cow-pox vaccination will continue to produce many hundred times more good than evil. So, although the great blessings of vaccination are not bought for nothing, still they are bought at a very trifling cost. And we may say boldly that vaccination is one of the grandest preserva- tive forces for lowering mortality, and raising the aver- age length of life." The, Effect of Vaccination upon the Ape-distribution of the Mortality from Small-pox.-Small-pox, when it oc- curs unmodified by vaccination, as in the last century, is essentially a disease of childhood ; it might almost be said, of infancy. M. Marc d'Espine says of it " The elective age of small-pox is childhood and infancy." Some of the names of this disease in different languages, which have come to us from ante-vaccination periods, are indicative of this characteristic, as Kinderpocken, Barn- kopper, and possibly the English name small-pox, i.e., pox of the small. It is as essentially a disease of children as scarlet fever or measles. In the latter diseases a regular declining series is presented when successive ages are considered. For these diseases no method of pre- vention is known, and hence the statistics of mortality express unmodified natural affinities of such diseases for the earliest periods of life. For small-pox, since the in- troduction of vaccination, this declining series is inter- rupted in a most remarkable manner. The interruption is purely artificial, and is the expression of the effect of vaccination in postponing the greater mortality to a later period of life ; and hence the necessity of revaccination, a subject which will receive further consideration. The adjoining table expresses in four series of figures what may be taken as the expression (at least approxi- mately) of the natural affinity of certain diseases. The population under five is a minority of the population (seldom more than fifteen per cent.), but it furnishes by far the majority of deaths from the diseases named- two-thirds of all deaths by scarlet fever, four-fifths of all deaths by unmodified small-pox, and a still greater proportion of deaths by measles and whooping-cough. In a word, these are all distinctively infantile diseases ; and the obviousness of this fact represents three con- ditions : First, that the susceptibility to those diseases develops itself very early in life ; secondly, that the susceptibility, when once acted upon by its correspond- ing exterior cause, becomes exhausted more or less ab- solutely for the remainder of life ; thirdly, that the ex- terior cause or infection has been of sufficiently frequent recurrence among the population for those relations of susceptibility to show themselves. For the meaning of the diseases being infantile is, not that any insusceptibility to contract them is acquired in the mere act of growing up, but that, because the susceptibility develops itself at the commencement of life, and because the exterior influence which acts upon that susceptibility is seldom absent, therefore all who have outlived the first year of childhood have commonly had each susceptibility exhausted by suffering the disease to which it relates. Hence, if all occurring cases of any such disease be classified according to the ages at which they happen, the resulting series of figures must neces- sarily have its maximum at that age when the special susceptibility is first fully developed. From this point it must undergo a more or less rapid and uninterrupted decline ; the uninterruptedness being determined by the fact that at each succeeding age there will be fewer and fewer susceptible persons, the rapidity being graduated by the frequency or constancy with which the exterior cause is in operation. Proportionate Distribution by Age of 1,000 Deaths in Geneva by Small-pox (1580-1760), before the Discovery of Vaccination, and of the same number of Deaths by Whooping-cough, Measles, and Scarlet Fever, as observed in 1847. Ages. Small- pox. Whooping- cough. Measles. Scarlet fever. 0-1 202% 404% 155% 63% 1-2 1M% 275 346% 145 ' 2-3 190 138% 201% 171% 3-4 132 77% 117" 153 4-5 88% 47% 68 123% 0-5 805 943 883% 656 5-10 155% 52% 91% 254% 10-15 18% 2% 13% 54% 15-25 13% % 4 12^ Above 25 7 1% 7 22% At all ages 1,000 1,000 1,000 1,000 Pursuing a similar line of inquiry with reference to the effect of vaccination at different periods subsequent to its introduction, the Registrar-General of England, in his forty-third Annual Report (1880), compares three periods with reference to the effect of vaccination as per- formed upon the population with varying degrees of effi- ciency. The first was from 1847 to 1853, in which gra- tuitous vaccination was offered to the public, but re- course to it was entirely optional. In the second period (1854-71), vaccination was obligatory, but the means of enforcing it were inefficient. In the third period (1872- 80), vaccination has been enforced by officers appointed for the purpose. Mean Annual Deaths from Small-pox at Successive Life- periods, per Million Living at each such Life period. Age. Period. All ages. 0- 5- 10- | 15- 45 and upward. 1. Vaccination optional (1847- 53) 305 1,617 817 337 94 109 66 22 2. Vaccination obligatory, but not efficiently enforced (1854-71) 223 243 88 163 131 52 3. Vaccination obligatory and more efficiently enforced (1872-80) 156 323 186 98 173 141 58 Entire period of obligatory vaccination (1854-80 198 633 222 92 167 135 55 531 Vaccination. Vaccination. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. These figures show that, coincidently with the grad- ual extension of the practice of vaccination, there has been, in the first place, a gradual and notable decline in the mortality from small-pox at all ages ; in the second place, that this decline has been exclusively among per- sons under ten years of age, and most of all among chil- dren under five years of age, in which group the rate fell no less than eighty per cent, in the interval between the first and third periods ; and thirdly, that after the age of ten years the mortality has actually increased ; very slightly among persons of ten to fifteen years of age, but very greatly for persons older than this ; and lastly, that the increase has been the greater, the more ad- vanced the time of life. These striking changes in the rates at successive periods of life are, it will be noted, not petty differ- ences, nor mere matters of decimal points, but enormous changes, of such magnitude as utterly to preclude all explanations which would refer them to chance fluctua- tions, or to errors in registration. Opponents of vaccination have attempted to account for the decline in small-pox mortality by referring it, not to vaccination, but to the general improvement that has been effected in the sanitary conditions of life. Such explanation will not account for the striking changes shown in the above table, unless it can be shown that similar changes, corresponding in regard to direction, extent, and the life-periods at which they oc- curred, have manifested themselves in the general death- rate, or, more precisely, in the death-rate from all other causes beside small-pox. For no one can possibly sup- pose that the general improvement in sanitary conditions can have had exclusive influence in the reduction of small-pox and left the other causes of mortality unaf- fected. To inquire further upon this point, whether the general death-rate has changed in a similar degree with that of small-pox, let the period (1847-53) in which vac- cination was optional be compared with the period (1870-80) in which vaccination was efficiently enforced. Each death-rate in the first period is taken as 100, and the figures in the table give the death-rates in the latter period as compared with that 100-in the first line for small-pox, and in the second line for all diseases taken together excepting small-pox. Death-rates {England} in 1872-1880 compared with those in 1847-1853, the latter taken as 100. and the more so the later the period of life. Doubtless, at first sight, this progressive rise in the small-pox rates at the later periods of life seems incompatible with the asserted protective influence of vaccination ; but on fur- ther consideration it will be seen that this is not the case, and, indeed, that such rise is what might naturally be anticipated from what is known as to the character and degree of the immunity conferred by vaccination. For it is quite generally recognized, and this on good grounds, that the immunity derived from vaccination is both less perfect and less permanent than that conferred by small pox itself ; its efficacy diminishing with the lapse of time, while the protective influence of small-pox remains practically unaltered. If we admit the exist- ence of this difference between the two forms of immu- nity, we have the following explanation of the fall of the rate in early life and its rise at the later ages. Before vaccination came into use few persons escaped having small-pox at some or other time in their lives. The great majority had it when young, and of these a large proportion died, causing a very high death-rate in the earlier age-periods. But those who survived the at- tack enjoyed a practically complete immunity for. the rest of their lives ; and, as they formed a considerable proportion of the population at the later age-periods, the small-pox death-rates at these periods of life were very low. But when vaccination came into use, and in pro- portion as its use became more and more general, the relative conditions of the different age-periods as regards immunity were materially altered, and partially in- verted. Childhood, previously altogether unprotected, now received a very considerable immunity ; while the later ages, previously much protected, now had their immunity considerably diminished, and the more so the later the period of life, and the more remote, therefore, the date of vaccination (" Registrar-General's Forty-third Report," England, 1880, pp. xxi.-xxvi). In further comment on the same subject, Dr. Bu- chanan, the Medical Officer of the Local Government Board of England, says in his report for 1884 : " Since 1857, as time has gone on, it has been observed that in England the share of small-pox mortality borne by chil- dren under five years of age has steadily decreased in amount. From the beginning of registration (1837) it had fallen from 700 out of every thousand deaths from small-pox to 560, 550, and 540 in the several five-year periods, 1855-59, 1860-64, and 1865-69 ; and then in the two five-year periods, 1870-74 and 1875-79, to 320 and 280, the amount of infantile contribution always keeping very closely the same in London and in the provinces. In the Metropolitan small-pox of 1884, the share of small-pox mortality borne by children under five years of age was only 240 out of a thousand deaths at all ages ; and another hundred deaths out of the thousand have formed the contribution of children between five and ten years of age." The reduction is, of course, to be regarded, in the first place, as an expression of the arithmetical fact to which attention has been called, namely, that the insuscepti- bility to small-pox gained by the English community during recent years and by the influence of recent legis- lation, has been gained in preponderating measure by the infantile section of the community ; wherefore the peculiar incidence of small-pox on the early years of life has to an increasing extent been reduced, and later pe- riods of life are contributing more and more to each thousand deaths by the current disease. On further consideration of the same subject by refer- ence to the death-rates from small-pox of persons living at each age, the Registrar-General's Reports show that in the successive periods already referred to, of optional vacci- nation, of obligatory vaccination partially enforced, and of obligatory vaccination efficiently enforced, the mean annual death-rate of children under five years of age fell from 1,617 per million, in the first period, to 817 in the second, and to 323 in the third ; and that of children be- tween five and ten years of age also fell from 337 to 243, and then to 186 ; while the death-rate of those between ten and fifteen years remained nearly stationary, the rates All ages. 0- 5- 10- 15- 25- 45- - - - - - - Small-pox 51 20 55 104 159 214 264 All other causes 93 94 70 67 71 88 97 It is clear that the correspondence required by the hy- pothesis does not exist. At each age-period after the tenth year the changes in the rates were in contrary di- rections ; the small-pox rate increased, while the rate from other causes declined. In the two age-periods un- der ten years the changes were in the same direction, but were utterly disproportionate to each other in amount. Especially was this the case in the first age- period, for while the death-rate from other causes at this age fell only six per cent, the death-rate from small-pox fell eighty per cent. The most, therefore, that can be claimed at this period of life as the effect of general sanitation, in regard to small-pox mortality, is that it contributed to its reduction in a small fractional de- gree. The hypothesis, then, that would explain the great fall in small-pox mortality by referring it, not to vac- cination, but to general sanitary progress, must be re- jected as utterly untenable. There can be no rational doubt that the death-rate from this disease fell not only coincidently with, but in consequence of, the extended use of vaccination. The difficulty is to explain why this fall was not common to all periods of life ; why the rate of mortality fell among young persons, but rose, and this very greatly, among those of more advanced age, 532 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vaccination. V accination. being 94, 88, and 98. At higher ages there was an in- crease in the death-rates. Nevertheless, when all ages are considered together, the average annual death-rate by small-pox (for all ages), 305 per million of the living pop- ulation in the optional period, fell to 223 in the obligatory period, and 156 in the later or period of enforced vacci- nation. Statutory enforcement of vaccination, then, as contrasted with its optional use before 1853, has availed exclusively for the protection of those who cannot pro- tect themselves, and it has become obvious that the trans- ferrence from infancy to later ages is not wholly an affair of abolition of infantile small-pox. Dr. Buchanan finds two circumstances which, in his opinion, have conduced to this increase in the death-rate at later periods of life. First, the probability that small- pox death-rates among adults were artificially low dur- ing the first period of 1847-1853 ; an exceptional num- ber of men and women of that time having very recently passed through their primary vaccination ; and, secondly, the increased mobility since the end of that period of the population, and chiefly of the adult population, which brought adults more and more into the towns and into contact with the infectious diseases which are specially prevalent in the towns. The resistance to adult small-pox formerly afforded by an infantile attack of small-pox was almost complete and life-long. It has been exchanged at the present day by a larger number of people for the resistance furnished by the average vaccination (" Fourteeenth Local Gov- ernment Board Report," 1884, pp. 16-20). It should be remembered, however, that the slight in- crease in the comparative death-rate from small-pox in adult years is far more than counterbalanced by the gain in the years of infant life. The enormous tribute of deaths from small-pox among infants and children no longer exists in a well-vaccinated community. For the methods of prevention of the increase in the death-rate from small-pox in adult life we must look to revaccination. The English vaccination system, although it provides facilities for renewal of vaccine protection at puberty, does not provide for a second enforcement of the opera- tion, but leaves the adult to decide whether, in his own interest, he will receive the full measure of protection that vaccination is capable of giving him. Yet in the case of some people, there is a period of life between childhood and manhood, before the age of legal responsi- bility is attained, in which period the protective influence of their infantile vaccination is so far lost as to leave them liable to small-pox, and in some instances to death by small-pox. And herein the German law of 1874 affords greater protection. This law, recognizing that vaccination might reasonably be trusted for ten or twelve years from the date of operation, provided that all chil- dren should be vaccinated a second time during their school period, and made the parents responsible for its performance. A recent report of the German Vaccination Commis- sion shows that during the ten years since the enactment of its compulsory law of 1874, Germany has not only had a smaller death-rate from small-pox than ever before, but has even passed from a position of inferiority to England to one of distinct superiority in regard to its immunity from small-pox. Small-pox mortality in the cities of Germany has become a trivial matter, while in London, Paris, and Vienna there have been quite appreciable epidemics, having their principal incidence upon the younger adult class of the population. The following statistics as to the incidence of small-pox at certain ages are from the Report of the Medical Officer of the Local Government Board of England, for 1884. While the 86 deaths among children under ten, stated in the column headed " Vaccinated community," con- trast strongly with the 612 in the preceding column of the unvaccinated, there is no doubt, as the medical officer states, that even this number 86 is far too high, and is in- dicative of sham vaccination ; since in a previous inquiry he had shown that 125 children under ten, said to have died of small-pox, who had been previously vaccinated, comprised in their number only one who had been vac- cinated by a public vaccinator, and in the manner con- templated by the instructions of the Board. "Ignorant people," says the medical officer, " may' still be found to demand and supply a factitious operation, well known to be inefficient, yet passing under the name of "vacci- nation." Contribution of Various Ages to 1,000 Small-pox Deaths at all Ages. Totals B B & g > 1 ? o 8 5 ? Ages at Death. 1,000 961 26* > 10 f 21 Geneva, 1580- 1760. I 1,000 1,000 • • So Kilmarnock, 1728- 1764. 00 03 00 QT U-L 1-1 to 03 CK London. 1848- 1851. 000'l 397 133 329 110 31 Paris, 1842-1851. 1,000 1,000 612 116 108 72 62 Unvaccinated community. London, 1884. 108 188 618 Sil 98 Vaccinated community. 1,000 343 170 213 142 132 Total inhab- itants. A comparison of the mortality from small-pox of children under one year of age living under the pro- visions of different laws, some of which are vigorously enforced, others optional or partially enforced, and also of populations entirely without vaccination, as was the case in the last century, is very instructive. Dr. Robert- son, of Edinburgh, made such a comparison, and found that under the optional system in practice in Scotland from 1855 to 1864, the number of deaths from small-pox of children under six months of age was about equal to that of children whose ages were six to twelve months. When vaccination became compulsory this ratio was greatly changed, and the number in the second six months was about one-fourth as large as that of the first six months. It was inferred that vaccination made the difference. A third fact, however, strengthened this in- ference, and that was the ratio existing before vaccina- tion was known. This was to be found in the carefully kept statistics of the Kilmarnock register. Ratio of Deaths from Small-pox between 6 and 12 Months of Age, to 100 Deaths from Small-pox under 6 Months, in Three Selected Periods. Ago. 1728-1763. 1855-1864. 1865-1879. Kilmarnock. Scotland. Scotland. Vaccination unknown. Vaccination optional. Vaccination compulsory. Under 6 months 100 100 100 From 6 to 12 months 491 103 26 The first ratio may be taken as the normal one of nat- ural small-pox. It is a disease nearly five times as fatal in the second as in the first six months of life. But when modified by optional vaccination in the second six months, the mortality is reduced from 491 to 103. And when vaccination becomes compulsory, as in the third period, the 103 is further reduced to 26. The question may be asked, how far is this decrease in small-pox mortality to be attributed to causes other than vaccination ? Improved hygiene and treatment may have exercised considerable effect upon the mortal- ity, but they can have but little bearing upon the facts quoted in the last table. Such an enormous improve- ment, at the rate of nearly 20 to 1, could never have been due to mere measures of sanitation. Let the following table of the rate of improvement of certain infectious diseases illustrate this. 533 Vaccination. Vaccination. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Bate per 1,000 per Year of Deaths from Certain Infectious Diseases in Kilmarnock in 1728-64, and in England and Wales in Different Periods. The principal point shown in this table is that, on an average, over eighty-eight per cent, of those who died in one epidemic had been born since the previous one; that ten per cent, who died had passed safely through one epidemic ; and that only one per cent, had lived through more than one outbreak. The next table shows that these epidemics, to nearly nine-tenths of their extent, did not practically occur in a population of 4,200, but in a population of 475 people. And the average number of deaths in this population was 60, or at the very high rate of 126 per 1,000 living in each epidemic year. Now the number of attacks in un- vaccinated children under five years of age is two for every death. As many die as recover. Therefore, of every 100 children born in Kilmarnock, no less than 25 were seized with small-pox at the very first epidemic after their birth. Section of Population Born since Former Epidemic. Disease. Rate in Kilmarnock. 1728-64. Rate in Eng- land. Rate of de- crease. Measles 0.615 (1861-71) 0.4399 100 to 70 Whooping-cough 0 7671 " ' 0.5273 Fever (including scarlatina)... S.4722 " 1.8474 100 to 53 Small-pox 4.1071 (1854-79) 0.208 100 to 5 Deaths from small-pox have therefore decreased 14 times faster than from measles, 13 times faster than from whooping-cough, and 10 times faster than from fever. From the instructive comparison given by Dr. McVail, the following conclusions are drawn : 1. Small-pox was epidemic every four and one-quarter years (1728-64). 2. Its death-rate per 1,000 per year was nearly 20 times as great as it now is. 3. Its death-rate under five years of age was 35 times as great as it now is. 4. The mean age at death from small-pox was two and one-half years in the last century, and is now nearly twenty years. 5. The death-rate from small-pox in the second half- year of life is now only a fourth of that in the first half- year, while formerly in the second half-year it was nearly 5 times as great as in the first half-year. 6. The small-pox death-rate has improved about 12 times as fast as the death-rate from measles, whooping- cough, and fever. The fact that small-pox when allowed to pursue its natural course, unmodified by vaccination, is essentially a disease of childhood, is illustrated in a most forcible manner in the sketch of small-pox in Kilmarnock in the last century, already quoted. Of the 622 persons who died of small-pox in that town between 1728 and 1764, 586, or 94.2 per cent., were five years of age and under. Seven only were over ten years of age, and the oldest was but twenty-six. In the different epidemics which fell upon that com- munity, the time from the height of the first epidemic to that of the second was but four years and eight months, and of the 45 children who succumbed in 1733, 44 were less than four years and eight months of age, the remaining one being seven years of age. Thus only one child that died in the epidemic of 1733, had been alive previous to the height of that of 1728. The disease had to secure its victims almost wholly from the population that had come into existence since its last visitation. One epidemic left almost no victims for its successors ; in the same way, hardly any had been left to it by its predecessors. It called at every door, and nearly all who were not disease-proof came within its grasp. o 9 3Q d ,P - § b ,P S-.P Height of epidemic. - s ~s to 5 E c c p p ■f, 1733 ober, 17 f. 1740 n* 33 c< OS 4.514 CJ s X 501 506 634 0: Born since height of former epi- demic. SC s 0 e 3 ^5 CO GC -r' GO 65 O Died of various dis- eases, excluding small-pox. 9 03 E □' s 527 517 404 394 412 438 65 Remaining to form a field for new epidemic. "These two tables show that, as regards small-pox, there were, in fact, three Kilmarnocks. One, a Kil- marnock of 3,700 persons, had no fear of its attacks. These had already met and battled with the disease-fiend. On many were to be seen the marks of the conflict. Some were blind, some had lost their hearing, many were permanently injured in constitution, and very many were scarred and disfigured for life ; and, for every one that conquered, another had fallen, never to rise again. There was indeed a second Kilmarnock under the green sod of the kirkyard. The Kilmarnock which had reason to dread the epidemic's approach was a Kilmarnock the least able to meet it. It consisted of a band of little children, numbering less than 500 in all. Every such group that came into existence had to face, within four or five years of its birth, the most terrible physical enemy that it would ever meet ; and, having fought the battle, some were added to the maimed and distorted who formed so large a portion of the popula- tion, and others were laid beside those who had been destroyed by former epidemics. One can barely imagine what must have been the feelings of a mother regarding these fearful visitations. Even w here the town was free from the pestilence, there would be the constant fore- boding of its all-too-certain coming ; and when at last the first case occurred-when the doctor was called in, and pronounced the disease to be the dreaded pox-his words would be heard as a sentence of death to some member of almost every family containing little ones; and, as the news spread from house to house, with what a despairing clutch would each mother press her darling to her breast, and beg Almighty God to command the destroying angel to pass by her door ! After the lapse of a hundred and fifty years, one can have little concep- tion of the real meaning of a small-pox epidemic. But the old parish register has enabled us to apprehend some- thing of its horror, and I venture to say that, if the anti- vaccinationists had their will, we would ere many years be again experiencing somewhat of the awful visitations which were so familiar in old Kilmarnock." Epidemic years. Interval since height of former epidemic. Total deaths, small- pox. Deaths of children born since height of former epidemic. Deaths among chil- dren who had passed safely through one epidemic Deaths among per- 1 sons who had passed through more than one epidemic. 1758-29 Unknown. 66 1733 4 years 5 months. 3 years 5 months. 3 years 7 months. 4 years 8 months. 5 years. 4 years 6 months. 3 years 2 months. 4 vears 8 months. 44 1 1736 66 58 7 1 1740 66 60 5 1 1744-45 74 67 6 1 1749-50 84 79 4 1 1754 95 84 11 1757-58 39 6 1762 66 53 H 2 Cases occurring between epidemics. 14 8 5 1 621 492 56 7 88 6 10 00 1 2 534 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vaccination. Vaccination. In every country where observations have been made with reference to tlie age-distribution of small-pox mor- tality, similar results are noticed, and the immunity of the first five years of life is found to'depend very largely upon the extent to which primary vaccinations are con- ducted. Other things being eqqal, that is, the quality of the lymph used, and the carefulness and thorough- ness with which it is used, the greatest freedom from small-pox in the earlier years of life will be found in those countries and in those municipalities in which the ra- tio of annual vaccinations approaches nearest to the num- ber of living and surviving births in such community. The following statistics are illustrative of this state- ment. Deaths from Small-pox in Different Countries by Age-periods. Distribution Deaths in each. 4U ana upward Not stated 30-40 o -' o o 1 JI 1 £ 1 tc r l-l Ages. OOO'I 805X 155^ 26^ 10 } 2^ Geneva. 1580-1760. Before introduction | of vaccination. 14 1,000 189 235 219 162 137 942 3!) 5 5 Kilmarnock. 1728-1764. - 137 194 447 177 41 4 1,000 Vaccinated. Japan. 1879-1880. .... :::: 519 216 196 46 17 6 1,000 Unvaccinated. 79 101 187 222 411 1,000 Vaccinated. Netherlands. 1870-1873. 478 204 154 71 .95 1,000 Unvaccinated. 200 ] I 800 ... 1,000 Vaccinated. 1883. Epidemic year. Brussels. 715 285 1,000 Unvaccinated. 294 706 1,000 Vaccinated. Buda-Pesth. 1876-1881. 766 234 1,000 Unvaccinated. "o o Laws and en- nuc forcemeat generally very lax. United States. 1880. Tenth Census, Vol. XI. . . . .... Vaccination S £ gi 2 S S moderately 1-1 enforced. Massachusetts. 1863-1886. Chicago. Cases of SmaU-pox Treated in Hospital in 1881-82, by Ages.* Under 1 year. Ito 2 years. 2to3 years. 3 to 4 years. 4 to 5 years. Total under 5 years. 5 to 10 years. 10 to 20 years. 20 to 30 years. 30 to 40 years. 40 to 50 years. 50 to 60 years. 60 to 70 years. 70 to 80 years. Not stated. Total. 1881 44 33 38 25 32 172 104 146 322 157 76 18 2 1 9 1,007 Percentage.... 4.4 3.3 3.8 2.5 3.2 17.1 10.3 14.5 32.0 15.6 7.5 1.8 0.2 0.1 0.9 1882 29 13 17 18 9 86 110 260 302 180 79 26 4 1 16 1.055 Percentage.... 2.7 1.2 1.6 1.7 0.9 8.2 10.4 24.6 28.6 17.1 7.5 2.5 0.4 0.1 ... * Fifth Annual Report of the State Board of Health, Illinois. Comparison of the Small-pox Mortality of Infants under one Year of Age, among theVaccinated and the Unvaccinated. Periods. London. Deaths from small-pox. Estimated pop- ulation. Deaths from small-pox per million of population. First 10 years ending 1719, before inoculation 21,288 675,691 31,416 Second 10 years ending 1749. inoculation partially practised 20,029 708,188 ■ 28,282 Third 10 years ending 1799, inoculation in general use 17.685 773,344 22,863 Fourth 10 years ending 1819, vaccination in general use 8,334 1,035.865 8,045 Fifth 10 years ending 1849, inoculation superseded by vaccination 9.174 1.912,172 4,798 Sixth 10 years ending 1876 * 13,840 3.254^ 260 4.253 Seventh 10 years ending 1886 * 9,689 3,816,483 2,539 * Compulsory laws in force. Small-Pox Epidemic in the Netherlands in 1870-1873. Deaths from Small-pox by Ages, of the Vaccinated, Revaccinated, and, Unvacdnated. Total .... 854 Not vaccinated. P O o Vaccinated. CO 7s 2,755 Not vaccinated. 1 to year a CO Vaccinated. ® Or ' 1,536 Not vaccinated. 5 to 2,249 § Vaccinated. 10 year Revaccinated. 5D 1,158 Not vaccinated. 10 tc 2,467 1,274 Vaccinated. । 20 yea o? Revaccinated. 3 533 Not vaccinated. S' 2,119 1,522 Vaccinated. । 30 yea - Revaccinated. cs co Oi Not vaccinated. 30 tc 3,321 2,586 Vaccinated. i 60 yea o Revaccinated. CD £ Not vaccinated. Over 313 to co Vaccinated. naX 09 Revaccinated. 7,555 Not vaccinated. 14,621 6,843 Vaccinated. 1'otal. 223 Revaccinated. 535 Vaccination. Vaccination. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Saxony. In Chemnitz (epidemic of 1870-71) there were 265 chil- dren under ten years of age taken sick with small-pox, of whom none died ; and of the unvaccinated there were 2,440 cases of small-pox, of whom nine per cent. died. Of the 953 vaccinated, 7 died, or 0.79 per cent. Of the 2,043 unvaccinated, 242 died, or 9.16 per cent. Leipzig, 1871. Ages. Vaccinated. Unvaccinated. Sick. Deaths. Death-rate. Sick. Deaths. Death-rate. Under 1 year .. Per cent. 69 35 Per cent. 50.7 1 to 2 years... 56 26 46.4 2 to 3 years... 57 24 42.1 3 to 4 years... 35 14 40.0 4 to 5 years... 2 23 3 13.0 5 to 10 years.. 25 20 Y 35.0 10 to 15 years.. 90 6 1 16.7 15 to 20 years.. 53 2 1 50.0 20 to 30 years.. 89 3 3.4 30 to 40 years.. 88 6 6.8 1 1 40 to 50 years.. 43 5 11.6 1 1 50 to 60 years.. 20 3 15.0 60 to 70 years.. 6 1 16.7 Over 70 years.. 1 i 1 Ages. Vaccinated. Unvaccinated. Cases. Deaths. Per cent- Cases. Deaths. Per cent. ■From 0 to 1 year.... From 1 to 2 years... From 2 to 3 years... From 3 to 4 years... From 4 to 5 years... From 5 to 6 years... From 6 to 7 years... From 7 to 8 years... From 8 to 9 years... From 9 to 10 years.. 8 15 30 31 43 35 46 24 18 15 373 528 444 331 222 197 105 98 98 71 102 51 26 21 9 7 1 2 1 21.3 9.6 5.9 6.3 4.6 3.6 0.9 2.0 1.02 In the same epidemic there were in all, in Chemnitz, 3,596 cases. Of this number 249 died, or 6.92 per cent. Under 1 year. 1 to 2 years. 2 to 3 years. 3 to 4 years. । 4 to 5 years. 1 5 to 10 years. 10 to 15 years. 15 to 20 years. 20 to 30 years. Over 30 years. Unknown. Total Recovered. Died. Per cent, j of deaths. Vaccinated Unvaccinated Totals Per cent, in each age-perio4 22 536 36 457 40 330 30 295 48 209 249 758 330 424 245 263 227 53 162 62 5 18 1,285 3,514 1,133 2,371 152 1,143 11.3 32.5 558 11.63 493 10.27 370 7.71 325 6.77 257 5.36 1,007 20.99 754 15.71 508 10.59 389 8.11 115 2.39 23 0.48 4,799 3,504 p 1,295 Small-pox in Japan, July 1, 1879, to June, 30,1880. Massachusetts. Distribution of 1,000 Deaths from Small-pox, Measles, and Scarlet Fever, for 24 years, 1863-1886. In Brunswick the distribution was as follows: From 0 to 5 years, 842; from 6 to 10 years, 148; 11 and over, 11. In Stockholm, since the introduction of vaccination, the following observation was made in the epidemic of 1873-1874. (Distribution of 1,000 deaths.) Deaths from Small-pox in Hospital. Ages. Small-pox. Measles. Scarlet fever. 0 to 5 years 324.0 808.1 661 2 5 to 10 years 70.6 88.1 247.4 10 to 15 years 33.8 16.0 49.5 15 to 20 years 85.4 19.4 17.3 20 to 30 years 264.8 31.1 15 3 30 to 40 years 103.6 10 7 4.6 40 to 50 years 43.8 9.2 1.1 50 to 60 years 29.6 3 8 1.0 60 to 70 years 17.5 4.2 0.5 70 to 80 years 9.1 4.9 0.2 Over 80 5.4 1.7 Not stated 12.4 2.8 1.9 Ages. Vaccinated. Unvacci- nated. From 0 to 1 year 5.3 13.3 981.3 148 473 284 27 68 From 1 to 5 years From 5 to 10 years From 10 to 15 years From 15 and over The following table presents in a clearer manner the actual incidence of small-pox at different ages, or the relative liability of persons at different ages to take small- pox ; since the number of deaths from small-pox at each period of life is compared with the number of persons living at that period. In Stockholm the total number of deaths from small- pox, from 1774 to 1800, was 5,113, which were distributed as follows, per 1,000 deaths : From 0 to 1 year, 345 | I From 11 to 15 years 22 From 2 to 5 years, 491 ( • • • • From 16 to 20 years 9 From 6 to 10 years 116 | From 21 and upward 6 Deaths from Small-pox in each Year, out of 100,000 Living at each Age-period. Populations without regular vaccination. Populations with regular vaccination. Vaccination moderately enforced. Ages. Netherlands. Berlin. Scotland. Bavaria. Canton Zurich. Massachusetts. From 1870 to 1872. From January, 1871, to July, 1872. 1855 to 1864. 1865 to 1874. From October, 1867. to Octo- ber, 1870. From October, 1870, to Octo- ber, 1875. 1870 to 1871. 1863 to 1887. Under 1 year 767.5 441.4 325* 122.7 11.1 222.4 172.2 1 to 2 years 203.2 225* 23.4 26.09 2 to 3 years 3 to 4 years I 455.0 148.4 112.2 137* 98* 18.3 15.9 I 4.7 10.2 8.7 4 to 5 years J 73.7 65* 18.7 5 to 10 years.... 145.0 27.6 17.0 0.9 3.3 1.8 5.84 10 to 15 years ... J- 72.5 5.9 18.6 8.6 5.6 14.3 2.94 15 to 20 years.... 12.4 20.3 7.25 20 to 30 years.... 87.5 23.3 20.2 2.4 25.5 12.9 11.43 30 to 40 years.... 36.3 21.9 6.4 35.5 28.4 5.75 40 to 50 years.... 85.0 48.5 12.2 7.1 54.0 47.5 3.17 50 to 60 years.... 70.9 9.0 12.5 68.9 45.5 3.11 60 to 70 years.... 89.7 9.0 13.9 82.2 29.5 2.90 70 to 80 years .... 37.5 20.6 2.0 6.4 40.5 3.15 Over 80 years.... 0.9 6.18 * Before the enactment of the vaccination law. 536 Vaccination. Vaccination. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The Duration of the Protective Power of Vaccination.- Gerstacker, as quoted by Wolff berg, states (Centralblatt fur Allg. Gesundh., 1888, p. 182) that the cardinal princi- ple of the duration and efficiency of the protection af- forded by vaccination depends essentially upon the in- tensity of the preceding vaccination, and upon those changes which-independent of every attempt at protec- tion-the natural individual predisposition to small-pox undergoes in the course of life, although reduced to a definite lower standard by vaccination. The Comparative Protection Afforded by Vaccination and by Small-pox.-Observations made at Marseilles, and also by the Epidemiological Society of London, appear to show that, while the protection afforded by thorough vaccination is very great, that which is afforded by an at- tack of small-pox is still greater ; and that which is af- forded by natural small-pox is also greater than that which was due to the practice of artificial inoculation, as was done in the last century. Both Marson and Simon expressed the opinion, before the Parliamentary Committee of 1871, that the protection afforded by an attack of small-pox against a subsequent attack was greater than that afforded by vaccination. (Replies 3517-3521 ; 4220-4224.) In the early years of vaccination it was quite a common practice to expose vaccinated people to the small-pox either by contact or by inoculation, for the purpose of testing the efficacy of the practice. The town of Milton, Mass., in September, 1809, voted to test the question upon twelve children who had been vaccinated in July of the same year. Twelve vaccinated children were therefore selected and inoculated with small-pox lymph. They were quarantined during fifteen days at a hospital pro- vided for the purpose, and the following certificate was issued on their release : Milton, October 25, 1809. The twelve children whose names are written on the back of this card were vaccinated at the town inoculation in July last; they were tested by small-pox inoculation on the 10th instant, and discharged this day from the hospital, after offering to the world, in the presence of most re- spectable witnesses, who honored Milton with their attendance on that occasion, an additional evidence of the never-failing power of that mild preventive, the cow-pox, against small-pox infection; a blessing great as it is singular in its kind, whereby the hearts of men should be elevated in praise to the Almighty Giver. Amos Holbrook, Oliver Houghton, Physician. Chairman of the Committee for Vaccination. As compared with the earlier practice of inoculation with small-pox lymph, vaccination has the great advan- tage over the latter that its protection is afforded without risk to life, without disfiguring the features, without causing loss of sight, or of hearing, and without the risk of propagating a highly infectious, loathsome, and dead- ly disease among the community. Bovine Vaccination.-The term bovine, or animal, vaccination is applied to that which is practised by the aid of vaccine lymph cultivated in bovine animals. Warlomont very truly says that the term animal vacci- nation is purely conventional : the vaccine lymph from an infant is just as much animal as is that from a heifer. Dr. II. A. Martin defines true animal vaccination as the inoculation of a selected young bovine animal with the virus of spontaneously occurring cow-pox, from this the inoculation of another similar animal, and so on in an endless series. With reference to the origin of the practice, Dr. War- lomont states that an aged physician had, in his youth, seen his father, the village doctor, inoculate the teats of a cow with human vaccine, preserved through the winter in order to renew the stock of fresh lymph at the com- mencement of each vaccinating season. Such was a com- mon practice, and it has been carried out for years in Germany, and especially in Bavaria. This method of practice has been called retro-vaccination. It has also been practised to a considerable extent in the United States. Supplies of vaccine virus were largely obtained for use in the army by this method during the latter part of the Civil War (1861-65), and while this method has been vehemently opposed by some, it is also true that no evidence has been adduced to show' that such vaccina- tion, when properly transmitted from a healthy infant to the heifer, and thence, after one or more successive trans- missions from animal to animal, is again transmitted to the human species, is less protective against small-pox than that which has never been cultivated upon other soil that that of the cow. The German Government takes this ground and sanctions its employment in its recent instructions upon this subject. That method to which is now given the term animal or bovine vaccination, is of later origin, and also has a more restricted application. Warlomont defines animal vaccination as " the product of natural horse-pox or cow- pox which has been cultivated upon heifers, and has never quitted that place (or medium) of cultivation (" n'ayant jamais quitte ce lieu de culture"). This method was practised in a limited degree as early as 1800, by Duquenelle, at Rheims, and by Valentine, at Nancy. It was introduced into Naples in 1810 by Gal- biati, and continued by his pupil, Negri. Both of these early experimenters occasionally resorted to retro-vacci- nation, but Negri finally began a series of continuous vaccinations, for which he obtained his original supplies, on two different occasions, from animals found to be af- fected with natural cow-pox. In 1864 M. Lanoix, a French physician, visited Naples to study this method of vaccination, and thence intro- duced the practice into Paris in the same year. A com- mission was appointed by the Government in 1866, whose report favored the practice of animal vaccination, and the first virus employed by them was that which had been obtained from Naples. A new source was soon found at Beaugency, in France, in 1866, and still later another at St. Mande, near Paris. Other cases of nat- ural cow-pox may be found detailed in a recent article in the Ikvue d'Hygiene (July, 1888) by Dr. A. Layet, en- titled " Les Sources naturelles du Vaccin." Dr. Seaton, in his report on animal vaccination to the Local Govern- ment Board of England, made after a visit to Paris and other parts of the Continent in 1869, states that Drs. Lanoix and Chambon, w'ho had introduced animal vac- cination into Paris, " saw no advantage in keeping these two lymphs distinct, and the virus which they have em- ployed since 1866 is a mixture of the two natural sources discovered at Beaugency and at St. Mande." Dr. Seaton's report is worthy of comment, since his conclusions are entirely at variance with the experience of animal vaccinators of the present day. They were as follows : First. That, apparently, even able and painstaking operators may find it impossible to transmit successive vaccination from calf to calf without very frequent re- currence of failures and interruptions. Second. That the transference of infection from the calf to the human subject, even under the most favorable circumstances (i.e., by experienced operators and with lancet direct from calf to arm), has in it such risks of failure that, for instance, at Rotterdam, the proportion of failures was nearly twenty times as great as in the or- dinary arm-to-arm vaccinations. Third. That the calf lymph, as compared with ordi- nary lymph, is peculiarly apt to spoil with keeping, and in the form of tube-preserved lymph can so little be re- lied upon, that the Rotterdam establishment, in distribut- ing supplies of lymph, now uses only lymph from the human subject. As to the first of these conclusions. In Dr. Cory's re- port to the Local Government Board for 1886, he states that 153 calves were vaccinated with lymph of 120 hours' growth, and all of them proved susceptible to vaccination ; 8,600 insertions were made, resulting in 8,242 vesicles (an insertion success-rate of 95.8 per cent.) ; 94 calves were vaccinated with lymph of 96 hours' growth, produc- ing 5,440 vesicles out of 5,631 insertions (an insertion success-rate of 96.6 per cent.); 3 other calves were vac- cinated with lymph of 160 hours' growth in 144 places, producing 142 vesicles. In 1885, 305 calves were vaccinated, all of which proved susceptible, 134 being vaccinated with 7,783 in- sertions, with lymph of 120 hours' growth, producing 537 Vaccination. Vaccination. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 7,302 vesicles (or 93.8 per cent, of insertions) ; 4,286 in- sertions were made in 71 calves, with direct lymph of 96 hours' growth, producing 4,029 vesicles, or 94 per cent, of insertions. In the writer's experience not more than five per cent, of bovine animals of different ages prove refractory to vaccination, and the operation of transmit- ting the vaccine infection successfully from animal to animal is not, in the hands of an expert, attended with difficulty. The reasons for the comparative insuscept- ibility of adult animals are given elsewhere. Second. As to the transmission of the infection from the bovine animal to the human subject (under like con- ditions as to the quality and freshness of the lymph used), the operation is quite as successful as with human- ized lymph, and by some authorities the percentages of success are reputed as greater than with humanized lymph. In Illinois, in 1882, out of 138,488 primary vaccina- tions with bovine lymph, 82.7 per cent, were typical, and out of 15,448 performed with humanized lymph, 76.9 per cent, were typical. Dr. Cory, acting under the authority of the same Board to which Dr. Seaton had rendered so unfavorable a report, found, in his report for 1886, that of 5,591 persons vaccinated with calf lymph, the result was successful in every one, or one hundred per cent., and in all but 25 the vaccination succeeded at the first attempt. The number of insertions made was five in each individual. Dr. Cory himself vaccinated 4,688 persons, and of these 4,212 were successful in five places, 238 in four places, 92 in three places, 51 in two, 37 in one, and 17 were unsuccessful in the first trial. Excluding a very few who did not return for inspection, Dr. Cory's insertion success-rate was 96.5 per cent., Mr. Murphy's 99.9, Mr. Stott's 90.6. In 1885, 4,054 persons were vaccinated at the same stations with calf lymph, and in all cases with success. In all but nine, vaccination was successful on the first trial. Dr. Pissin, of Berlin, in 1882, reported that he had made 12,679 vaccinations from 18 calves, with a ratio of success of 98.1 per cent, in primary vaccinations, and 91.3 per cent, in revaccinations, using scarifications only. Pfeiffer, of Weimar, obtained a success of 98.6 percent.; Rissel, 97.8 per cent.; Reissner, 98.6 per cent., and Voigt, 99.4 per cent. At the Hamburg vaccine establishment the ratios of reported success were as follows : In 1878, 69 per cent. ; in 1879, 82 per cent. ; in 1880, 73 per cent. ; in 1881, 82 per cent. ; in 1882, 85.4 per cent. Weiler, on the contrary, found the humanized lymph to give better results, obtaining 97.3 per cent, in pri- mary vaccinations with humanized lymph, and 86.8 per cent, with bovine lymph. The following are the results of the German vaccina- tions 'for the years 1879-1882, in percentages of success : lished the possibility of such preservation for a period of two years. His results were as follows : The lymph referred to in these observations was partly of ninety- six and partly of one hundred and twenty hours' growth, none being taken later than one hundred and twenty hours after insertion. He also states that lymph taken at a later period deteriorates more rapidly, and is apt to produce spurious results, just as happens occasionally with humanized lymph taken at a later date than the eighth day. Number of days which lymph ws served in tubes using. during is pre- before Number of in- sertions with it on calves. Successful in- sertions on calves. Insertion suc- cess-rate per cent. 2 3,998 3,390 84 7 4 1,438 1'139 74.2 255 184 72.1 9 431 309 71.6 11 to 12 337 273 70.6 14 263 214 81.3 16 288 207 71 9 IT to 46 639 472 73.8 53 to 93 445 332 74 6 100 to 200 .... 388 258 66 5 200 to 500 104 17 16.3 500 to 600.... .... 135 45 33.3 600 to 700 82 24 35.0 816 to 858 72 4 5.5 (2) As to its use upon the human subject. Like the former, this lymph was also of one hundred and twenty and of ninety-six hours' growth, in about equal proportions. A part was stored in tubes and a part upon ivory points, in regard to which Dr. Cory says that within four months of storage there is an advantage in points over tubes as a method of storage, and one hun- dred and fifty-four days appears to be the longest interval that should be allowed to elapse between the taking of calf lymph on points and its use on children. For longer periods the lymph in tubes retained its powers better than that preserved upon points. The following were the results of Dr. Cory's observa- tions on this point : Results of Vaccination with Calf Lymph, Preserved on Points and in Tubes, for Various Periods. Mode of storage. Time during which lymph was stored. A,ggregate . • . number of Aggregate number of inceptions cnccpaafnl rondo fR tn successiui Percentage of inser- tion-suc- cess. eachchild). insertions. Under 10 days.... 40 34 85 10 to 20 days 25 21 84 Points .... 4 20 to 50 days 50 to 100 days .... 70 70 63 51 90 73 1 100 to 154 days ... 60 29 48 Over 154 days 30 r Under 10 days.. . 75 65 87 10 to 20 days . ... 25 17 68 Tubes .... - 20 to 56 days 50 to 100 days .... 65 45 47 39 72 87 100 to 154 days.... 20 17 85 159 to 280 days.... 40 33 82 Year. Total vaccina- tions. Success- ful. With human- ized lymph. With bovine lymph. Ratios of the vaccinated. Success- ful. Human- ized.* 6 Q M.g 1879.. 1,247,864 1.215,391 1,196,478 37,641 97.40 94.78 2.98 1880.. 1,233,010 1,201,104 1,184,438 46,122 97.41 95.09 3.70 1881.. 1,196,919 1,164.164 1,139,549 57,136 97.30 94.25 4.73 1882.. 1,195,910 1,158,696 1,103,462 91,941 95.98 91.40 7.62 Revaccinations. 1879.. 1,022.156 864,124 985.092 20.368 84.54 96.37 1.99 1880 . 1,004,530 862.268 971.080 27.110 85.84 96.67 2.70 1881.. 1,038,357 910,817 1.001.744 33,107 87.72 96.47 3.19 1882.. 1,024,720 898,601 954,915 66,514 87.69 93.19 6.49 * These two columns indicate ratios of the kinds of lymph used and not ratios of success. Comparative Results of Primary Vaccinations with Hu- manized and Bovine Vaccine Virus in Illinois (1881-82). Totals. Results. Typical. Modi- . fled. Bad. Bovine vims 138,488 114,605 12,295 11,588 Percentages ........ 82.7 8.9 8.4 Humanized virus 15,448 11,893 2,275 1,280 Percentages 76.9 14.8 8.3 Totals 153,936 126,498 14,570 12,868 Percentages 82.2 9.5 8.3 Third. As to the preservation of animal lymph as compared with that of humanized lymph. (1) As to its use upon calves. Dr. Cory, in the re- port already alluded to, made careful observations as to the preservation of lymph stored in tubes, and estab- 538 •REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vaccination* Vaccination. Comparative Results of Revaccinations with Humanized and Bovine Virus, 1 llinois (1881-82). In the United States bovine vaccination had been at- tempted on various occasions previous to its more gen- eral introduction in 1870-71. Dr. John Yale, of Ware, Mass., writes to me that in 1855, his cow " had the cow- pox, a single umbilicated vesicle on the udder adjoining the teat ; I took the crust, and vaccinated with it, used the matter upon calves, and so kept up a supply for years." He also stated that in 1844, he had observed cow-pox in a herd of thirty cows belonging to Mr. Tru- man Curtis, of Torringford, Conn. The milkmaids and some of the men-servants contracted vaccinia upon their hands from this herd. In March, 1865, Dr. E. Cutter, of Woburn, Mass., de- tected kine-pox in at least two instances in the town of Lexington, where the disease was more or less prevalent, and at times very troublesome at dairy-farms. From two of these cases he vaccinated two cows, and obtained a succession of lymph, which was used to a considerable extent in the vaccination of soldiers in the Army of the Potomac, in the spring of 1865. A report was made upon these cases by Surgeon J. J. Milhau, U. S. A. (dated March 29, 1865), who visited and personally in- spected twelve of the animals thus vaccinated. (" Medi- cal and Surgical History of the War of the Rebellion," Medical volume, part iii.) Previous to the date referred to, March, 1865, Dr. Cutter, as stated in his report of 1872, had employed retro-vaccination quite largely, and with excellent suc- cess, and in this respect had followed very much the same methods which had formerly been employed by Negri, at Naples. Dr. Warlomont, in commenting upon this practice as performed by Negri, says, " Should we reproach him for it ? We should be careful not to do so. Our own theory of the unicity of vaccine forbids it. We know that natural horse-pox loses some of its viru- lence by transference to the heifer. So also the natural vaccine of the heifer may be deprived of some of its ac- tivity in its transfer to the child. But nothing prevents our believing that, if carried again to the cow, human vaccine virus might develop in such a manner as to dis- play again all the qualities of cow-pox, just as the latter may rise again to the dignity of horse-pox when trans- ferred again to the horse. The question is one of soil. We have, therefore, no reason to object to the practice of retro-vaccination, the condition being always main- tained, that a culture carefully made may have insured a restoration to their original power of the products of emigration." Occurrence of Natural Kine-pox in the United States.- Kine-pox is not of unusually rare occurrence, as some have believed. It has been observed on various occa- sions, and at various places, in the United States, and re- ported as follows: 1. Dr. John Yale, of Ware, Mass., as previously stated, reports having observed it in 1844, at Torringford, Conn., and in 1855 at Ware ; in the latter case confirm- ing its character by testing it upon the human species, and also by continuing its use upon calves. (Transac- tions of the American Medical Association, 1872, p. 216.) 2. Dr. Currier observed it at Lexington, Mass., in 1850, and tested it by insertion upon infants. 3. Dr. E. Cutter observed it upon several occasions, as stated in his report of 1872. 4. Dr. H. Darlington observed it and reported upon it as occurring at Concordville, Pa., in 1872. 5. Drs. McMillan and Trask observed it in Marion County, Cal., in 1871, and confirmed its character by ex- periment. 6. Dr. Jonathan Brown observed it in Wilmington, Mass., in 1867, and tested it by experiment. 7. Dr. H. A. Martin reported a case as observed by him at Cohasset. 8. Cases were reported at Reading, Pa., in 1872. 9. The writer has also visited and inspected at least twenty cases which occurred at seven different dairies or farms in Middlesex and Essex Counties, in Massachu- setts, in 1872, 1873, 1881, and 1882. These all occurred during the prevalence of the two small-pox epidemics of those years. Totals. liesuits. Bad. Typical. Modi- fied. Bovine virus 76,154 45,187 14,010 16,957 Percentages 59.3 18.4 22.3 Humanized virus 3,250 2,206 430 614 Percentages 67.9 13.2 18.9 Totals 79,404 47,393 14.440 17,571 Percentages 59.6 18.2 22.2 Per cent, of vaccinations with bovine virus 79.2 Per cent, of vaccinations with humanized virus 20.8 Illinois, 1881-82. Reporting physicians who prefer bovine virus, eighty- five per cent. Reporting physicians who prefer humanized virus, fif- teen per cent. Reasons stated by such physicians for preferring bovine virus: "Freedom from danger of transmitting other diseases," this statement being modified by many by the further statement, " because of popular prejudice ;" "greater protective power," "greater uniformity of re- sults," " greater certainty," " convenience," etc. Reasons stated for preferring humanized virus: " Greater uniformity of results." " Less severe local and constitutional effects, with equal, or greater, or proved protective power." " Greater promptness of action." " Greater reliability." "Freedom from serious complications." From Italy and from France the practice of bovine vaccination extended to other countries. In February, 1865, it was introduced into Brussels by Dr. Warlomont, who employed successively lymph from the Neapolitan source, afterward from the Beaugency source, and finally from a third source obtained at Esneux. A State Vac- cinal Institute was finally established at Brussels under his charge, where the practice of bovine vaccination has been carried out with the greatest care, for the gratui- tous distribution of lymph both of humanized and of bovine stock. The institute was established on condi- tion that both sorts of lymph should be distributed from it. Dr. Warlomont, by the thorough character of his work, as well as by his published writings upon the sub- ject, has accomplished very much tow'ard the general introduction of bovine vaccination. Bovine vaccination was introduced into Berlin in 1865, by M. Pissin, and is still conducted there, and also at Vienna ; the amount of bovine lymph used, as compared with the humanized, having increased rapidly, from year to year, since its introduction. Establishments for the production of animal lymph are now in operation at Ber- lin, Halle, Kiel, Kassel, Munich, Nuremberg, Dresden, Bautzen, Leipsic, Frankenberg, Stuttgart, Cannstadt, Karlsruhe, Darmstadt, Schwerin, Weimar, Bamberg, Lubec, Hamburg, Bremen, Strasburg, and Metz. This practice has gradually made its way into other countries of Europe, and now nearly every large city has its vac- cine institute or establishment for the propagation of bo- vine lymph. It is also in use under the auspices of the British Government in India. It was introduced into Bombay in 1881, and into Madras and Bengal in 1882, and has recently been introduced into Japan. England was slow to adopt the new method of vac- cination ; Dr. Seaton's unfavorable report in 1869 un- doubtedly delayed its introduction. This report, how- ever, contained much valuable information upon the subject, which led to its careful consideration, and fi- nally to its introduction under the direction of the Local Government Board in 1881, the use of either humanized or bovine lymph being optional. The experiments of Dr. Cory establishing the possibility of the transmission of syphilis by humanized virus, even under the most rigorous conditions, undoubtedly strengthened the posi- tion of the Board in introducing the bovine virus. 539 Vaccination. Vaccination. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. In 1870, Dr. Henry A. Martin, of Roxbury, Mass., im- ported lymph of French origin, and organized a well- equipped vaccine establishment at which a constant suc- cession of heifers has been vaccinated since that time. To him, the work of successfully bringing bovine vacci- nation to popular notice in the United States, as a sub- stitute for humanized vaccination, wras largely due. Dr. Martin also obtained lymph from cases observed in the neighborhood of Boston, which was also successfully transmitted to a succession of heifers. Others soon fol- lowed him in different parts of the United States, espe- cially Dr. F. P. Foster, of New York, and Dr. E. L. Griffin, of Fond Du Lac, in Wisconsin. At present it is safe to say that at least four-fifths of all the lymph used for vaccination in America is of di- rect bovine origin-produced by artificial propagation. There are certain advantages in the employment of animal lymph which may be detailed as follows : 1. The avoidance of the transmission of certain diseases common to mankind, which it has been conclusively proven may be transmitted by the process of vaccination ; for while it is undoubtedly true that millions are an- nually vaccinated without the occurrence of a single case of such transmission, it is also true that a sufficient number of cases are on record to establish the possibility of such transmission. The French Academy of Medicine had, as long ago as 1830, proclaimed, almost in dogmatic terms : " Vacci- nate without fear, for the vaccine virus taken from sub- jects afflicted with complaints susceptible of communica- tion by contagion, such as syphilis, does not convey such germs, in any case, and gives rise only to vacci- nia." The question was again fully discussed in 1864, by the same body, and it was finally admitted by the Academy that vaccinal syphilis was an incontestable fact, and while it was of very rare occurrence, its possibility could not be doubted. Ricord said of it: "I at first denied the possibility of the transmission of syphilis by vaccination, but facts repeating themselves, and becoming more and more confirmatory, I admitted with reserve, and even with repugnance, this mode of transmission. To-day I do not hesitate to state it as a fact." Proofs of the occurrence of vaccinal syphilis are to be found in the writings of Depaul, of Viennois, and others, where about three hundred cases are given in de- tail. The reported cases are mainly of French and Italian origin, those detailed by Professor Cerioli and the Rivalta cases constituting a large part of the number. While the earlier English writers have been slow to ac- cept the possibility of such transmission, some recent experiments have apparently settled the question conclu- sively that the danger exists, although the transmission is of extremely rare occurrence. After carefully reviewing the different cases on record, Dr. Seaton said of them: "None of the alleged cases, then, have established, in my opinion, that syphilis has ever been imparted in the due and proper performance of vaccination, i.e., with the unmixed lymph of a genuine vaccine vesicle. They are not even, in my opinion, con- clusive as to this having been done by the inoculation, along with lymph, of a small quantity of syphilitic blood, although I hope that it is unnecessary for me to say that this is not a matter in which the slightest possibility of risk should be allowed, and that a practitioner would be indeed highly culpable who should vaccinate with any- thing but pure and unmixed lymph, or who, in fact, should knowingly vaccinate from a syphilitic child at all. But whether from admixture of blood, or from admixture of the inoculable secretions or products of syphilis, as through foul lancets or in any other way, the real risks are, I believe, entirely risks of carelessness-risks which, with due regard to the rules which have been laid down for the proper performance of vaccination, could not oc- cur." ' It is certain that hundreds of thousands of vaccinations are made every year without the occurrence of the ac- cident in question, and hundreds of busy practitioners pass through the period of active practice, during which they are called upon to make frequent vaccinations, with- out meeting a single case. Three methods have been detailed as possible for the occurrence of vaccinal syphilis : (1) By the mixture of vaccine lymph with the prod- ucts of a syphilitic skin eruption. (2) By mixture with the blood of a syphilitic person. . (3) By the use of the clear lymph of a vaccine vesicle existing on the person of a sphilitic. With reference to the question of the transmission of syphilis by inoculating the blood of a syphilitic upon a healthy person, there can be but little question. The question has been proven, both by observation and by experiment. In 1862, at Florence, Dr. Bargioni submitted to an in- oculation with blood taken from the arm of a woman twenty-five years of age, who exhibited at the time all the symptoms of constitutional syphilis, and was inno- cent of all previous treatment. Every precaution was taken to exclude other sources of disease. Dr. Bargioni was healthy and free from taint. The blood was applied to his left arm by transverse incisions. On the twenty- fifth day afterward (March 3d), he found a slight eleva- tion at the point of insertion, and from this date to April 22d the symptoms of syphilis clearly supervened, and mercurial treatment was begun. Dr. Warlomont says of this experiment : " Nothing is deficient in this observation, neither the merit of the master, nor the courage, nor the perseverance of the vic- tim ; the experiment is pushed as far as possible, and, the proof obtained, master and pupil proclaim the result aloud, bravely making sacrifice upon the altar of science and of truth of all considerations drawn from human respect." The following comments, by the same au- thority, are stated with all the dogmatism of a firm adhe- rent of bovine vaccination. "The fact of the inocula- bility of syphilitic blood being established, the danger of introducing syphilis with vaccine no longer needs demon- stration. The danger is there ; it is palpable and alto- gether inevitable ; for if the blood is contagious, it is impossible that vaccine lymph, which rests upon a sur- face impregnated with this blood, should not in its turn be to a certain extent saturated. It follows, therefore, that no precaution can with certainty place a doctor be- yond the risk of transmitting syphilis in vaccinating." With reference to the transmission of syphilis through the medium of the clear vaccine lymph containing no blood, the more recent experiments of Dr. R. Cory, an officer of the Local Government Board of England, have established the possibility of such communication. These experiments were witnessed by a committee of experts comprising the noted surgeon, Jonathan Hutch- inson, together with Drs. Bristowe, Humphrey, and Bal- lard. Three successive attempts did not succeed in con- taminating the system, while the vaccinifers bore evident traces of syphilis. On July 6, 1881, Dr. Cory was vaccinated with lymph perfectly free from admixture with blood, and taken from a vaccine vesicle on the arm of a child having a syphilitic eruption in the immediate neighborhood of the vesicle. The vaccine did not take, but on the twenty-first day, July 26th, Dr. Cory observed that two or three punctures had each become the site of a red papule. On August 10th Drs. Hutchinson and Humphrey examined the arm, and agreed as to the syphilitic nature of the papules. The sequelae confirmed their diagnosis. They consid- ered it as proven that the inoculation of vaccine lymph from a syphilitic subject was capable of transmitting syphilis to the vaccinee. On the thirty-sixth day after the inoculation Dr. Cory had the papules excised. Nev- ertheless, on August 31st a roseola appeared upon the forehead, the back of the neck, behind and below the ears, and on the lower part of the abdomen. These ex- periments were of such a character as to impress upon physicians the necessity of exercising the greatest care in the choice of vaccinifers and also to insure a preference for bovine lymph. 540 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vaccination. Vaccination. The principal reporters of vaccinal syphilis are as fol- lows : syphilis is not hereditary, and a mere coincidence or evo- lution of the vaccination. (3) Whether, if it be acquired syphilis, this has not some other origin unconnected with the vaccination or attempt to vaccinate. (4) Wheth- er, if the acquisition of the syphilis be reasonably trace- able to the vaccination or attempted vaccination, there is evidence, direct or presumable, that the so-called vacci- nation had been made from a genuine vaccine vesicle, and that the products of that vesicle had not been mixed with some of the inoculable products of syphilis. Not until all this was settled would any question arise about admixture of blood. When it is remembered that at least five hundred mill- ions of persons have undoubtedly been vaccinated since the beginning of the century, the ratio of these cases of transmitted syphilis to the whole number is surprisingly small. 2. Another reason for the use of bovine virus lies in the facility with which an abundant supply of lymph may thus be secured for use at short notice. The oc- casional advent of small-pox among the crowded popula- tions of large cities renders the production of large quan- tities of vaccine lymph in a brief space of time an absolute necessity. This is especially true of the large cities of the United States, the population of which is being constantly increased by the arrival of great numbers of emigrants, many of whom are unvaccinated, or have come from foreign ports in which small-pox was prevalent at the time of their departure. Local Boards of Health conse- quently require quantities of vaccine lymph sufficient to vaccinate several thousand people at once, this lymph to be delivered fresh and ready for use within a specified time. The possibility of obtaining humanized lymph in large quantity from healthy infants is not an easy task. Parents neglect to present their children for inspection on the proper day for the collection of lymph ; many children are not suited for such collection in consequence of ill-health ; again, there exists a prejudice in the minds of many against vaccination at certain seasons of the year ; and others absolutely refuse to allow lymph to be taken, so that the various conditions for the collection of humanized lymph are reduced to very narrow limits. In England, under compulsory law's, where every child, without regard to the season of the year, must be vaccinated within three months of its birth, under penalty for neglect, and must also be returned for in- spection on the eighth day, and also be employed as a vaccinifer if necessary, a deficiency of vaccine lymph is of rare occurrence. The amount of vaccine lymph which may be obtained from one animal, as compared with the paucity of ma- terial which it is practicable to obtain from a healthy infant, is very large. From 2,000 to 10,000 charges of effective lymph upon ivory points is not an unusual quantity to be taken from a single heifer. It is, therefore, a decided advantage to be able to resort to the cow, and thus to avoid the objec- tions which may be raised against the taking of supplies of lymph from infants. It is especially desirable, wdien lymph is supplied by the authorities of state and city governments, that such lymph should be of the best quality. Such authorities are under moral obligation to furnish to the people a vaccine lymph which is beyond all suspicion in the matter of freedom from contamina- tion of disease. These two faults, the possibility of contamination with syphilis and the relative paucity of lymph, were especially the faults of the Jennerian method of vaccination-and in animal vaccination may be found a method wherein lies the remedy for both ; that is, the avoidance of syph- ilitic contamination and the capability of indefinite multi- plication of vaccine material. The possibility has been suggested of communication of bovine disease other than vaccinia, especially of tuber- culosis of the cow. Tuberculosis is known to be inocu- lable, as demonstrated by Villemin, and more recently by the experiments of Koch. Inoculated tuberculosis starts from the point of its insertion, as shown by experimen- tation upon the guinea-pig, rabbit, and other animals. Chassaignac 1 cases. Sebastian 1 " Trousseau 1 " Devergie 1 " Cullimore 1 " Herard 1 " Monelli 1 " 8. Smith 1 " Hulbe 1 " Viani 2 " Collins 2 " Lecoq 2 " Adelasio 2 " Oldham 3 •* Hiibner 8 cases. Galligo 14 " In Lebus 18 " Surgeon B 19 " Hutchinson 24 " Maronni 34 " Marcolini 40 " Cerioli 40 " In Rivalta 46 " Tassani 46 " Fuqua 52 " In Algiers 58 " Depaul 59 " In many of these cases, especially in some of the larger groups of cases, the accounts of their occurrence are de- tailed in the loosest manner ; in several of them no in- quiry was made until eight months after their alleged occurrence, and in others the only persons from whom information could be obtained were the mothers of the vaccinated children. The collection of this list is mainly due to the re- searches of the opponents of vaccination, who have searched for them with the greatest diligence. Since the introduction of animal vaccination generally into different countries, the reports of such cases have be- come comparatively rare. Dr. E. Foster, in his report to the American Public Health Association, also gives a list of experimenters who have purposely vaccinated with lymph from syphilitic vaccinifers in order to test the question of possibility of transmission. The experimenters were Bidard, Moun- tain, Schreirer, Jonkoffsky, Delzenne, Bourguel and Guerin, Boeck, Cullerier, Taupin and Heyman, and the number of vaccinations made was over three hundred, but in every case the attempt to transmit syphilis was unsuccessful. Mr. Hutchinson's cases appear to have been observed and reported with greater care, and they were thoroughly discussed by the Royal Medical and Chirurgical Soci- ety ; in his remarks at that time (1873) he stated that it was of the first importance to diffuse widely among the profession the knowledge that vaccinal syphilis is possible. He emphasized the importance of avoiding vaccination from children whose parents are unknown to the vacci- nator ; also of declining to use first-born children as vac- cinifers, waiting until, by the development of one healthy child, a guarantee of freedom from taint on the part of the parents has been given ; and, finally, of avoiding the use of blood-stained lymph. He also showed that it was highly probable that the syphilitic virus is not con- tained in the vaccine lymph, but is derived from or asso- ciated with some cell-elements of the blood, and probably these need not be visibly red. He also recommended that the period of vaccination (three months, as pre- scribed by the English law) should be extended at least to six months, and directed attention to the feasibility of animal vaccination. It cannot be doubted that the dis- cussion of these cases of Mr. Hutchinson's led the way to the introduction of animal vaccination in England. The editor of the Lancet, in a later discussion of these cases, believed the chances of vaccinal transmission of syphilis to be reduced to a minimum, since the following conditions must necessarily be present to insure such a result: (1) A syphilitic vaccinifer ; (2) an active condition of the syphilitic element of the vaccinifer's blood, but, at the same time, (3) an absence of such external symptoms of syphilis as would deter any upright surgeon from using the subject presenting as a vaccinifer ; (4) the gross imprudence of employing either blood or serum obtained after the emptying of the vesicle. Mr. Henry Lee also suggested that revaccination will occasionally light up the dormant disease in a person already the sub- ject of syphilis, and without a previous knowledge of the patient this may readily lead to a suspicion that impure lymph has been used. Seaton suggests, as a proper line of inquiry in all cases of suspected vaccinal syphilis : (1) Whether we are really dealing with syphilis. (2) Whether, if this be so, the 541 Vaccination. Vaccination. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. It may be transmitted by means of the tubercle bacilli present in a tubercle itself, in the blood of an infected animal, or in the air exhaled from a diseased lung. Upon this point Dr. Warlomont says: "The importance of these facts as related to bovine, as well as to humanized vaccination, are worthy of consideration, and one fact should be stated at the outset, that it is impossible to inoculate tubercle by means of superficial insertion of bacilli, which is the usual method of the insertion of vac- cine lymph. The latter develop very slowly, and cannot, like those of splenic blood, rapidly infect a small wound. If we desire to make an animal tuberculous, we must carry the bacilli deeply into the tissues. Thus it is ex- plained why it is that no one has been infected while making autopsies of tuberculous subjects. Thus, d for- tiori, is it explained why no one has ever been infected with tuberculosis through vaccination. ... So much for theory ; now for the practice. Let them show, among the millions of subjects vaccinated in the past twenty-four years, either with humanized or with bo- vine lymph, a single case that has exhibited, at the spot of insertion of vaccine lymph, anything that resembled a tubercle. Nothing of the kind has ever happened, al- though it is probable that, among so large a number of inoculated persons, some must have received vaccine from tuberculous vaccinifers." With reference to transmission of diseases of the "charbon" type, Dr. Warlomont states that "it has been completely demonstrated that laudable vaccine vesicles would never develop in animals affected with charbon. These affections are not common in animals sold at markets or elsewhere for purposes of vaccina- tion." All of these difficulties, if they are worthy the name of difficulties, may be avoided by the method adopted in many of the Continental establishments at present, which consists in delivering or using the lymph from any ani- mal for the purpose of vaccination only after such animal has been proven by autopsy to have been absolutely healthy. This precaution is worthy of adoption in the United States. The Question of the Degeneration of Vaccine. -The question whether vaccinia, in its transmission from the cow through a series of human beings year after year, loses any of its primary efficiency has been a subject of discussion since the earlier years of the present century. At present the weight of opinion appears to be in favor of such deterioration, although many keen observers who have followed up a series of vaccinations year after year, which originally came from the Jennerian stock, or from some other origin nearly as remote as that of Jenner, appear to hold to the belief that no such degen- eration exists. Jenner did not admit such a possibility, although fre- quent applications were made to him, within two or three years after his discovery, for lymph " as recent from the cow as possible." A further experience of twenty years satisfied him that the hypothesis of such degeneration was groundless. He was, however, careful to require that the successive transmissions of lymph should be made through healthy subjects. In 1816 he stated that "the matter may undergo a change that may render it unfit for further use by passing even from one individual to another, and this is as likely to happen in the first year of vaccination as in the twentieth." But that with proper care and attention, however, lymph underwent no change he considered to be proven, by the fact that the vesicles he was then producing were " in every re- spect as perfect and correct in size, shape, color, state of the lymph, period of the appearance and disappearance of the areola, its tint, and, finally, the compact texture of the crust, as they were in the first year of vaccination ; and to the best of my knowledge, the matter from which they were derived was that taken from a cow about six- teen years ago." The argument as thus stated was, that if lymph could undergo eight hundred or nine hundred transmissions through men without giving evidence of change, it should also remain equally unchanged after an indefinite number of such transmissions, and many observers after forty years declared the same opinion. The National Vaccine Board of England, in their annual report for 1854, declared ' ' that the vaccine lymph does not lose any of its prophylactic power by a continued transit through successive subjects." Ceely, in 1841, stated that during the preceding three years he had observed and noted the effects, on a variety of subjects, of more than fifteen different stocks of vac- cine lymph, of which six had been from the natural dis- ease, taken either direct from cows or from vesicles on the hands of milkers, and seven artificially produced in the cow. These stocks had all varied in their effects, both locally and constitutionally, but none had lacked the essential qualities and properties, nor had any pos- sessed them in a superior degree to those indicated in the description and illustrations of Jenner. " This is the standard," says he, " to which we may at all times con- fidently appeal." Marson stated, in his article on small-pox published in "Reynolds' System of Medicine" in 1866: "We feel bound, however, to say that we have lately produced, with lymph brought into use by Jenner more than fifty years since, vaccine vesicles which, on comparison, ex- actly correspond with the vesicles sketched in Jenner's original work explaining and illustrating the vaccine disease." Mr. Steele, of Liverpool, an able and experienced teacher of vaccination, confirmed the same observation. Marson, however, admitted that he found cicatrices which were left .by lymph which he had employed for many years which " were not now so good as those which the same lymph formerly produced." Seaton concludes his discussion of this question by ad- vising that vaccinators should be very careful to whom they apply for lymph, and should also be just as careful in the selection of subjects for its propagation. He also quotes several instances, notably those of Passy in 1836, and of Estlin in 1838, in which certain lymph-stocks at first produced an unusually irritative manifestation, which subsided, after several transmissions, into a normal vaccination. Several instances are on record of long-continued trans- missions of humanized lymph. The National Vaccine Establishment of England uses lymph which is mainly, as Seaton asserts, Jenner's lymph transmitted from the original stock, and he also says of it: "So far as the correct character and course and the energy of the vac- cine vesicle are evidences of its prophylactic power against small-pox, I cannot but concur entirely, from personal observation, with the statement which the Na- tional Vaccine Board made in 1854, that the vaccine lymph loses none of its prophylactic power by a con- tinued transit through successive subjects, and that it is a fallacy to predicate the necessity of resorting to the origi- nal source of the cow for a renewed supply." In the United States one of the most noted instances of long-continued transmission of humanized lymph is that recorded by Dr. E. M. Snow, Superintendent of Health of Providence, R. I., and his successors. In a report pub- lished by Dr. C. V. Chapin in 1886 he says : " The record of the vaccine now used in the public vaccinations in this city may be traced from arm to arm by name and date continuously back to February 29, 1868 ; a date fully two years before the importation of the famous Beaugency stock of animal virus, from which the country has since been so largely supplied." He states, further- more, that "all the traditions concerning the matter are to the effect that the virus then in use was of the stock sent to this country to Dr. Waterhouse, of Cambridge, by Dr. Jenner in the spring of 1801, with the statement that it was from his original stock." A letter from Dr. C. H. Leonard, chief of the vaccinat- ing staff of Providence, detailing his experience with over twenty thousand vaccinations, says : " I agree with Dr. Snow in asserting that it has not materially de- teriorated." The theory that vaccine lymph has suffered degenera- tion by successive transmissions through the human 542 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vaccination. Vaccination. species is chiefly of Continental origin. Many French authorities have affirmed this principle as a reason for frequently resorting to the cow for a renewed supply of lymph. Kinglake also, in England, as early as 1814, had advanced the theory of degeneration. The Royal Academy of Sciences of France in 1838 of- fered a prize of ten thousand francs for the best essay on this subject, thus indicating the importance which was attached to the problem at that early day. It was not till 1845 that a report was made on the thirty-five essays re- ceived. The prize was divided between Bousquet, Fiard, and Steinbrenner, each of whom answered the question affirmatively. The Sanitary Commission of the Grand Duchy of Baden in 1817 reported in favor of a frequent resort to the cow, in consequence of the degeneration of lymph. Brissot also became an earnest advocate of the same doctrine as early as 1818, and published his views in several monographs upon the subject. His assertions rested mainly upon the following proofs : (1) Proofs founded upon the analogy between the vac- cine virus and other sorts of virus, and the contagious miasmata. (2) Proofs furnished by epidemics of varioloid which every year attack a considerable number of vaccinated subjects. (3) Proofs drawn from the evident difference between the local and general symptoms then found and those of former periods. (4) Proofs drawn from the difference between the cic- atrices of vaccinia to-day and the still-existent cicatrices of vaccinia of the earlier years. At a still later period, the Royal Academy of Medicine of Belgium in 1867 was requested by the Government to consider the question, and replied that: (1) " The Academy has recognized the utility and even the necessity of regenerating or renewing vaccine, and has not changed its opinion on the subject." (2) "A really practical mode of securing the regenera- tion would consist in a liberal use of animal vaccination derived from the inoculation of spontaneous cow-pox on animals of the bovine race, from which the products of such inoculation would be constantly preserved by pro- cedures recently introduced into science." Dr. Warlomont sums up the question as follows: " This theory corresponds to the ideas which have just been expressed. Whatever may be the origin which we may attribute to vaccinia, whether attenuated variola or a special virus, the human organism is certainly strange to it. It is not the soil upon which it was at first devel- oped (eclosion). So much being admitted, let us see how this soil behaves with respect to the variolous germ and the vaccine germ which may be introduced into it. The variolous germ finds there, by right of previous occupa- tion, a marked welcome by means of general absorption, which restores it to the state of natural small-pox. With the vaccinal germ it is no longer the same thing ; in vain is it introduced there artificially, it never shows itself with all its attributes ; horse-pox and cow-pox always convey it to man. Take it from one or other of these latter conditions, and inoculate it on man ; its first care is to descend a degree in the scale of virulence. Further, once descended, it never reascends to the superior grade, unless under the condition of finding once more a soil propitious to such reascension-the body of the cow or that of the horse. "It is natural that, on this thankless soil, which is only a land of adoption, the vaccine germ should lose some of its activity ; but if, as often happens in its migra- tions, it should finally meet with sickly or unfavorable subjects, it will of necessity degenerate still more, and become, in its turn, the founder of a family whose mem- bers will be unsuited to originate healthy stocks. Thus do stocks decline which, in spite of all the care bestowed on them, terminate by making unfortunate alliances. Thus explained, the so-called degeneracy of vaccine cultivated in the human organism is not a condition in- herent to its existence ; it is merely the consequence, al- most fatal, of the course which we have caused it to take, and of which the difficulties have not been successfully avoided. In a word, it is not the vaccine that degener- ates, but the stocks that use or abuse it. " Bovine vaccination, as now practised and commonly employed in certain countries, permits of constantly pro- ducing in man a breed of strong and healthy products. This is one of its most certain benefits, and, of all, assur- edly the least contestable, and the least contested. The decline of human vaccine, under these conditions, from whatever point of view we may regard it, is henceforth easily avoided." It is quite evident that, to secure a transmission of vaccine lymph for a long period of time through the hu- man organism, which shall preserve perfectly all its original characteristics, two conditions are essential : (1) The vaccination should be made from arm to arm, or, in other words, the lymph should in every instance be fresh ; and (2) the subjects selected for such transmission should be in a condition of perfect health, and should never have been vaccinated before. The Technique of Bovine Vaccination.-Leaving out of the question the horse as an appropriate soil for the propagation of lymph, experiments by Warlomont and others having shown the unfitness of the animal for this purpose, the best animals for use in bovine vaccina- tion are heifers, from the age of four or five months to two years. Warlomont says " they should weigh at least one hundred kilos (220 lbs.), and be in good health." The recent German regulations state that calves of " five weeks and upward are to be preferred." (Dr. Voigt, of Hamburg, employs calves from three to four months old.) Vaillard prefers calves from two and a half to three months old, and gives as a reason the consequent avoid- ing of tuberculous stock ; and states that out of 21,320 calves killed at Augsburg not one was found which had tuberculosis, while there were 321 tuberculous animals in 10,988 adult horned cattle. At Munich, the proportion of tuberculous cattle was 1.13 per cent. ; among cows it was 5.3 per cent., among bulls 0.73 percent. Among calves there was scarcely one per 100,000. M. Leclerc, the chief inspector at Lyons, had met but five tubercu- lous calves out of about 400,000 slaughtered animals. Furthermore, the researches of Lothar-Meyer, Bol- linger, Chauveau, Josserand, and Strauss, in the inocu- lation of animals with lymph taken from other animals known to be tuberculous, show that tuberculosis is not thus transmitted through the medium of the vaccine lymph. Strauss sums up the following reasons for his belief in the improbability or the impossibility of transmitting tuberculosis in this manner : (1) The age of the animal usually employed. Young animals are very rarely tuberculous. (2) Supposing the vaccinifer to be tuberculous, the chances are against the possibility of the serum of the vaccine vesicle containing any tubercular germs. (3) The superficial mode of inserting vaccine virus would be unfavorable to the communication of tubercu- losis. Animals with red or white skins are most favorable for the purpose, and are therefore usually preferred to black animals. The stock selected for the purpose of vaccine propagation should be in perfect health, and if fatigued by long travel on the railroad, or affected with diarrhoea from improper feedhlg, they should be allowed to rest for a day or two until they are in good condition, before being submitted to vaccination. The stable should be well ventilated, and kept at a me- dium temperature. For young animals, the feed should be mainly of milk, and for older animals, hay and the lighter meals may be used. In Holland, the feed of calves at vaccinating establishments consists of ten litres of milk, and from two to four eggs, daily, for each calf. Older animals are often used for the propagation of lymph with good success, and milch-cows have not in- frequently been employed for the purpose, such animals yielding an abundant supply of lymph, the process of vaccination apparently having no effect upon the quantity 543 Vaccination. Vaccination. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. or the quality of the milk. Such animals, however, pre- sent the disadvantage of large size and consequent diffi- culty of management. If a large yield of lymph is not called for, they may be vaccinated, and the collection of lymph may be made without laying the animal upon the vaccinating table. Another disadvantage presents itself in the fact that a small percentage of milk-giving cows, Chainbon and Vaillard deline a much larger region for use, namely, the entire surface bounded by the axillary fold in front, the inguino-crural fold behind, an antero- posterior line running near the umbilicus below, and above by a horizontal line connecting the middle of the axillary fold with a corresponding point behind. Upon this broad rectangular surface may be made from one hundred and fifty to one hundred and eighty insertions of lymph. Typical vesicles may also be raised upon the escutcheon, or milk-mirror, of adult animals, the disadvantage of this region lying in the risk of soiling. For the fixation of the animal in a con- venient position for the requisite opera- tions, a tilting-table will be found to be useful for all animals weighing less than 300 pounds (140 kilos or less). This table should be constructed of two-inch plank, strongly fastened together and provided with rings for securing the straps or thongs used for fastening the animal; one broad strap will be found useful to encircle the body. The table should be secured to the framework by four strong strap-hinges. To place the animal upon it, it should be led alongside the table, secured to it firmly, and then the table be tilted into a horizontal position and the animal more securely fast- ened in place. The region for vaccination is thus ex- posed for the necessary manipulations preliminary to vac- cination. To free the animal it is only necessary to tilt the table back to the vertical position, loosening first the fetters and then the large abdominal band or surcingle. The shaving of the animal is a laborious task ; it is usually accomplished by the use of the scissors in the first place, although the operation may sometimes be facilitated by the use of a clipper such as is used for shearing horses, if it is a good one. The parts should then be lathered with soap and warm water, and care- fully shaved with a razor, an operation which is by no means easy, especially if the animal be restless. Fig. 4444.-Vaccinating Table. (From Vaillard's Manual.) and especially of the older animals as found in farms, have usually suffered with cow-pox at some period of their lives. It is useless to attempt to vaccinate such animals. With reference to the effect of vaccination upon the value of the animal, either alive or as slaughtered for beef, the following statement from Dr. Warlomont should be received as authority. " We must, indeed, not forget that, at the latest, the animal should yield all its harvest in the course of the sixth day, and that it may be killed on the seventh, before the possible development of suppurative fever. . As a matter of fact, it does not suf- fer in consequence of vaccination, however numerous the insertions may be. It may suffer from the fatigues and ill-treatment of the journey, from the management of the dealer, from change of stable, or from its separation from the mother, but vaccination of itself is by no means the cause of any depreciation in the animal. This may be laid down as an axiom in the matter of responsibil- ity." Animals vaccinated upon the abdo- men may injure the vesicles by abra- sion against the floor, an accident which may be prevented by the use of a pad, or by bedding with clean straw, or with sawdust, fresh supplies being afforded daily. To prevent injury of the vesicles by biting with the mouth, or lashing with the tail, Dr. Warlomont recom- mends the use of a wicker muzzle to the mouth, and a contrivance consist- ing of short wooden splints applied to the tail to prevent its bending. The vaccination of the animal con- sists of a series of operations, as fol- lows : (1) The shaving of the skin in the region to be used. (2) Making upon this surface a series of scarifications, punctures, or incisions. (3) Insertion of lymph at each of these points. Region to be Selected for Inoculation.-Since the days of Negri, who introduced bovine vaccination, most of the continental vaccinators have chosen the inguinal region as the point of election. Lanoix, Depaul, and Ciaudo preferred this region, including a space from six to eight inches (15 to 20 ctm.) square. Warlomont defines the region of election as about as large as " the crown of a man's hat," and lying between the inguino-mammary region and the umbilicus. Fig. 4445.-Calf upon the Vaccinating Table. (From Vaillard.) Insertion of lymph may be made by various methods, by puncture, or by scarification by a sharp lancet, or by slight incisions. The writer has found an instrument of the shape represented in Fig. 4446 very convenient for the purpose. It consists of a large spring scarificator having four blades at a distance of about one inch (2| ctm.) apart. With this instrument four incisions may be made quickly, and with but little disturbance to the ani- mal, presenting the following arrangement (Fig. 4447), so that the work of making the incisions may be done very rapidly. The depth of the incisions is regulated by a screw, as in the ordinary surgical scarificator. Warlomont gives careful details as to the method of 544 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vaccination. Vaccination. securing the animal to the table, for which purpose he employs live assistants, the duties of each being carefully defined. Both Warlomont and Vaillard give preference to incisions as a mode of insertion rather than to punctures, for the reason that the former are developed earlier, are more productive, and admit of be- ing more easily enclosed and iso- lated by the curved clasp of the, expression forceps when the latter are required. Two of the forceps in common, use are shown in the accompany- ing cuts. Fig. 4448 is that of Cham bon, and Fig. 4449 that of Warlomont. A slight pressure only is neces- sary to hold the vesicle and facili- tate the flow of lymph, and it often happens that no forceps are neces- sary. The Development of the Vesicle. -If the inoculation is successful, each incision will begin to show a light-red border at the end of about forty-eight hours ; at the end of another day a slight swelling ap- pears, increasing in size ; and by the end of the fifth day a well-formed vesicle will be seen at the seat of each successful insertion. These vesicles are shaped according to the method of insertion. In the case of punctures they are circular, and in the case of inci- sions they are shaped like the half of an " elongated coffee-berry," having a cicatricial depression, surrounded by a zone of silvery white, and encircled by an outer zone of a reddish hue, the distinct- ness of color varying with the amount of pigmentation of the skin at the places of insertion. The swelling of the vesicle increases until about the seventh or eighth day, when the transparent zone becomes yellowish in color, and in the following days the vesicle be- comes purulent, dries up, and is converted into a brown crust, which falls off from the fourteenth to the twentieth day. According to Warlomont, if the modes of insertion by incision and by puncture be practised on the same ani- mal, the eruption will be developed twenty-four hours later in the latter, a circumstance which may prove of advantage, by having two stages of development in the same animal, and by the consequent possibility of collect- ing mature lymph bn two successive days if necessary. The proper time for the collection of lymph is a period of about twenty-four hours in length, and in order to obtain lymph of the best and most efficient quality, the opportune moment for collection should be carefully studied. This moment is not of necessity the time when the most abundant flow takes place, but an earlier period. For greater clearness of expression, it is best to state the period in hours, since the expressions, third, fourth, fifth day, etc., are differently in- terpreted by different writers. Negri often made use of the vesi- cles of 3 x 24 hours. Through- out the Continent, it is common to make the collection of lymph either at the termination of 5 x 24 or 6 x 24 hours. The more common custom in the United States is to collect lymph at the end of 7 x 24 hours, or on the same day of the week with its insertion ; or if the collection requires several hours, to complete the operation at that time, after the meth- od employed by La- noix. Vaillard says the precise time for col- lection begins with 5 x 24, and ends with 6 x 24 hours. It can- not be doubted that temperature modifies the development of the vesicle, and that in warm countries, like the South of Europe, the term of develop- ment is shorter than it is in the North of Europe, or in the United States. The practice in Holland, with reference to the period of collection of lymph, is as follows : In Rotterdam, a portion of the calves, 5 x 24 hours ; another portion, 6 x 24 hours. In The Hague, 5 x 24 hours. In Utrecht, a calf is vaccinated on one side with lymph taken 6 x 24 hours after insertion, and on the following day on the other side with lymph taken 5 x 24 hours after insertion. In Amsterdam, a portion, 4 x 24 hours, and another portion, 5 x 24 hours. In Haarlem, 5 x 24 hours. In Brussels, 5 x 24, and 6 x 24 hours. In England, the usual practice is to take lymph 5 x 24 hours after insertion. The following table gives some of the data as to methods of vaccination in Holland and in Lon- don. Fig. 4446.-Scarificator for Bovine Vaccination. Fig. 4448. - Chambon's Expression Forceps. Fig. -4447.-Scarifications made by the Instrument above described. Fig. 4449. - Warlomont's Expression F orceps. Place. Surface vaccinated. Mode of vaccination. Number of insertions. Age of animal. Feed. Rotterdam The Hague Utrecht ... Amsterdam Haarlem Brussels London Abdomen only Abdomen only Abdomen and flanks ... Abdomen and flanks ... Abdomen only Abdomen only .. .... Abdomen and flanks.... Puncture Puncture Puncture Puncture Puncture Incision Incision 100 70 to 80 200 100 to 150 100 to 120 80 to 100 60 to 70 3 to 5 months.... 3 to 5 months.... 3 to 9 months.... 3 to 5 months.... 3 to 5 months.... Under 6 months . Variable 10 litres milk. 2 eggs. 10 litres milk, 2 eggs. 10 litres milk, 2 eggs. 10 litres milk, 2 eggs. 10 litres milk, 2 eggs. 10 litres milk, 4 eggs. 2 gallons milk. Collection of Vaccine Lymph.-The vesicles propagated upon bovine animals usually require more pressure, in order to obtain a supply of lymph, than is necessary in the collection of humanized virus, especially from the arms of infants, in whom the skin is tender. From these the lymph usually flows readily at the slightest puncture or incision. In bovine animals, however, hav- ing a skin of greater thickness, considerable pressure is usually required to cause a free flow of lymph. Before opening the vesicles they should be washed with soap and water, and then wiped dry with a clean towel. 1. Vaccine Lymph in the Dry Condition.-(a) On ivory points. The points in use in the United States at pres- ent are of a pretty uniform size, being about 37 mm. in length, 6 mm. in width, and about J mm. in thick- ness. By far the greater number are produced at 545 Vaccination Vaccination. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. several establishments in Connecticut, where bone points of the same size and shape are also made for the same purpose, at less cost. Larger and smaller sizes have also had a limited use. One end of the point is usually made square, and the other end pointed, and the rounded edges near the point are often bevelled, this de- vice having been adopted for the purpose of allowing the point to be used as a lancet. (Fig. 4433.) Such use, however, is not found to be practicable when compared with the employment of a sharp lancet or scari- ficator. In order to charge the points, they should be ap- plied to the lymph exuding from the vesicle, first upon one side of the point and then upon the other, until they are quite uniformly coated with the lymph for a distance of from one to two centimetres from the point. By some propagators, it is customary to allow the points to dry, and to recharge them with lymph, either from the same or from another animal. The points should be carefully laid to dry upon the edge of any convenient place, where the charged portion may project in such a manner as to al- low of its drying readily. If the points are not of a hard or very firm texture, Dr. Warlomont advises that they should first be coated with a layer of mucilage of gum arabic, and this allowed to dry in order to prevent the lymph from penetrating the ivory surface, and also that a succeeding layer of mucilage be applied to the outside of the lymph as a protection against the action of the air. To the first of these processes, however, it may be ob- jected that mucilage is a putrescible fluid, and unless the character of the gum of which it is made, and that of the solvent used, are both beyond suspicion, it cannot be con- sidered as a proper substance to be thus employed ; and, secondly, it is too insoluble when well dried to be used as an outside coating, since it does not admit of solution with sufficient freedom for ready use. Another objec- tion exists in the fact that, in the hands of unscrupulous vaccine-propagators, the use of mucilage would be sug- gestive of a ready method of substitution in cases of a dearth of genuine lymph. Evidence was not wanting in one of the recent American epidemics of small-pox that such substitution was actually practised. Ivory vaccine points are adapted to use in connection with the method by scarification, rather than by puncture. As ordinarily prepared, the lymph upon ivory points will usually retain its activity, when the points are kept at an even, cool temperature of 40° to 60°F. (4° to 15°C.), for a month or more. (It is customary to warrant them for a period of three weeks.) They have been known, however, fre- quently to retain their activity for very much longer pe- riods, ten months or more having been reported. A very ingenious and convenient contrivance has been devised, or brought to notice, by Dr. F. Kimball, of An- care. By this means a crevice or slit of uniform depth is left which will hold the points quite firmly when the pieces of wood are glued together. It will be noticed that the pieces of wood are not of the same width, so that when glued together at the bottom, the upper edge of one projects about one and a half millimetre beyond that of the other, thus forming a narrow ledge or shoulder which greatly facilitates the in- troduction of the points. The inner edge of the narrower piece is also slightly bev- elled for the same purpose. Care should be used in gluing the pieces that none of the glue enters the crevice intended to hold the points. A transverse section of the "stick" has the appearance showm in Fig. 4450. Each one of these sticks is in- tended to hold fifty points of ordinary size. In Fig. 4450 a portion of one end of this device is shown, filled for use, to- gether with a transverse section. These sticks are best adapted for use in cases in which there is a free flow of lymph. In order to use them, a sufficient number should be filled or set with the points, ready for charging. The vesicles and the vaccinated surface should then be washed with a disinfecting solution and wiped dry. Gentle pressure should then be ap- plied to several vesicles with the forceps, after carefully removing their outer por- tion. As soon as the lymph appears at the surface, a glass rod with a flattened end (like the handle of a glass syringe) (Fig. 4451) should be charged with the lymph, a drop at a time, and applied to the ends of the points, and it should be moved along the row until all are charged upon both sides. They will be found to be quite uniformly charged, and may be allowed to dry, and may then be recharged with a second and third coating, if it is deemed necessary. It will be found convenient to have one hundred or more of these sticks, each holding fifty points, and racks holding from ten to tw'enty sticks may be made for the purpose of facilitating the rapid drying of the lymph. Various methods are employed for packing charged points for transportation. Those methods are best which most efficiently protect the points from the air, from moisture, and from changes of tem- perature. The method employed by Dr. Martin, of Roxbury, answers the purpose very well. The points are first wrapped with clean absorbent cotton, then with thin w'hite paper, and finally are wrapped in an outer coating of thin sheet gutta-percha, which is easily made perfectly tight by a very moderate degree of heat. Fig. 4451.-Glass Hod used for Charging the Points. Fig. 4450.-Kimball's Device for the Rapid Collection of Lymph. dover, Mass., for the purpose of facilitating the rapid collection of lymph upon points when considerable quan- tities are required at once. This device consists of two thin pieces of pine wood glued together, of the following shape and dimensions. Length, 31 ctm. ; width of one piece, 2 ctm.; of the other piece, 2.15 ctm.; thickness of both pieces when glued together, 7 mm. From one of these pieces a thin shaving of a uniform width of a little more than one centimetre is removed before gluing them together. The shaving should be a little thinner than the points which are used, and should be planed off with great Fig. 4452.-Method of Charging the Points. Another method, quite convenient but not so efficient, is to pack them in small metallic tubes. 546 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vaccination. Vaccination. (b) Quills.-Another method of storing dried lymph, which has been in use for many years, is to apply the lymph to the ends of small pieces of goose-quill, which may be either blunt or sharpened at one end. These may be employed for vaccination by scarification, as in the use of ivory points, or if the lymph is applied to a pointed end, they may be used for vaccination by punct- ure. For this purpose a bit of the pointed end is usu- ally cut off and placed in the puncture, where it is left for a few hours, being kept in place by a bit of court- plaster. One advantage which the quill possesses is its capabil- ity of subdivision. (c) Crusts.-This method of using vaccine material has, fortunately, largely gone out of use in places where bo- vine lymph can be obtained, and it is desirable that it should be abandoned altogether, as relating both to bo- vine and to humanized lymph, since the crust consists of the products of the vaccine vesicle which have passed the period of maturity, when the clear transparent lymph has advanced to the purulent stage and the vesi- cle has become a pustule. If the vesicle may properly be said to have degener- ated, such process takes place in the stage of crust for- mation. The vesicle is also more liable to have been ruptured in the later than in the earlier stage, and hence to have absorbed foreign material. Experience also shows that the lymph in this stage becomes less effi- cient, and the ratio of successful vaccinations becomes less and less as compared with those which are per- formed with fifth, sixth, or seventh-day lymph. It sometimes, however, becomes necessary, in case of sudden outbreaks of small-pox, to use crusts, and in such cases those should be selected which are as recent as possible, and are of a brownish color, seinitranslucent, of regular shape, either round or oval, and having a cen- tral depression. Although crusts are not usually so effective as lymph dried upon points, nevertheless it is true that they will retain their efficiency for a longer period. A few years since, bovine crusts were offered for sale in the shape of masses, or cones, -which consisted of powdered crusts, formed into shape by the aid of press- ure and other means. Examination showed that these masses contained a considerable quantity of foreign ma- terial, such as might be expected to be found in the crusts formed upon animals which had not been carefully kept. Serious results following the use of these devices soon put an end to their use. It is hardly necessary to allude to the fact that crusts, like other organic material, undergo rapid putrefactive changes in the presence of heat and moisture. Instances are on record of serious injury from so-called vaccinations made by the use of crusts kept dissolved in water for a considerable period. (d) Dried Vaccine Lymph in the Form of Powder.- This method of using vaccine lymph has been employed to some extent, but has not come into general use. M. Ciaudo says he has obtained good results with dried vesi- cles after from one hundred and ten to one hundred and thirty days. Warlomont experimented with vesicles cut into small fragments and rapidly dried in a drying appa- ratus. These fragments at the end of two or three days were reduced to a fine powder and preserved in tubes closed only with cotton. When the powder was used in this condition the vaccinations were not very successful ; but if the powder was allowed to macerate in glyce- rine and water for twenty-four hours (thus allowing the vaccine microbes to pass from a latent state to one of ac- tive life) and was then used, good results were obtained, even though the powder was more than three months old. 2. Vaccine Lymph in the Moist Condition-Pulp.-This method, first introduced" by Ciaudo, of Milan, consists in excising the vesicles, freeing them from all detritus, making a homogeneous paste, and adding to each vesi- cle a half gramme of chemically pure glycerine; this is placed in a small glass vial, and covered with more glycerine to exclude the air. Vaccine material thus prepared preserves its activity for a long period, and is very efficient. Its effects are, however, occasionally quite irritant. A similar mode is adopted in Holland, the pulp being preserved between glass plates. Warlomont advises the following method : The vesi- cle is first cleansed of every possible impurity, the scab or crust especially being removed ; that which remains- the core of the vesicle-is reduced to a thin mass, and is treated with glycerinized water. This emulsion is then introduced into glass tubes for preservation. He also mentions a ''pomade vaccinale," prepared with an aseptic excipient. These will preserve their efficiency for a month or more. Capillary Tubes.-These were first brought to public notice by Dr. Husband, of Edinburgh. Their essential characteristics were stated to be as follows : 1, They should be so slender as to admit of ready sealing in the flame of a lamp ; 2, they should be large enough to con- tain lymph sufficient at least for one vaccination ; 3, they should be long enough to admit of sealing without subjecting their contents to the heat of the flame ; 4, they should be strong enough to admit of handling with- out breakage. Dr. Husband advised the following dimen- sions : Average length, 2f to 3 inches (about 7 to 8 ctm.); diameter, -/g inch (about 1 mm.). Another form is made with an enlargement at the centre of the tube. These tubes are sometimes made with closed ends, that the in- terior may be kept clean until ready for use. When they are required for use the closed ends should both be bro- ken, an open end should be applied to a drop of clear lymph as it exudes from the vesicle. The lymph will enter by capillary attraction, and also more freely if it be allowed to flow downward into the tube, thus adding the force of gravity to that of capillary attraction. If the Fig. 4453.-Capillary Vaccine Tubes. (The bulb in the upper tube should have been made larger). lymph does not enter freely, its flow may be aided by striking the wrist upon the arm. The ends are then sealed by holding them in the flame of a candle or lamp. Greater care is required to seal the second end, but a lit- tle practice will enable one to seal it tightly. When re- quired for use the ends should be broken off, a larger glass or rubber tube attached, and the lymph should be blowm out upon a glass plate, from which it may be con- veyed with the lancet to the scarifications. Bousquet said of the use of tube lymph : " The vac- cine may, indeed, be preserved for a long time in them- ten, twelve, fifteen months, or more; but to say that a thing may be, is not to say that it always or often hap- pens." He also adds : " We find that vaccine deteriorates rapidly enough in the tubes ; and if there were not ex- ceptions in everything, it would be easy to state a period after which it loses all its properties. " I do not know what happens in the capillary tubes, but I have very often observed that when one keeps them a certain time the vaccine disappears, little by little ; then one is greatly astonished, at the end of five or six months, to find them nearly empty. ... 1 conclude from this fact and from others that vaccine in tubes undergoes changes which can only be fatal to its properties." Warlomont confirms the observations of Bousquet, and says: "We have collected the vaccine into large-sized tubes, and have observed that, although the tubes were full of the clearest vaccine, hermetically sealed, at the end of two or three days we have found the liquid al- ready clouded, become milky, with white clots form- ing. ... If we now empty the tube, we find that the vaccine has acquired an odor more or less dis- tinctly mouldy, which becomes putrid if we wait a little longer." It would appear, then, that this method of preservation of vaccine lymph is not worthy of general adoption. The exposure of lymph to the air and its subsequent storage in a moist condition subjects it at once to the liability of 547 Vaccination. Vaccination. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. putrefactive change, a fact which is shown by the mouldy odor to which Dr. Warlomont alludes. It would cer- tainly be wise to abandon this method of storage alto- gether. Disinfection.-It is not until recent years that disin- fection has been proposed as an additional means of se- curity in connection with vaccination. It should be distinctly understood just what is meant by disinfection in this connection, and also how far such measures should be carried. Vaccination is itself an infective process, performed with infectious material. Hence any process by which disinfecting or even antiseptic sub- stances are incorporated with vaccine lymph, must nec- essarily impair its value, unless such substances are employed as will select for their action harmful micro- organisms only, leaving the vaccine microbes unaffected. To such a state of perfection the science of disinfection can scarcely be said to have attained. Until such meas- ures have been perfected, is it quite clear that the ques- tion of disinfection, as applied to vaccination, must be limited in its action to the accessories employed in the process of vaccination, and the collection, storage, and preservation of lymph ; so that the question is at present confined to narrow limits. The subject of disinfection, as applied to many ques- tions of a sanitary nature, resolves itself very largely into absolute cleanliness as an essential measure. The removal of filth as fast as it collects, and the careful cleansing of all implements employed in the processes of vaccination and the collection of lymph, are necessary conditions to the successful operation of every vaccine establishment. For use in the stables of bovine vaccine establishments, the chloride of lime is an economical as well as valuable disinfectant, and should be liberally used. It should not be employed, however, as a mere substitute for the careful removal of all accumulations of filth, but should be used in connection with such removal. For the cleansing of implements, glass tubes, and plates employed in vaccination and the collection of lymph, a solution of the bichloride of mercury (1 to 1,000) or a three per cent, solution of carbolic acid should be em- ployed, and the implements then wiped dry with a clean towel or napkin. The walls and floors of stables and operating-rooms should be washed at regular intervals with similar solutions, care being taken that the former is not used in connection with the feed-troughs and other receptacles of food, or with such parts of the walls as are liable to be licked by the animals. In the discussion of this question Gerstacker says, the faultless nature and condition of the various instruments and utensils employed in the preservation of lymph is an essential qualification. In the lively controversy as to the propriety of mixing lymph with antiseptic fluids, the decision has apparently been made against such mixture. There is probably no antiseptic agent, and no practicable solution of the same, which has not been ex- perimented with, and commended by some one or other in recent years. A new treatise by Freund, of Breslau, gives a complete list of the literature upon this question. Almost everywhere, experience with these additions or mixtures, having the power to render pathogenic germs innocuous, shows that they also lessen, if they do not de- stroy, the efficiency of the vaccine lymph, while weaker solutions which have no effect on the vaccine lymph, also have no effect upon foreign micro-organisms. The Action of Disinfectants upon the Contagium of Vac- cine Lymph. Messrs. Carsten and Coert, of La Haye, experimented upon vaccine lymph in 1879, w'ith the following results : 1. Bovine vaccine lymph heated to 64.5° C. (148° F.) for thirty seconds loses its virulence. 2. Bovine vaccine lymph heated to 52° C. (125.5° F.) for thirty minutes does not lose its virulence. 3. But when it is heated for thirty minutes to 53° C., and especially to 54° C. (127.4° and 129.2° F.), it loses all its virulence. Vaccine lymph diluted in five hundred, and also in two thousand, parts of distilled water does not lose its power after artificial evaporation of the water. (Chauveau found that vaccine lymph frequently failed when diluted with fifty times its weight of water, and once it suc- ceeded when diluted with one hundred and fifty volumes of water.) Dilute solutions of acetic acid, 1 to 1,000, and of hydrochloric acid, destroy its power after very short exposure. Dr. Dougall, of Glasgow, in 1874, showed that vaccine lymph exposed for thirty-six hours to the vapor of car- bolic acid, and for twenty-four hours to the vapors of chloroform, camphor, ether, and iodine, remained active. In 1872, Dr. Cameron, of Dublin, experimented with lymph stored on ivory points, submitted to the action of the fumes of chloride of lime, decomposed by acids. The results were partial successes. Dr. Sternberg (1879) tested the action of sulphurous acid on fresh lymph stored on points. Infants were vac- cinated on right and left arms with the intact and with the neutralized virus, with the following results : Experiments. Quantity of sulphur" burned. Length of exposure. Successes. Intact. Neutral- ized. 27 and 28 5 grains - 30 centigr.. . 4 hours 8 29 1 grain - 6 centigr 4 hours 5 30 and 31 % grain = 3 centigr 12 hours. 9 1 32 % grain = 1.5 centigr .... 12 hours. 3 The recent regulations of the German Government, with reference to many of the points considered in this paper, are so carefully drawn that we have inserted them in full. Decree of the Bundesrath of April 28, 1887. Instruc- tions Relative to Procuring, Preserving, and Sending out Animal Lymph. I. Selection and Examination of Ani- mals for Vaccination.-§ 1. In procuring animal lymph, only those animals are to be chosen whose state of health can be determined by slaughter, and by an examination of the internal organs after taking the vaccine lymph. §2. Asa rule, calves should be employed. Older ani- mals are only to be used when calves cannot be had. The calves should be at least three weeks old, and the navel must be free from suppuration and inflamma- tion. Calves of five weeks and upw'ard are to be pre- ferred. § 3. Before vaccination the condition of the animals must be determined by a veterinary surgeon. Only those animals which are perfectly healthy are to be employed. The selected animals are to be numbered and registered immediately after the examination. § 4. The temperature of the body must be noted at the time of vaccination and at the time of collecting the lymph. If the temperature exceeds 41° C. (105.8° F.), or if there are other signs of illness, except slight digestive disturbance, the animal must be excluded. § 5. After taking the vaccine lymph the animals must be killed and examined by a veterinary surgeon. The examination should especially be directed to the condi- tion of the navel and of its vessels, the peritoneum and pleura, the lungs, liver, and spleen. § 6. The veterinarian must give a certificate of every examination. § 7. The lymph must only be issued to the vaccinat- ing physicians when the autopsy shows that the animal was healthy. II. Care and Feeding of Animals.-§ 8. The stall for the vaccine animals must be light, dry, easily ventilated, cleaned, and disinfected. In large vaccine establishments appliances must be at hand for sustaining a uniform temperature at all seasons. § 9. Care must be taken that the care and feeding of the animals are conducted by suitable and trustworthy persons. § 10. The straw for these animals must be fresh and never before used. The vaccine animals and their floor- ing must be kept absolutely clean. § 11. Sucking calves must be fed with good, undi- 548 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vaccination. Vaccination. luted, warm milk, to which are added after a while some eggs or meal mush. III. Vaccination and Collection of Lymph.-§12. Ani- mals which have come from a distance must not be vaccinated until the day after their arrival. § 13. The room for vaccination and lymph collection must be light, airy, easily cleaned, disinfected, and in large establishments easily heated. § 14. All of the implements used in vaccination and in the collection of lymph, as well as those used in the subsequent handling and transporting of it, must be of a material and shape permitting thorough cleansing and disinfection. They must be used for one purpose only, and before and after each use they must be cleansed and disinfected when necessary. § 15. The place to be selected for vaccination is de- fined as follows : On young animals the posterior part of the abdomen, from the perineum to the neighborhood of the navel, including the scrotum an> the inner surface of the thigh ; but in older animals the scrotum, the udder, the milk-mirror (escutcheon), and the neighbor- hood of the vulva. § 16. The surface selected for vaccination must be shaved and thoroughly washed with soap and warm water. Afterward it must be disinfected with a solu- tion of mercuric bichloride (1 to 1,000), or a three per cent, carbolic-acid solution, and finally rinsed w'ith boiled water. § 17. Vaccination may be made by puncture, by short or long incisions, or by scarifications over surfaces of large or small size. Large scarified surfaces must be surrounded by isolated vaccine spots, in order that their development may be more easily watched. § 18. In the vaccination of animals there may be used : (a) Humanized lymph taken from the vesicles of a primary vaccination, subject to the laws of the Bundes- rath of June 18, 1885. Lymph from revaccinated persons must only be used in emergencies, and after careful examination of the health of the vaccinifers, who are subject to the same laws. Humanized lymph may be introduced into the animal, either Unmixed, direct from the arm, preserved in a capillary tube, or dried upon a bit of quill; or, Mixed with the purest glycerine, and conveyed thence to a capillary tube, or preserved in a well-corked, per- fectly clean vial. (b) Animal lymph subject to the same conditions as humanized lymph. (c) Tiie solid and the fluid portions of the so-called natural cowT-pox. § 19. The collection of the vaccine virus from animals should be made before the suppuration of the contents of the vesicles, and before a considerable redness of the neighboring parts appears. § 20. Collection of the lymph must be preceded by careful cleansing of the whole vaccinated surface with soap and warm water, and the removal of all foreign material. § 21. Only well-developed vesicles are suitable for the collection of lymph. Repeated use of the same vesicle on different days is not permissible. § 22. The collection of lymph may be made by means of the lancet, sharp spoon, or spatula, with or without pressure (squeezing). The texture of the vesicle is to be removed as much as possible by scraping and scratching {Schaben und Kratzer^. § 23. Use as vaccine material the fluid as w7ell as the firm portion of the vesicles. IV. The Preservation and Sending out of Lymph.-§ 24. The sending out of the crude material (lymph) taken from the vesicles, unprepared for use in vaccinating human beings, is forbidden. § 25. The vaccine material intended for preservation and sending away, is to be taken from the totality {ge- sammt Materiale) of the vesicles. The mixing of vaccine lymph taken from different an- imals on the same day is permitted. § 26. The choice of vaccine material for preservation must be made immediately after taking it from the animal. § 27. This vaccine material may be preserved : a, in fine powder, quickly dried ; ft, after careful rubbing in a mortar with the purest glycerine (which may be di- luted with distilled water), in the shape of a mass of the consistency of an extract, or a syrup ; c, after rubbing with glycerine and allowing the solid portions to settle, the latter may be used in the form last described, or the supernatant fluid may be employed. § 28. Only clean capillary tubes which can be readily closed, or other similar glass vessels, may be used in the preservation and sending out of vaccine lymph. The lat- ter vessels may be closed with a good cork. All articles for the preservation of lymph may be used a second time, after thorough cleansing and disinfecting. (Best done by boiling water.) § 29. It is recommended, before sending out vaccine material, to try its efficiency by test vaccinations. § 30. Every consignment (package) of vaccine material should be accompanied with its registered number and directions for use, and with a request to communicate the result of the vaccination. It should be urged that the instructions given in the Appendix be followred. V. Record.-§ 31. The record to be kept is as follows : a, Number of the animal; b, breed, sex, color, and age of the animal; c, date of receipt of the animal, last exam- ination, and discharge from establishment ; d, day and hour of vaccination, and of collection of lymph ; e, kind and source of lymph used in vaccinating ; f, temperature and weight of animal at the time of vaccination and col- lection of lymph ; g, health of animal during seclusion, and the development of vesicles ; h, condition of the vis- cera after slaughter as determined by the veterinary surgeon ; i, result of vaccination ; k, mode of preserva- tion of lymph (see § 27); I, remarks. § 32. A record-book is to be kept for recording the sending out of lymph, to contain the following items: a, Number; b, name and business of the receiver ; c, address of receiver ; d, date of receipt of order; e, date of sending lymph ; f, source and age of lymph ; g, mode of preservation ; h, quantity of lymph sent; i, -remarks. VI. Scientific and Practical Inquiries as to Animal Lymph.-§ 33. The public vaccine establishments are in duty bound scientifically and practically to improve vac- cination, and consequently to carry on investigations by way of experiment, clinical observation, or otherwise. Appendix (§ 30). A. Directions for Vaccinating with Qlycerine-animal- lymph.-The vaccine material is to be kept in a cool, dark place, where it will keep its strength for weeks. When required for use the necessary amount is to be taken from the capillary tube or glass vial and placed upon a clean glass slide, or directly upon the instrument used for vaccinating. Vaccination is generally performed upon the upper arm. It should never be made by puncture, but by scar- ifications not less than two centimetres apart. In pri- mary vaccinations, from three to five shallow scarifica- tions of a size not larger than one centimetre, should be made upon each arm ; in revaccinations, from five to eight shallow scarifications upon one arm. Drawing blood freely should be avoided. Apply the lymph just as it comes ; rub it into the scarifications re- peatedly, the incisions being opened by bending the arm tense. The application of vaccine material with a brush is forbidden. Lymph once taken from the tube must not be returned to it. B. Directions for Vaccination with Powdered Animal Lymph.-The pow'der must be kept in a drier. When used, it must be rubbed into a thick mass upon a care- fully cleansed glass plate, mixed with chemically pure glycerine, with pure distilled water, or with a mixture of both. 549 Vaccination. Vaccination. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. (The directions as to the place and the number of scar- ifications are the same as under A.) Small portions of this pulp are to be carefully and re- peatedly rubbed into the cuts, as directed for the liquid lymph. The unused portion of the pulp is to be de- stroyed. The following data from the report of the Vaccinal Institute of Saxony, for the year 1886 (Arbeit. KaiserL Ges. 2 Bd., p. 447), will illustrate many of the principal points in the administration of the work of animal vac- cination in Saxony, as well as in the German Empire. The establishments named in the report are those of Dresden, Leipzig, Frankenberg, and Bautzen. In a few instances the returns were deficient, as the tables show. Cost of Maintenance. Number of Animals Employed, Time of Vaccinating, etc. Dresden. Leipzig. Franken- berg. Bautzen. January 2 .... February 2 March April 3 i 6 May 12 Y 'C I o June 10 6 w j J uly 6 3 August 1 2 J- S' । •> September ... 1 3 . M October 5 November. ... 2 Total.... 45 22 37 12 „ | Male. .. 1 14 1 | Female . 44 23 11 Age X to IX year.. 7 to 8 weeks... Average X to IX 23.6 days. year. Weight 147 to 362 kilos. Average of 9^.6 = 323 to 796 lbs. kilos. = 217 lbs. Dresden. Leipzig. Franken- berg. Kent of stables and establishments .... Cost and use of animals, and transport- ation of the same Marks. Marks. 200.00 Marks. 940.00 1,084.20 879.60 Pay of attendants and assistants in vac- cinating and collecting lymph 674.25 • 617.06 84.50 Services of veterinary surgeons 470.00 55.00 245.50 Instruments, vaccinating tables, etc. Travelling expenses, superintendence, etc. 34.86 9.00 46.00 564.00 Totals 2,119.11 1,965 26 1,819.60 The principal noteworthy point in this table is the great difference in the age of animals employed. Time of Collection. In Dresden: Once at the end of ninety-six hours. Ten times at the end of one hundred and eight hours. Twenty-seven times at the end of one hundred and twenty hours. Twice at several times between ninety-six and one hundred and forty-four hours. In five instances the lymph was not col- lected, in consequence of its scarcity and the imperfect character of the vesicles. Leipzig : Lymph was collected at the close of ninety- six hours. Frankenberg : Collection of lymph at the close of ninety-six and of one hundred and twenty hours. Bautzen : As a rule, at the end of one hundred and eight hours. Average, 111.3 hours. Kind of Lymph Employed in the Vaccination of Animals. Dresden. Leipzig. Franken- berg. Bautzen. Humanized Bovine Humanized and bovine together 4 times. 10 times. 31 times. Partly fresh humanized and partly fresh bo- vine lymph 3 times 34 times. 12 times. Totals 45 times. 22 times. 37 times. 12 times. Quantity of Lymph Collected. Dresden. Leipzig. ♦ Frankenberg. Bautzea ( Quantity of J lymph collected. | I Average per ani- mal 95.8 grams vaccine pulp, without serum. 2.59 grams vaccine pulp, without serum. 100.6 grams. 8.38 grams. Quantity of prepared vaccine material. - 9,288 tubes, each suffi- cient to vaccinate ten persons. 5,114 tubes ; 4,193 large and 921 small. 691.0 grams in 5,862 tubes, averaging 0.13 gram in each. 119 large tubes for fifty per- sons each; 307 medium sized for twenty persons ; 1,831 small for six per- sons. * The least product of a calf was 0.6 gram, the greatest 6.0 grams = 9 minims to 1% drachm Number of Children for whom the Lymph Sufficed to Vaccinate. Summary of Results. In Dresden 92,880 In Bautzen 23,360 Primary vaccinations. Revaccinations. Total. Success- ful. Ratio of success Total. Success- ful. Ratio of success Dresden 11,779 11,730 99.6 9,054 8.672 95.8 Leipzig- Public vaccinators. 15.252 14,759 96 8 11.22- 10,140 90.3 Private physicians. 519 512 98.7 127 119 93.7 Total 15,771 15,271 96.8 11,352 10.259 90.4 Frankenberg 32,915 31,924 97.0 25,907 24,575 94.9 Bautzen 6,153 5,756 93.7 5,306 4.755 89.6 Totals 66,618 64,681 97.1 51,619 48,261 93.6 Leipzig and Frankenberg make no returns on this point. Distribution of the Lymph Collected. Dresden- Number of distributions to private physicians, 743. Number of tubes issued, 1,356, each tube containing enough for live vaccinations. Number to public vaccinators, 409. Number of tubes issued for vaccinators, 4,456, each tube containing enough for fifteen vaccinations. Number of distributions to military surgeons, 21. Number of tubes issued, 1,096, each containing enough for ten vaccinations. The greatest number of distributions were made in May, and the least in March. The cost of distribution was 349.45 marks.. 550 Vaccination. Vaccination. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dr. L. Voigt, supervising vaccine physician of Ham- burg, gives the following precepts as results of his ob- servations : (1) Vaccine lymph may be obtained by vaccinating kine with lymph from the pustules of small-pox patients, but too much dependence cannot be placed upon the success of the experiments. (2) On account of its energetic action, variola vaccine obtained in this manner is fit for human vaccination only after it has been transmitted from animal to animal, and thus lessened in its vigor. (3) In the first year of its use, lymph thus obtained possesses greater value than bovine lymph from a source several years old. (4) Vaccinia and variola spring originally from the same contagion, and give to the person inoculated a certain immunity from the evils incident to such source. (5) The duration of the immunity depends upon the intensity of the sickness. (6) Those whose attack of small-pox dates from a pe- riod of about twelve years previous, have about the same susceptibility to vaccination as vaccinees of twelve or more years ; therefore school-children, twelve years of age, vaccinated in their first year, present a tolerable amount of susceptibility to contagion. (7) Consequently the Imperial law, requiring vaccina- tion in infancy and revaccination in the twelfth year, fulfils the actual necessities of the operation. (8) Bovine lymph, originally very active, when trans- mitted from calf to calf, weakens in its activity sooner than when it is transmitted from arm to arm. In gener- al, humanized lymph gives the best results upon men and upon the cow ; consequently, bovine lymph of old stocks gives less promise of success than retrovaccine of the first generation. (9) Lymph which originates in, and is but a few re- moves from, variola vaccine, and is judiciously propa- gated on good soil, is the most effective vaccine agent, not only in the bovine, but also in humanized, method of propagation. It therefore follows that variola vaccine should be propagated afresh whenever opportunity offers, in order that lymph of the greatest protective power may be obtained. The Morphology of Vaccine Lymph and its Artificial Cultivation.-The study of the essential nature and com- position of vaccine lymph is comparatively recent. As recently as May, 1871, Sir William Jenner, in his evi- dence before the Parliamentary Commission, said : "Vac- cine lymph is sui generis altogether ; it has no micro- scopic or chemical character, but I should judge it by its effects, just as I should judge that two seeds were dif- ferent, although I could not examine them, one produc- ing an oak, and the other an elm." Before the expression* of this opinion, however, Keber (1868), and Hallier and Bender (1859), and also Salisbury, in the United States (1868), had examined the microscopic constituents of vaccine lymph, and had called attention to the existence of bacteria therein. Bender writes that, in 1859, he di- luted a small drop of vaccine lymph with sweetened water, placed it in warm air, which had been filtered through cotton. "Four days later, a multitude of quickly moving points appeared, whose motion was stopped by acetic acid. Fourteen days after, I succeeded in raising threads which greatly resembled the oidium of aphthae." It would hardly be proper to consider either these or the later experiments of Hallier with cultivations of vaccine and variola lymph upon lemons, white of egg, cork, and starch moistened with phosphate of ammonia, as genuine cultivations of the vaccine contagium. In 1868, Keber reported that he had found bacteria in vaccine lymph, which he filtered through paper, and vaccinated both with the filtrate and with the residuum. With the latter he produced vaccine vesicles, and with the former none. Chauveau and Burdon Sanderson also reported similar results, and the former proved that the cocci found in small-pox lymph are, in their physical aspect, identical with those found in vaccine lymph, and that they also form the sole infective principle of small-pox. Weigert, in 1871, found bacteria in the vesicles of variola. Cohen, in 1872, demonstrated the presence of minute spheroidal corpuscles in fresh vaccine and variolous lymph, and Klebs confirmed the same. In 1882,. Pohl-Pincus ex- amined fresh lymph from the pock of the calf (from the fifth to the sixth day after vaccination), and detected micrococci. In 1884 M. Ferri reported upon the presence of micro- organisms in vaccine lymph, and gave a minute descrip- tion of their morphological characteristics. Quist, of Helsingfors (Finland), claims to have succeed- ed in the cultivation of vaccine virus in an artificial me- dium. According to his observations, the essential element is a spherical micrococcus of very minute size, and a ba- cillus which appears to be the adult form of the same. It dies when deprived of air, and must be cultivated in glasses or tubes of large size, not completely closed. The culture media are alkaline. The following are two of the formulae used for this purpose : 1. White of egg 1 part. Mucilage of gum arabic 6 " Carbonate of potassium /0 " 2. Serum of blood 2 parts. Glycerine v 1 Distilled water 2 " Carbonate of potassium 4£0 " Garre {Deutsche Medicinische Wochenschrift, 1887, Nos. 12 and 13) gives a summary of his inquiries relative to the micro-organisms of vaccine and variola. He found in the pustules two or three kinds of cocci. They were of about half the size of staphylococci; bacilli only were present when pieces of the pustule were introduced into the nutrient medium. The cocci germinated in culture ovens on agar-agar or blood serum. Attempts to vacci- nate men with these cultures failed. The vaccinees neither developed any local or constitutional phenomena, nor wTas immunity to further vaccination secured. Garre sums up his conclusions as follows : 1. In animal vaccine are to be found micrococci which when cultured exhibit certain characteristic marks. The lymph may be usually preserved as a pure culture if prop- erly withdrawn from beneath the skin. 2. When vaccinated into the cow, isolated, finely round- ed pustules were developed, which, when transmitted to man as well as to animals, produced the normal vaccine vesicle and imparted immunity from infection to the vaccinated individual. 3. By direct vaccination of the cocci from the pure cultures into men no result followed. 4. Subcutaneous injections of cocci and other methods of insertion produced no inflammatory phenomena. Tenholt (Thuringer arztliches Correspondenzblatt, 1887, No. 6) made investigations upon the micro-organisms of animal vaccine lymph, and demonstrated in it twelve different sorts of cocci and two bacteria, but did not suc- ceed in isolating the peculiar effective principle or virus. Dr. Dougall, in his essay on the cultivation of vaccine lymph, describes it as follows: "Fresh vaccine lymph is a limpid, albuminous, alkaline, and to the naked eye, an apparently homogeneous fluid. When examined with a power of seven hundred diameters, or even less, it is found to contain great numbers of spherical, motion- less, translucent, non-ciliated, non-flagellated, non-nu- cleated cells or micrococci. These cells occur chiefly singly, but some are double, in the form of dumb-bells, and some in groups of three, and of four. I have never seen them in vaccine lymph in chains. The single cocci measure about of an inch in diameter." A new stimulus has been given to the study of this most interesting question by the offer of a prize of £1,000, by the Worshipful Company of Grocers of Lon- don, in 1883. The problem being stated as follows : " To discover a method by which the vaccine contagion may be cultivated apart from the animal body in some medium or media not otherwise zymotic ; the method to be such that the contagion may, by means of it, be mul- tiplied to an indefinite extent in successive generations, and that the product, after any number of such gencra- 551 Vaccination. Vaccination. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tions, shall (so far as can within the time be tested) prove itself of identical potency with standard vaccine lymph." The great importance of such an inquiry can scarcely be over-estimated, since certain great advantages would thus be secured. On the one hand, the ability to pro- duce unlimited quantities of vaccine material for imme- diate use in the face of an epidemic of small-pox, and, on the other hand, the ability to overcome the objections urged against animal virus of either sort, humanized or non-humanized, namely, the possibility of transmission of disease, however slight the foundation of such objec- tions might be. Vaccine cocci, like those of many other kinds, are cap- able of rapid multiplication when placed in a suitable medium, as, for example, when inserted in the arm of a child. They multiply by fission ; the cell elongates, be- comes transversely constricted, at this stage forming a dumb-bell, or diplococcus ; subsequently the constriction increases and cuts the cell in two. From these facts it appears that the vaccine cells are endowed with vitality, and that the human body is a congenial soil for their re- production. In many instances, however, the soil only yields a single crop of cells. The first harvest of these so utterly exhausts or decomposes some special ingredient or pabulum in the soil, absolutely necessary for their growth and reproduction, that for several years the soil is unable to feed another crop of the same cells, no matter how active the seed or how thickly sown. There is also another well-known peculiarity of this human soil-namely, that if, previous to its having been sown with vaccine, it had been sown with variolous cocci, the latter in all likelihood would have grown lux- uriantly, and so exhausted it of their specific pabulum . . . that subsequent sowings of either vaccine or variolous seed would probably for some years after have yielded no crop, i.e., vaccination hinders small-pox, and vice versa. These facts seem to prove that the pabulum of vaccine and of variolous cocci is identical, and also that the cocci are identical. In the further discussion of this subject, Dr. Dougall asks : " Can the pabulum or condition of soil in which vaccine cocci live and propagate, be produced artifi- cially ? If so, I think the problem of their artificial cul- tivation may be solved. In order to solve the question, it is essential to make the artificial culture fluid as nearly like the vaccine plasma as possible, and then, after sow- ing this soil with vaccine seed, to maintain it under the various conditions resembling those of the maturing vac- cine vesicle, and finally to test its vaccinating power on the calf or human subject." Fresh vaccine lymph varies somewhat in density, as every vaccine propagator has occasion to observe. Thin lymph contains fewer cells than thick viscous lymph. Dr. John Clark, of Glasgow, gives the following results of the proximate analysis of twenty-four tubes of vac- cine lymph, of rather thick quality : Per 1,000 parts. Albumen compounds 148 Mineral compounds 37 Total solids 185 Water 815 1,000 (Reaction alkaline.) He does not state whether the twenty-four tubes were from one animal or from several. Comparing this analysis with that of fresh human lymph from the lymphatic vessels, and also with liquor sanguinis and with the white of egg, he found that the latter approached more nearly to the density of vaccine lymph than either of the other two. They were all three like the vaccine lymph in being fluid, transparent, albu- minous, and alkaline. Dr. Dougall, therefore, selected these, together with many other media, for experiment. That no specific organisms are found in apparently pure active vaccinia, except vaccine cells, seems to indicate the aseptic nature of the human nidus, and of the vaccine serum. Hence it appears that artificial media for the cultivation of those cells should also be aseptic. In the operation of vaccination as actually practised, however, the skin is often far from clean, sebaceous matter, epi- thelium, dust, etc., being often inserted with the lymph. Nor is the lymph, when being taken from the vesicle, free from risk of contamination, nor during its transit from arm to arm, nor from calf to arm, nor when being stored in, or taken from, tubes, or other appliances for storage ; the tubes also may not have been cleansed from dust before they are filled. Even syphilis is shown not to prove an impediment to the development of vaccinia, and it has been known to run its course along with, and uninfluenced by, scarlatina, measles, and chicken-pox. In Dr. Dougall's experiments, the temperatures main- tained varied from 70° to 100° F. (21° to 38° C.), and the time was from four to seven days. Vaccinations made from these cultures were always by scarification, and usually in two places, the upper receiving the artificial lymph and the lower the natural lymph. The results were noted on the eighth day. In every case the natural lymph produced a characteristic vesicle. In the majority of vaccinations, the artificial lymph used had been fertil- ized from the same stock of natural lymph used, and the latter lymph was chiefly obtained from the successful vesicles produced by the natural lymph inserted simulta- neously with the artificial lymph. In testing the results of cultures, both by the microscope and by vaccination, the fluid was always taken from the surface, and where the nature of the experiment would permit, also from the bottom. Humanized and calf lymph were both em- ployed, but chiefly the former. Dr. Dougall's experiments were one hundred and eigh- teen in number, extending over a period of three years. The soils used were of various sorts, such as white of egg, veal and beef broth, blood serum, gelatine, meat peptone, decoction of barley, extract of malt, etc. ; then an alkali was often added to render the soil either alka- line or neutral. Glycerine, which is not harmful to the cocci, was added in some instances to prevent decompo- sition. Dr. Quist, of Finland (Gazette hebdomadaire, Feb- ruary 3, 1884), says that the microbes of vaccine can bear a pretty large quantity of glycerine, much more than other micro-organisms. Fifty-eight soils contained white of egg, and of the thirteen partially successful cultures ten contained white of egg. With reference to sterilization of the soils employed, Dr. Dougall states that the absolute sterilization of soils for the reproduction of vaccine cells, so that the product shall equal in potency standard vaccine lymph, does not seem necessary, since the cells multiply in company with other zymotic poisons. He also deemed it proba- ble that the sterilization of soils, by heating or boiling, might impair their adaptive sensibility to the procreative functions of the seed. He therefore employed some soils with and some without sterilization. The seed em- ployed w'as mainly fresh, active, humanized lymph from tubes, and directly from the vesicle, calf lymph a few days old on ivory points, typical crusts from a few days to three months old, and portions of epidermis, or the covering of what Jenner called the " pearl on the rose" vaccine vesicles. After detailing the methods of sowing the seed, and describing the microscopic appearances of the cultures as examined, Dr. Dougall honestly acknowledges the failure of his experiments, and attributes the few appar- ently partial successes to two causes : (1) The possible mixture of a portion of the natural lymph of the lower vesicle (insertion) witl^ the artificial lymph introduced into the upper vesicle (insertion). (2) The artificial lymph being merely diluted natural lymph. In further criticism of the experiments of Quist, Dr. Dougall very justly attributes the apparent success to the fact that Quist mistook the diffusion of a solid mass of vaccine cocci in his cultures for their reproduction. He concludes by saying, " I fondly hope that some other candidate has succeeded in twining such a splendid laurel around the brow of the goddess of science ; its 552 Vaccination* Vaccination. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. far-reaching results would almost, if not altogether, sur- pass those of Jenner's immortal discovery." Laws of Different Countries Relative to Vac- cination.-Herewith are presented the essential features of the vaccination laws of different countries in which vaccination has been introduced. England.-The several acts by which it was endeav- ored to secure general vaccination throughout the coun- try were repealed by the enactment of 30 and 31 Vic- toria, chap. 84, in 1867. The sections of this Act which are of general interest are as follows : § 16. The parent of every child born in England shall, within three months after the birth of such child, or where, by reason of the death, illness, absence, or inabil- ity of the parent, or other cause, any other person shall have the custody of such child, such person shall, with- in three months after receiving the custody of such child, take it, or cause it to be taken, to the public vac- cinator of the vaccination district in which it shall be then resident, according to the provisions of this, or of any other Act, to be vaccinated ; or shall, within such period as aforesaid, cause it to be vaccinated by some medical practitioner ; and the public vaccinator to whom such child shall be so brought is hereby required, with all reasonable despatch, subject to the conditions herein- after mentioned, to vaccinate such child. § 17. Upon the same day in the following week, when the operation shall have been performed by the public vaccinator, such parent, or other person, as the case may be, shall again take the child, or cause it to be taken, to him, or to his deputy, that he may inspect it, and as- certain the result of the operation ; and, if he see fit, take from such child lymph for the performance of other vaccinations ; and in the event of the vaccination being unsuccessful, such parent, or other person shall, if the vaccinator so direct, cause the child to be forthwith again vaccinated, and inspected as on the previous occa- sion. This Act was amended in 1871, by 34 and 35 Victoria, chap. 98, by the provisions of which Act the guardians of every union or parish are required to appoint a vac- cination officer, whose duties are similar to those im- posed by the Act of 1867 on registrars of births and deaths. By the Act of 1871, a person refusing to allow a public vaccinator to take lymph from a child he has vaccinated is rendered liable to a penalty of £1. The criminality of inoculating with small-pox enacted by 3 and 4 Victoria, chap. 29, is re-enacted by this Act. The English law does not compel the parent himself to be vaccinated, but compels him to afford to his help- less child, at the public expense, the best protection available against a dangerous disease. The Roman father had by the Roman law the child's life at his dis- posal. Such power, however, is not conferred by the English law. The child belongs to the nation, and the parents are bound to provide for his safety. (Thirty- fifth Registrar-General's Report, Supplement, p. Ixvii.) Italy.-The law of 1859 (June 14th) provided that no one should be admitted to a public school, or to exam- ination for a public office, or to a college or other in- stitution of instruction dependent upon, or aided by, or authorized by, the government, without a certificate that such person has had the small-pox, or has been success- fully vaccinated. Italy supports fourteen vaccine es- tablishments, at Bologna, Milan, Genoa, Ancona, Venice (2), Bergamo, Areggo, Verona, Vicenza, Rome, Modena, Ravenna, and Rimini. Norway.-In Norway, vaccination was made obliga- tory by law in 1811. In Austria, Roumania, Turkey, and in Greece the Government assumes the right to vaccinate all the un- vaccinated, and in some of these countries to revaccinate all who have not been vaccinated within seven years. Vaccination is not compulsory in Belgium and in Spain. In France attempts have been made to enforce vaccina- tion, and notably in 1880, when, at the proposal of the Society of Public Medicine, Dr. Lionville prepared a bill which was presented to the Chamber of Deputies, provid- ing for compulsory vaccination within six months of birth, and revaccination every ten years up to fifty years of age. This bill, however, failed to pass. Several min- isterial circulars have been issued in France upon this subject, notably those of 1803, 1814, 1824, and 1843. By the first of these a central committi e on vaccination was formed who encouraged the practice. The'decree of October 31, 1814, offered prizes of 1,000, 2,000, and 3,000 francs for the greatest number of vac- cinations made, and the greatest ratio of successes. By the circular of 1824 prizes of 1,500 francs, four gold, and one hundred silver medals were also offered. Tardieu's statistics of vaccination in France show a great disparity of vaccinations in the different depart- ments. In 1859 they varied from twelve per cent, of the births in the department of Cher, to ninety and ninety- one per cent, in the departments of Tarn-et-Garonne and Seine-et-Oise. In accordance with a custom early inaugurated in France, mothers or guardians of recently vaccinated infants were paid a fee for the privilege of taking lymph from the vesicles upon such infants, the fee varying con- siderably in different times and places, from three to fif- teen francs. This has to some extent proved a hindrance to general vaccination, and may have been one of the minor causes which led to the introduction of bovine vaccination. Vaillard, in his report upon the practice of bovine vac- cination at the school of military medicine of Val-de- Grace (1884), offers this as an additional reason for the use of bovine lymph, showing that in consequence of this indemnity paid to mothers the cost of humanized vaccination is from two to three times greater in France than the cost of vaccination with bovine lymph. Another source of hindrance to successful vaccination has been the custom, largely in vogue, of deputing vac- cination to the midwives, who very frequently failed to fulfil the necessary requirements. Vaccination of all new recruits in the French army is obligatory, and to this regulation is undoubtedly due the comparative immunity of the army from small-pox as compared with the people at large. Holland.-In Holland vaccination is not compulsory, and for many years it was the custom to delay vaccina- tion until the child was more than two years of age. There are at present four vaccine establishments, at Rotterdam, Amsterdam, The Hague, and Utrecht, and three temporary establishments at other places. Bovine lymph is mainly used at these. Germany.-In Germany every child must be vaccinated before the September of the year following its birth. All scholars in public and private schools must be revacci- nated in the twelfth year, if they have not already had the small-pox. When the vaccination and revaccination are not successful, they should be repeated in the two fol- lowing years. Only attested physicians may vaccinate. The special control of vaccination is left to the separate states. The public vaccinations are free to all. The cost is paid from the public treasury. Humanized lymph, retro-vaccine lymph, and animal lymph may be employed indiffer- ently. The lymph must be taken only from strong, thor- oughly healthy vaccine sources, and at least one-half of the vesicles must not be opened. The children from whom the vaccine is taken must be at least six months old. The different states are to provide for the erection of vaccine establishments, and for the sending out of good vaccine lymph. (Wernher: " Resultate der Vaccination u. Revaccination.") Dr. Wernher makes the just comment upon the age limit for vaccination, that it is delayed too long for chil- dren, since children born in January may become twenty months old before their vaccination is obligatory. Denmark.-Vaccination was established by law, both in Denmark and in the Faroe Islands, at the beginning of the present century. By the laws of Denmark no child can be admitted to school, or present itself for con- firmation, until a certificate of vaccination is produced. 553 Vaccination. Vaccination. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Revaccination is also enjoined for soldiers, and seamen in the navy. In Iceland, which was subject to devastating epidemics of small-pox in the last century, one country physician and eight district physicians are appointed for the con- trol of vaccination, .nd every clergyman, after having received the necessary instruction of these physicians, shall be the vaccinator ex officio of his parish, and keep a register of those who are vaccinated. The district phy- sicians provide a supply of vaccine virus from Copen- hagen. Sweden.-The law in Sweden prescribes, as a general rule, that children shall be vaccinated before the age of two years, and in case of epidemic small-pox vac- cination is recommended in the first months of life. Re- vaccination is generally recommended at the age of fif- teen years, and is prescribed for recruits in the army and navy.6 Japan.-Vaccination was introduced into Japan in 1849 by Dr. Monnik, a Dutch physician at Nagasaki, and vaccinating offices were afterward opened ; but the re- sults were not at first satisfactory, in consequence of the want of a regular supply of good lymph, and its dete- rioration, or on account of the imperfect performance of the operation. In June, 1874, a central office was opened for the purpose of collecting vaccine lymph from calves and distributing the same to the local authorities through- out the empire in the spring and autumn, and wherever small-pox should be prevalent. In December of the same year (1874), vaccination was made compulsory, and regulations were issued for its performance and for the collecting of statistics relative to vaccination and revaccination. Professor E. S. Morse, who has been a keen observer of all matters of public interest in Japan, says : " It is gratifying to know that small-pox, which was formerly endemic, is now coming under control by the Govern- ment taking active measures to insure vaccination. The frightful scourges of small-pox in past times are seen in the sadly scarred faces of many of the people, and in the number of blind persons one encounters." United States. -The following resume contains the es- sential points of the vaccination laws of the principal States of the Union. In Alabama the county health officer is required from time to time to obtain necessary supplies of reliable vac- cine matter which, without charge, he must, on applica- tion, furnish to the practising physicians of the county ; and when prepared, vaccinate without charge all indi- gent persons of the county applying at his office. Arkansas has no State law as to vaccination. California has no State law relative to vaccination. In Connecticut the town Boards of Health may adopt such measures for the vaccination of the inhabitants of their respective towns as they deem necessary. Every person who refuses to be vaccinated, or prevents anyone under his control from being vaccinated, on application of a member of a board of health, or of a physician em- ployed by the board for such purpose (unless in the opinion of another physician it would not be prudent on account of illness), shall forfeit five dollars to the town. The Board of School Visitors of any town has authority to require every child to be vaccinated before such child is permitted to attend a public school. The expense of vaccination is to be paid from the town treasury, when necessary. In Delaware the school authorities are required to en- force the vaccination of all school-children, unless they are previously protected either by vaccination, or by small-pox. A copy of the law must be posted for two weeks at the door of every school-house. Illinois has no State law relative to vaccination. The State Board of Health has issued an order excluding un- vaccinated children from the public schools. Indiana has no State law as to vaccination. The State Board of Health has issued certain rules especially ap- plicable to epidemic seasons. It has also ordered that bovine virus should be used for vaccination, with certain exceptions. Iowa has no State law as to vaccination. In Kansas there is no State law as to vaccination. In Kentucky the law requires that all unvaccinated persons over twenty-one years of age shall procure their own vaccination. Parents and guardians must have their children and wards vaccinated within twelve months after their birth. All unvaccinated persons coming into the State from other places shall procure their own vac- cination and that of their children within six months. Practising physicians are to be designated to vaccinate the poor. Town and city authorities are required to make rules and affix fines and penalties relative to vac- cination. Superintendents of public institutions are re- quired to have the inmates vaccinated. The Secretary of the State Board of Health is required to furnish vac- cine virus to local boards of health for the gratuitous vaccination of the poor. Louisiana has no State law as to vaccination. A city ordinance relative to school attendance is enforced in New Orleans. In Maine the city or town authorities are required an- nually, or oftener if they deem it prudent, to provide for "free vaccination with the cow-pox" of all inhabitants over two years of age, to be done under the care of skilled practising physicians, under such circumstances and restrictions as the authorities may adopt. School committees may, if they deem it expedient, exclude un- vaccinated children from the public schools. In Maryland, a State vaccine agency is established which is required to keep a supply of fresh vaccine virus for the use of physicians. The governor is required to appoint a vaccine agent with prescribed powers and duties. Physicians are authorized to vaccinate children born in their practice. A penalty is provided for the use of virus of bad quality. Parents are charged with the duty of having their children vaccinated within twelve months after their birth. Unvaccinated children are not to be admitted to the public schools. In Massachusetts the first law relative to vaccination was enacted in 1809, and provided for the inoculation of the inhabitants with the cow-pox, under the direction of the town boards of health, or of a committee chosen for the purpose. The present law provides that parents and guardians shall cause their children and wards to be vac- cinated before they attain the age of two years, and re- vaccinated whenever the town authorities shall, after live years from the last vaccination, require it. The town authorities shall also require and enforce the vaccination and revaccination of all inhabitants when the public health requires it. The penalty for neglecting to comply with these provisions is $5. Towns shall furnish means for vaccination to those 'who cannot pay for it. Incor- porated manufacturing companies, and superintendents of public institutions, are required to see that the inmates of such institutions are vaccinated. Towns may make further provisions for vaccination, under the direction of the Board of Health, or of a committee chosen for the purpose. School committees are required to exclude un- vaccinated children from the public schools. In Michigan townships may make suitable provision for the "inoculation of the inhabitants with the cow- pox," under the direction of the Board of Health, or of the health officer. The Board of Health of each munici- pality may at any time direct its health officer or physi- cian to offer vaccination with bovine vaccine virus to every child not previously vaccinated, and to all other persons not vaccinated within the preceding five years. Any health officer is also authorized to order the prompt vaccination or isolation of persons who have been exposed to small-pox. In Minnesota parents and guardians are charged with the duty of having minors vaccinated. Missouri has no State law as to vaccination. In New Hampshire the law is permissive as to the ap- pointment of agents for the vaccination of towns. Un- vaccinated children are excluded from the schools. In New Jersey the school authorities may prohibit the attendance of unvaccinated children who have not had the small-pox, and may decide whether revaccination 554 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vaccination. Vaccination. shall be required when small-pox occurs in any city or district. In the enrollment of children by the school authorities, inquiry must be made as to the fact of vac- cination, and if the parents desire, children are to be vaccinated by a regularly licensed physician. In New York it is the duty of local boards of health to provide at stated intervals supplies of vaccine virus, of a quality and from a source approved by the State Board of Health. During an epidemic, local boards of health are to obtain fresh supplies of virus, at intervals not ex- ceeding one week, and at all times to provide thorough and safe vaccination for all persons who may need it. North Carolina has no law relative to vaccination. In Ohio local boards of health may take measures, supply agents, and afford inducements and facilities for gratuitous vaccination. They may also make and en- force such rules and regulations to secure the vaccination of school-children as in their opinion the safety and in- terests of the people require. Pennsylvania has no vaccination laws. In Rhode Island the town councils shall provide an- nually for the gratuitous vaccination of the inhabitants. They shall also contract with and provide physicians to vaccinate. Such physicians are to record the names and ages of persons vaccinated. Unvaccinated children are excluded from the public schools. The maximum fine for violation of the law is $50, or imprisonment for thirty days. South Carolina has no vaccination laws. In Tennessee the State Board of Health has power to prescribe rules to prevent the introduction of epidemic diseases. In Virginia unvaccinated children are excluded from the public schools. The governor is required to appoint an agent annually, who must furnish, by mail or other- wise, to every citizen of the State who applies for it, genuine vaccine virus, free of charge, with directions how to use it. The agent must advertise that he is ready to furnish such virus. The town and city authorities may cause the inhabitants to be vaccinated, and may en- force obedience by fixing fines and penalties for violation. West'Virgiuia also had a statute requiring the appoint- ment of a vaccine agent, but this has recently been re- pealed. Wisconsin has no vaccination laws. Anti-vaccination.-Vaccination, like almost every important discovery which has ever been made, has had its opponents from the very outset. After twenty-five years of patient observation, Jenner proclaimed his won- derful discovery, only to be met by ridicule and opposi- tion on the part of a considerable number of his country- men. The same spirit of opposition has continued down to the present day, and has, in some countries-notably in England, some parts of Germany, and in Switzerland, a considerable following. Organized societies exist in some European countries, the object of which is mainly to secure the repeal of vaccination statutes of an obliga- tory character, the chief claim being made that such statutes are an infringement upon personal liberty. The London Society for the Abolition of Compulsory Vac- cination has a large membership. Its president, P. A. Taylor, Esq., M.P., was one of the Select Committee who signed the noted parliamentary report of 1871, which re- commended that " the State should endeavor to secure the careful vaccination of the whole population," an act which he afterward publicly retracted in a pamphlet en- titled " Current Fallacies about Vaccination." The ob- jects of the society are stated as follows : I. The aboli- tion of compulsory vaccination. II. The diffusion of knowledge concerning vaccination. III. The publication of literature relating to vaccination, and as a centre of information and action. Another society, with a wider range of action, is the National Anti-compulsory League, also an English organization. The literature of anti-vaccination is quite considerable, and consists of about three hundred and fifty pamphlets in English, by about one hundred authors, the principal writers being Messrs. Gibbs, Tebb, Taylor, Young, and Wilkinson. Six journals devoted to the same cause are published in English, the Vaccination Inquirer being the organ of the first-named society. There are also from fifty to one hundred continental pamphlets upon the same subject, chiefly in French, Ger- man, and Swedish. The most decided resistance to the vaccination acts in England has been for several years in the county of Lei- cester, where the number of unvaccinated children has increased during the past few years, until, in the returns for 1884, the medical officer of the Local Government Board states that "Leicester continues to be the worst offender against the vaccination laws, the neglect of infantile vaccination amounting to 23.5 per cent, of the births," and in the city it amounted to 47.9 per cent, of the births, as against 5.5 per cent, for England and Wales, and 6.8 per cent, for London. The same officer also adds: "There is accumulating in parts of this, and in some other counties, a very serious number of unvacci- nated children, and they will, after a while, if the vacci- nation laws are not enforced upon their parents, have to pay with their lives very dearly for their parents' luxury of disobedience." Dr. Farquharson, in addressing the House of Commons (in June, 1888) with reference to the disturbances at Leicester, alluded to the inconsistency of its inhabitants in consequence of their bitter opposition to compulsory vaccination, while the same people submitted without complaint to the requirements of compulsory notification of disease, compulsory removal to hospital, and compul- sory disinfection. Dr. Arnould, in his treatise on " Public Hygiene," rec- ognizing the fact that an unvaccinated person is a constant menace to the public safety, reasonably inquires whether the liberty of those who do not wish to have the small- pox is not as worthy of respect as the liberty of those who do not desire to be vaccinated. In France, the opponents of compulsory vaccination succeeded in preventing the enactment of the bill pro- posed by Dr. Lionville, in 1881 ; and in Switzerland a similar organized opposition secured the repeal of com- pulsory acts in 1882, the effect of which action has al- ready become evident in a decided increase of small-pox in that country. Wernher, in his work already quoted, makes the fol- lowing comment upon anti-vaccination as manifested in Stuttgart: " Stuttgart, the stronghold of the opponents of vacci- nation in Wurtemberg, was, with a few exceptions, the source of those small-pox epidemics which spread throughout that country. This city had in 1860, 60,000 inhabitants, and its population is now about 80,000 (1883). The garrison has about 3,000 soldiers." The following figures speak for themselves. Wurtemberg. Year. Civil population. Stuttgart. Army of the whole country. * Sick. Deaths. Sick. Deaths. 1859 to 1860 0 0 0 0 1860 to 1861 41 0 1 0 1861 to 1862 27 1 0 0 1862 to 1863 143 11 1 0 1864 1.200 56 9 0 1865 819 33 16 0 1866 66 0 6 0 1867 15 0 1 0 1868 17 1 0 0 1869 721 50 0 0 1870 2,102 160 0 0 Total 312 * Except the Militia Battalion of Stuttgart. " The enormous responsibility which these opponents of vaccination have heaped upon themselves, speaks without commentary upon these statistics. In the five years (1864-1868), in a population of 1,760,000, Wiirtem- berg had 11,092 cases of small-pox, and 800 deaths. The revaccinated troops had no small-pox." 555 Vaccination. Vaccination. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The opposition to vaccination is based mainly upon the following objections : 1. Alleged infringement of personal liberty. Upon this subject, Dr. J. M. Toner, of Washington, makes the following excellent comments: " The assumption that the individual has the right to protect, or to abuse and neglect, his own health at pleas- ure, is false in morals, and, as we believe, equally in op- position to social and statutory laws. And, as a numer- ous population is of the highest importance to the strength and welfare of a nation, it should be the anxious study of legislators to favor that end by the enactment of such laws as will best protect the health and lives of the peo- ple. It is a well-known fact in the economy of popula- tion, that the conditions which most favor the multipli- cation of the human species are health, the enjoyment of peace, and an abundance of food ; and, per contra, of necessity, the conditions which most seriously retard the increase of population are pestilence, war, and scarcity of food. " The Eastern nations were, from the earliest ages of historic record, visited by occasional pestilential plagues, so terribly devastating in their career as almost to de- populate whole cities and extensive districts of country. Yet historians do not hesitate to say that, vast as was the mortality from the plague, it was even exceeded by that of small-pox. . . . Up to the last one hundred and fifty years, it was the most frequent, the most fatal, and the most injudiciously treated of all the pestilences that have afflicted mankind. . . . Notwithstanding the accumulated experience of practice, the medical profes- sion, during all that time, had discovered neither pre- ventive nor cure, remaining a sad spectator of its desola- tions, and utterly unable to afford relief. It defied alike the measures devised by civil rulers, and the appli- ances of medical science, continuing for ages unimpeded in its work of death and disfigurement. " There may be some diversity of opinion as to the steps proper and necessary to be taken to secure to every in- dividual in society the full protection which a successful vaccination gives against variola, though to our minds it is clearly a question to be settled by our legislators, upon the principle that it is their duty to secure the greatest good to the greatest number. In this particular instance, all would be benefited and none injured. With us, the belief had become prevalent that the temper of the Amer- ican people would not tolerate any interference on the part of the government in matters of a purely personal and domestic character. The experience of the last few years, however, shows us to be as submissive to the will of rulers and governments as any people on earth. There is not only wisdom, but a necessity, for a people loving liberty and cherishing independence, to guard with jeal- ous care every encroachment upon their political rights and constitutional privileges ; but it is believed that sim- ilar reasons would not be urged or found pertinent in hy- gienic measures which aimed to secure the health of the individual while equally protecting that of the whole community. . . . " The medical profession is unanimous in the belief that the universal application of the vaccine prophylactic, and the repetition of it at proper intervals of time, will ulti- mately exterminate the small-pox from among us, or render it harmless. This belief is not founded upon theo- ry alone, but upon the experience and accumulated evi- dences of its power, gained by practice and observation during nearly three-quarters of a century. . . A practice that has proved successful in protecting large bodies of moving troops throughout all their depart- ments, can be made equally efficient in protecting every member of society. The experience which has been gained in the subject of vaccination and revaccination, and its prophylactic efficacy when recently performed, warrants the profession in entertaining the confident be- lief that variola can be annihilated or rendered harmless, if the authorities will enforce universal vaccination. The individual who is not protected from small-pox by vaccination, or who has not had that disease, is in a con- dition liable on the slightest exposure to be attacked, and thus become the centre and source of spreading a loath- some malady which may destroy the lives of others. " The question of the prophylactic power and safety of vaccination is so well settled, that the individual who fails to protect himself against variola by it should be looked upon by the community with aversion, and treated as a nuisance (as he really is, so far as the social interests are concerned), and be compelled to submit to vaccination for his own safety and the protection of the public. " Parents and guardians have no more right to with- hold or neglect to provide vaccination for the children under their protection, than they have to jeopardize the lives of their helpless infants by not furnishing them with food or clothing. It is criminal to neglect either, as death may be the consequence ; but the failure to pro- vide protection against small-pox seems to be more ma- liciously wicked than to neglect either food or clothing, as the former may not only cause the death of the child, but may be the means of spreading disease and death among many others ; while the evil which arises from the latter ceases with the death of the victim." One of the highest authorities in public hygiene, John Simon, Medical Officer of the Privy Council of England, commends compulsory vaccination in the following language: "Persons unacquainted with the circum- stances under which this law was made, have doubted whether it was not an improper restriction of personal freedom. It being assumed as the limitary principle of human law, that men may be left free to follow every inclination which relates only to themselves, it would certainly seem foreign to the province of legislation to insist on one's caring for one's own health ; and if a man having small-pox could affect none but himself, little need be said against his right of having it ad libitum. Even in this light, however, it deserves consideration, that he who indulges a preference for small-pox, does so to the detriment or danger of his neighbors ; and as they often suffer by his infection, so they might reasonably claim to be heard on that question of his privilege. Still the main object of the obligatory law, as I under- stand it, is not to prevent adults from cultivating (if they be so minded) a personal taste for small-pox. Its object is to prevent them from compelling (for, in this case, al- lowing amounts to compelling) their children to incur the worst perils of that disease. The interference of the law was an interference between parent and child-a kind of interference very sparingly exercised in this country, and the exercise of which, on slight grounds, would, of course, be intolerable. The practical justifica- tion of any such law depends on the amount of evil which it is designed to correct, and four or five thousand annual deaths (in England), by one specific parental omission, constituted in this case a strong argument. It was under pressure of this appeal that the compulsory vaccination act was passed. The option which the new law restricted was not that of a conscious agent deliber- ately preferring for himself the dangers of small-pox to the securities of vaccination. The thousands who an- nually died of non-vaccination had never raised their voices for the privilege of unrestricted small-pox. The so-called ' liberty,' thenceforth to be abridged, was that of exposing unconscious infants to become the prey of a fatal and mutilative disease. It was this liberty of omis- sional infanticide, which the law took courage to check." 2. As to the claim that vaccination does not protect from small-pox. The amount of protection afforded by the process of vaccination, when properly performed, has been quite fully discussed in the earlier portion of this article. At the present day, but very few authorities claim that the protection afforded by a single vaccination is absolute. Not even small-pox itself is protective in all cases against a second attack. All eruptive diseases (the exanthemata) may in rare instances occur a second time in the same individual, and the same is true of small-pox. The ear- lier writers and observers undoubtedly believed that the protection was absolute. But a few cases of small-pox occurring after vaccination were observed as early as 556 Vaccination. Vaccination. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 1806, and gradually modified the belief of those who had strenuously asserted its absolute protective power. There is scarcely any law in the natural or physical world which has not some exceptions. But in this case the exceptions are extremely rare. The amount of protection afforded is quite well shown by the statistics of epidemics. Dr. Buchanan, medical officer of the Local Government Board of England, showed that the small-pox death-rate among adult per- sons vaccinated was ninety to the million ; among the un- vaccinated it was three thousand three hundred and fifty per million. Among vaccinated children under five years of age it was forty and a half per million ; among unvaccinated children of the same age it was five thou- sand nine hundred and fifty per million. Seaton regards the quality of the vaccination as having a most important bearing upon the protective power of the operation, and in this he is in accord with the ma- jority of individual authorities. The quality of the vac- cination includes not only the age and the genuineness of the lymph used, but also the expert character of the vaccinator, and the thoroughness and care with which he performs his work. No case of small-pox should ever be recorded as post-vaccinal until the physician has taken pains to ascertain that the vaccination was an ef- fective one. This is by no means always the case, and cases of small-pox are often recorded as post-vaccinal on the mere statement of parents or guardians that the per- son in question " had been vaccinated," without any in- quiry being made as to the result of the operation, a sim- ple question often eliciting the fact that the vaccination had not taken effect. The words "vaccination" and " vaccinated," as commonly used, so often refer to the mere performance of the operation irrespective of its re- sults, that, in any case of small-pox in a person said to have been vaccinated, the health officer should inquire, first, as to what the actual results of the operation were, and, second, he should examine for himself the charac- ter and number of the cicatrices. 3. As to the claim that vaccination introduces other diseases besides vaccinia. As has already been stated, the fact that such cases have occurred is not denied. It is also true that cases of such injury are exceedingly rare. So far as the introduction of diseases of human origin is concerned, this objection is entirely overcome bylhe employment of bovine virus ; and with reference to the possibility of introducing any of the diseases com- mon to the cow and to man, the question has been suffi- ciently answered by the quotations already given from the observations of Dr. Warlomont and others. In this objection, says Dr. J. F. Edwards, the anti-vaccinator fails to distinguish " between the end to be acquired and the means by* which this end is accomplished. Because vaccination does, in some cases, produce worse evils than small-pox itself would or could, therefore they reason that vaccination is wrong, and should be abolished. They condemn the entirety without considering or en- deavoring to correct the particulars that make this entirety dangerous." With reference to the various incidents which occa- sionally follow vaccination, very much has been attrib- uted to the operation which does not belong to it, on the entirely erroneous principle of post hoc, ergo propter hoc. The mortality from all causes among children is large, and in a large number of annual vaccinations, as for example, among the two millions or more of the German Government, it is not remarkable that a consid- erable number of deaths should occur within a short pe- riod of vaccination, and cases of harm are attributed to the operation which actually have no connection with it, in the line of cause and effect. In the recent reports of the Royal Health Office of Germany, certain diseases and lesions are named as hav- ing special connection with vaccination, to which refer- ence is herewith made. Severe inflammation of the skin in the neighborhood of the vaccine vesicles is one of the more common results, but no cases of permanently impaired health, or of death, were observed from this cause. The causes of this in- creased inflammatory action were by many observers at- tributed, especially when occurring among the revacci- nated, to irritation by the clothing, by scratching, and other mechanical means, as for example, by arduous toil in the fields. Out of the more than two and a quarter million vac- cinated in one year, there were four cases of inflamma- tion of the lymphatic glands and ducts. There was no mention of permanently injured health or a fatal result from this cause. Of erysipelas there were a greater number of cases, and eleven deaths in all, in five dis- tricts. In many of these cases, faulty methods of vaccination, or carelessness on the part of the vaccinees, or of their parents, were found to be the rule. Out of the entire number no cases of syphilis con- tracted by vaccination were observed. The report also states that certain cases of illness were charged to vaccination by the opponents of the operation, which had nothing to do with it, or at least no connec- tion could be proved between them. In the noted vaccine discussion at Vienna, Boing re- lated the case of a vaccinating physician at Oedt, who was vaccinating during an epidemic of small-pox, and spread the disease by taking lymph from a vaccinee who was in the incubation stage of variola. He suggests that the physician may have mistaken a vesicle of variola ly- ing between true vaccine vesicles for the latter, and thus spread the disease by taking lymph from the variola vesicle. With reference to this question, Dr. Korosi says : " It is really impossible to prove in general that a y equals the preceding x ; for strictly speaking, have we not, even in a case which may be reduced to its simplest ele- ments, nothing more than that y naturally follows x, and not the fact that y is the effect of x; or, in other words, that the propterea, transforms itself, even in the simplest experiments, into a mere posted ? " 4. A singular argument often urged by the opponents of vaccination is, that small-pox is not caused by conta- gion, but by filth, and hence its proper preventive treat- ment should be accomplished simply by sanitary meas- ures, without vaccination. Undoubtedly, filth and bad hygienic conditions promote the spread of small-pox, but that they directly cause the disease in the absence of a previous case of small-pox has never been proven. On the other hand, the contagious germ of small-pox has been isolated, examined, experimented with, and the disease has been shown to be contagious and inoculable in the highest degree. With reference to the theory of the origin of small-pox from filth, Dr. Carpenter says : " As regards small-pox, there is not any difference of opinion on this point. It certainly requires the introduction from without of some form of particulate contagion (a germ, or living organism), however much meteorological states and per- sonal diet may promote its growth ; and if the contagion be absent, small-pox cannot arise." 5. Displacement of mortality (Carnot's doctrine). This theory was proposed by M. Carnot, a French artill- ery officer. He alleged that, while certain diseases, such as small-pox, measles, convulsions, and croup were decreasing, other diseases, such as cholera, ty- phoid fever, and dysentery were increasing ; that the births were tending to become less in number than the deaths ; that the depopulation of France was an imminent danger; and that vaccination wTas the cause of all this disturbance. Mr. Simon comments upon this remark- able theory as follows : " Supposing Carnot's statistics to be correct, does he give any sufficient reason for as- cribing to vaccination that deteriorated state of adult life which he professes to have discovered ? So little does he this, that in any of the sentences where damnatory conclusions are drawn, if there were substituted at haz- ard for his word vaccination, the mention of any other historical event belonging to about the same period of time as Jenner's discovery, M. Carnot's logic would scarcely suffer by the change, or his new conclusion be less warrantable than his first. Post ergo propter was 557 Vaccination. Vaccination. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. never more whimsically illustrated. For the argument goes simply to claim as the effect of vaccination whatever evils have occurred since its discovery ; and M. Carnot's moderation may be praised, that, with the infinite re- sources of this proof, he did not also convict Jenner of causing last year's inundation of the Rhone." M. Charles Dupin, in 1848, and Dr. Bertillon, in 1854, also exposed the fallacy of Carnot's proposition. It was shown that, whether his arithmetic were right or wrong, his medical conclusions were wholly untenable. His evidence was purely local and applied to France, in which there were, it is true, certain facts of an unfavor- able character relative to the growth or movement of the population ; and yet these same observations were not ap- plicable to England, nor to Sweden, nor to Russia, nor to any other countries in which vaccination was practised as well as in France. In Sweden, for example, where careful records of mor- tality have been kept for a long period, the statistics show no evidence whatever to prove the theory of the " displacement of mortality " ascribed by Carnot to vac- cination ; on the contrary, they show that the chances of every period of life are better now than they were then. In the following table it will be seen that, even in the period in which cholera in one year (1834) killed 12,637 persons, the population at all the ages under thirty years, consisting for the most part of vaccinated persons, showed a much smaller death-rate than the population of similar ages in the last century. The figures in bolder type relate to that portion of the population which was born since the introduction of vaccination, and of which (persons under thirty in the fourth, and under forty in the fifth column) the greater part had undoubtedly been vaccinated. Of persons ten years older, especially in the last column, many had been vaccinated ; of persons still older, a diminishing pro- portion. Annual Mortality in Sweden per 1,000 of the Living Population. man ; when farmers and shop-keepers breakfasted on loaves the very sight of which would raise a riot in a modern work-house ; when men died faster in the purest country air than they now die in the most pestilential lanes of our towns ; and when men died faster in the lanes of our towns than they now die on the coast of Guiana." According to M. Carnot, there ought to have been very little natural small-pox in those days. But the pages of Pepys's and of Evelyn's diaries bear abundant testimony to its horrible frequency, and its terribly fatal results. Curious discussions took place in the last century relative to the effect of inoculation upon the duration of life, and Bernouilli undertook to solve the problem. D'Alembert attacked his position, and the controversy showed that the mathematical difficulties of the problem were much greater than had been supposed. After the introduction of vaccination Duvillard took up the sub- ject, and in his classic work endeavored to supply the defective data by the resources of higher analysis. He concluded that vaccination would add three and a half years to the existing man's lifetime. He makes the mean lifetime 28,76 years, and if no one died of small- pox, it wmuld be 32.26 years ; and he says the cessation of small-pox would raise the population of France from 28,763,192 to 32,255,755. Has Vaccination Increased the Liability to other Dis- eases ? and has it Increased the General Death-rate ?-Both of these propositions have been advanced by the oppo- nents of vaccination. Let it first be inquired what is meant by these propositions. " A child whose liability to small-pox has just been extinguished by well-performed vaccination," says Si- mon, " may to-morrow, like an unvaccinated child, be run over, or be drowned, or become sick of measles, or suffer with teething, or be struck with- any other of the numberless shafts of death. And the vaccinated sub- ject, advancing to adolescence, to middle life, or to old age, must encounter, like the unvaccinated, the several risks of each period of life. And obviously, if vaccina- tion on a given day, in England, secures a thousand lives from death by small-pox, sooner or later those lives will be subject to the inevitable lot; sooner or later the thou- sand deaths will be written against the names of other diseases than small-pox ; and such diseases may then be said to have been rendered more frequent by vaccination. In the same sense every life that is snatched from fire, or flood, or poison, counts at last as a death from some other cause ; and to say in this sense that such causes are more fatal than before vaccination, is but another form of saying, what Jenner would most have wished to hear, that small-pox is less fatal than it was." Dr. W. Channing relates a case of a young mother who desired to have her child vaccinated, but hesitated and declined to have it performed. In a few days the child was covered with a loathsome eruption. Had vac- cination been performed, the disease would undoubt- edly have been attributed to the operation. (Boston Medical and Surgical Journal, March 1, 1860.) If it is urged that the general mortality has been in- creased, either in consequence of or after the introduc- tion of vaccination, it would be impossible to find data which would confirm such a proposition. The following are some of the statistics relating to the difference in mortality-rates in the two periods, before and after the introduction of vaccination. In each case the mortality-rate is shown to be less in the latter period. Average Annual Death-rate from all Causes, and at all Ages, in London. in in a gS CtJ 7-1 Ages. 0) o £.3 * 0 0)0 -H m O TH th 0 to 5 years 90.1 85.0 61 .3 56.9 5 to 10 years 14.2 13.6 7.6 7.8 10 to 15 years 6.6 6.2 4 7 4.4 15 to 20 years 7 6 7.0 4 9 4 8 20 to 30 years 9.2 8.9 7.8 6.8 30 to 40 years 12.2 11.6 11.8 9 8 40 to 50 years 17.4 16.1 16.7 14.5 50 to 60 years 26.4 23.9 26.0 23.6 60 to 70 years 48.1 49.3 49.4 46.3 70 to 80 years 102.3 104 1 112.9 102.8 80 to 90 years 207.8 197.4 243.7 228.5 90 and upward 394.1 351.3 396.4 375.8 All ages 28.9 26.8 23.3 20.5 Furthermore, it has been alleged that if vaccination has made mankind less susceptible to small-pox, it has ren- dered them more susceptible to other diseases, especially to consumption and to typhoid fever. Statistics show that in neither of these cases is the assertion true. Both Dr. Farr and Dr. Greenhow have shown the fallacy of the statement. Dr. Farr states that " fever has progressively declined since 1771, and the combined mortality from small-pox, measles, and scarlet fever is now only half as great as the mortality formerly occasioned by small-pox alone." In fine, says Mr. Simon, there has never been adduced a tittle of evidence to show that vaccinated individuals suffer more than non-vaccinated individuals from any ailment whatever. The statement of Macaulay in his third chapter applies with remarkable force to this inquiry. " It is now " (he says) " the fashion to place the golden age of England in times when noblemen were destitute of comforts, the want of which would be intolerable to a modern foot- Date. Mortality-rate per 10.000 of the livinp population. 1681 1690 421 1746 1755 ... 355 1875-1884 218 The periods named above are selected because a census was taken at the middle year of the period, and an accu- 558 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vaccination. Vaccination. rate knowledge of the population is essential to any cor- rect study of mortality-rates. In, Sweden. port sur les Vaccinations pratiquees en France pendant l'annco 1812, (ditto) 1864, Paris, Imprimerie ImpEriale. Gerstiicker, Dr. Rudolph : Die historische Entwicklung und hygien- ische Bedeutung der Revaccination. Vierteljahrsschrift fiir off. Gesund, 20, 1, 1888. Garre: Uber Vaccine und Variola. Bacteriologische Untersuchungen. Deutsche Med. Wochenschrift, 1887, Nos. 12 and 13. Germany: Arbeiten aus dem Kaiserlichen Gesundheitsamte, 1 und 2 Bd. Ergebnisse des Impfgeschaftes im Deutschen Reiche, 1882, 1883, 1884. Berlin, 1885-86. Die allgemeine Einfiihrung der Animiilen Vaccination im Deutschen Reiche. Vierteljahrsschrift fiir (iff. Ge- sund heitspflege. Bd. 17, 1885. Hart, Ernest: The Truth about Vaccination. London, 1880. A Prelim- inary Report on Vaccination. London, 1880. Hering: Ueber Kuhpocken an Kuhen. Herz, Marcus: Briefe an Domeier uber die Brutalimpfung, und deren Vergleichung mit der Variola humana. Hufeland's Journal, b. xiii., 1801. Husband, W. : Exposition of a Method of Preserving Vaccine Lymph Fluid and Active. Edinburgh, 1859. Illinois: Fifth Report of State Board of Health, 1882. Jenner, Edward : An Inquiry into the Causes and Effects of the Variola Vaccinse. London, 1798. On Artificial Eruptions. London, 1822. Dr. Barnes' Life of Jenner. London, 1838. Jones, Dr. Joseph : Contagious and Infectious Diseases ; Reasons for their Prevention and Arrest. Vaccination, Spurious Vaccination, etc. (8 colored plates). Baton Rouge, La., 1884. Japan: First, Second, Third and Fourth Reports of the Central Sanitary Bureau of the Home Department of the Imperial Japanese Govern- ment. Tokio, 1875-79. Health Matters in Japan, by Edward S. Morse. New York, D. Appleton & Co., 1878. Kussmaul : Zwanzig Briefe fiber Menschenpocken und Kuhpockenimp- fnng. Freiburg, 1870. Korosi. Dr. Josef : Kritik der vaccinations-statistik und nene Beitriige zur Frage des Impfschutzes. Ninth International Medical Congress. Washington, D. C., 1887. Layet, D. A. : Le service de la preservation de la variole a Bordeaux. Revue d'Hygiene, September, 1886. Les Sources naturelies du Vaccin. Revue d'Hygiene, July, 1888. Laberge, Dr. Louis: Report on the Sanitary State of the City of Montreal for the year 1885. Montreal, 1886. Martin, Dr. Henry A.: Animal Vaccination. Boston, James Campbell, 1878. Martin, S. C. : The Inoculation, Propagation, and Preservation of the Virus of Animal Vaccine. Boston, 1885. Massachusetts : Report of the Committee on the Judiciary of the Legis- lature of Massachusetts of 1861, containing a Memorial of a Committee of the Boston Sanitary Association ; a Paper on Small-pox, by Robert Ware, M.D., and on Vaccination, by James C. White, M.D. House Document, 153, 1861. McVail, John C., M.D. : An Inquiry into the Prevalence of Small-pox in Kilmarnock, in the Last Century. Report of Local Government Board, Supplement. London, 1884. Marson, J. F. : Evidence before the Select Committee of Parliament, 1871. Pearson, Dr. George : Inquiry Concerning Cow-pox. London, 1798. Pissin : Vierteljahrsschrift fiir gerichtl. Med. u. off. Sanitatswesen, 1883. Pohl-Pincus : Untersuchungen uber die Wirkungsweise der Vaccination. Berlin, 1882. Reitz, Dr. W. : Versuch einer Kritik der Schutzpockenimpfung. St. Petersburg, 1873. Sacco : Trattato di vaccinazione. Milan, 1809. Seaton, E. C. : Handbook of Vaccination. London, 1868. Vaccination. Article in Reynolds's System of Medicine, vol. i., 1876. Simon, John : Papers Relating to History and Practice of Vaccination. Strauss : La Tuberculose, est-elle transmissible par la Vaccine ? Societe Medic, des Hopitaux (February, 1885). Paris. Stevens, T. M., M.D. : The Relative Value of Bovine and Humanized Vaccine Virus Practically Considered. Indianapolis, 1883. Taylor, P. A. : Vaccination ; a Letter to Dr. W. B. Carpenter. London, 1881. Tebb, William : Sanitation, not Vaccination, the True Protection against Small-pox ; a paper read before the Second International Anti-vaccina- tion Congress, at Cologne, October 12, 1881. Titeca: ktude sur la pratique de la vaccine ; ce qu'elle est; ce qu'elle devrait etre. Bulletin de 1'Acad. r. de Med. de Belgique. 3me eEr., t. xix., No. 6, 1885. Vaccination Vindicated by John C. McVail, M.D., D.P.H. London, 1887. Vaccination Inquirer and Health Review : The organ of the London Society for the Abolition of Compulsory Vaccination, 1879-1888. Lon- don. Vaillard, L.: Manuel Pratique de la Vaccination animale technique. ProcedEs de conservation du vaccin. Paris, 1886. Viennois ; de la Transmission de la Syphilis par la Vaccination. (Ar- chives generales de Medecine, 1860.) Vogt, Dr. Adolf: Fiir und wider die Kuhpockenimpfungund der Impfz- wang. Berne. 1879. Voigt, Dr, L. : Vaccine und Variola. Vierteljahrsschrift fiir off. Gesund- heitspflege. B. 14, 15, 1882, 1883. Warlomont, Dr. E.: Traite de la Vaccine et de la Vaccination humaine et animale. Paris, 1883. Willan : On Vaccine Inoculation. London, 1806. Woodville, W. : Reports of a Series of Inoculations for the Variola Vac- cines or Cow-pox. London, 1799. Samuel W. Abbott. 1 Ziemssen's Cyclopaedia, vol. ii„ p. 401. 2 Journal of the Gynaecological Society, Boston, vol. vi., p. 289. 1872. 3 Order of Local Government Board, February 3, 1888. London, 1888. 4 Deutsche Vierteljahrsschrift fiir offentliche Gesundheitspflege, vol. xx., p. 87. 1888. 5 Traite de la Vaccine, p. 283. Paris, 1883. 6 Appendix to British Parliamentary Report on Vaccination, 1871, pp. 409-415. Date. Mortality-rate per 10,000 living. 1755-75 289 1776-95 268 1821-40 233 1841-50 205 Much importance has been attached by the opponents of vaccination to certain statistics which were published in 1872-73 by Dr. Keller, the chief physician of the Austrian State Railway, who was himself an opponent of vaccination. These statistics were quoted largely by Lorinser, of Vienna, Vogt, of Berne, and by Reichsper- ger, all of whom were anti-vaccinationists. Korosi re- cently investigated the sources of these statistics, and ascertained that Keller was dead, and that the original documents could not be found. He then corresponded with all of the physicians who had contributed material to these statistics, who were still living and could be found, and learned that not only had Keller suppressed important data, but had actually altered the returns to suit his own views. One of the physicians who contributed to the returns confessed that "the data were prepared in con- formity to the taste of their chief, whom he knew to be opposed to vaccination." The committee of the Ninth International Medical Congress who examined the proofs of these statements, reported that they were " forced to declare that the sta- tistics of Dr. Keller were found to be false ; that they are an unpardonable effort to mislead public and scientific opinion, and that henceforth no weight should be attached to them, having been proved by us to be entirely incor- rect." Bibliography. Arnould, M. le Dr. J. : De la creation d'un office vaccinogene central dans le departement du Nord; avantages, inconvenients, et mode d'emploi de la vaccination animale. (Rapport presente a la FacultE de Medecine.) Revue d'Hygiene, February, 1886. Arpe, Dr. Carlo d': La Vaccinazione Animale. Gazz. di med. pubbl. Ballard, Edward : On Vaccination. London, 1868. Bryce. James: On the Inoculation of Cow-pox. Edinburgh, 1802. Bollinger, Dr. M. O.: Ueber Animale Vaccination. Leipzig, 1879. Bousquet: Nouveau traitE de Vaccine. Birch, John: An Appeal to the Public on the Hazard and Peril of Vac- cination. London, 1817. Buist, Dr. John B. : Vaccinia and Variola, a Study of their Life-history. London, 1887. Ceeley, Robert: Transactions Provincial Med. and Surg. Assoc., vols. viii. and x. Chauveau: Nature des Virus. Determination expErimentale des Ele- ments qui constituent le principe virulent dans le pus varioleux et le pus morveux. Acad, des Sciences de Paris, Seance du 24 Fevrier 1868. Gazette hebd., 13 Mars, 1868. Ciando : Du vaccin de GEnisse. ktude comparative du Vaccin Animal et du Vaccin Humain. MEmoire couronne par 1'Academie de Mede- cine de Paris, 1879. Cory, Robert: Report by a Committee appointed to Investigate Dr. Cory's Experiments in Vaccinating himself from Syphilitic Children. Report of Local Government Board, Supplement. England, 1883. Depaul: Accidents graves, suite de la Vaccination. La Syphilis Vacci- nale, devant 1'AcadEmie ImpEriale de MEdecine de Paris. Seances de DEcembre, 1864, Fevrier et Mars, 1865. Du Bois, H. A.: Report on Animal Vaccination. San Rafael, Cal., 1888. Duvillard: Analyse et tableaux de 1'influence de la petite vErole. Paris, 1806. Decanteleu, J. E. B. Denarp: Monographic des Cicatrices de la Vac- cine. Paris, 1837. Eimer. Charles H. : Die Blatternkrankheit in pathologischen u. sanitiits polizeilichen Beziehung. Leipzig, 1853. England : Report from the Select Committee on the Vaccination Act (1867). Proceedings of the Committee. Minutes of Evidence, 4°. London. 1871. Reports of the Medical Officer of the Privy Council, 1858, 1876. Reports of the Local Government Board, Supplements, 1872-1886. Report of the Epidemiological Society of London on Vac- cination, 1850, 1870. Foster, Dr. Eugene: The Relative Merits of Humanized and Bovine Virus. Augusta, Ga., 1882. Freund: Animal Vaccination and the Antiseptics of Vaccine. Breslau, 1887. Foster. Dr. F. P. : Animal Vaccination : being a portion of a Report made to the Trustees of the New York Dispensary, New York, June 1, 1871. Propositions in Regard to Animal Vaccination. New York, 1877. Furst, Dr. : Bericht uber die Thatigkeit der Anstalt fiir Animale Imp- fung zu Leipzig in 1880. France: Rapports du comitE central de Vaccine de 1'Academie de Mede- cine sur les vaccinations pratiquees en France de 1803 a 1862. Rap- 559 Vacci ilium. Vagina. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. VACCIN1UM MYRTILLUS Linn. {Airelle Myrtille, Co- dex Med.). Order, Ericaceae. This is a sort of blueberry, growing in France and Germany, and valued for its rather pleasant edible berries. It is retained in the French Pharmacopoeia, apparently for no other reason than that agreeable syrups, confec- tions, etc., can be made from them. Citric and other fruit acids and sugar are the principal constituents. A number of species of this rather large genus are valued for their berries; V. pennsylvanicum Lam.; V. canadense Kohn; and V. corymbosum Linn., are the common blueberries of this country ; while V. oxycoccus Linn., V. macrocarpus Ait., and V. vitis Idaa, are the cranberries of both countries. See also Bearberry. W. P. Bolles. VAGINA AND UTERUS. The form of the female genital organs has been compared to a boot ■without a sole. The foot of the boot corresponds with the exter- nal organs, and is compressed from side to side ; the leg of the boot corresponds to the vagina, and is compressed from front to back. The urethra is situated on the in- step. Opposite the urethra the hymen projects from the posterior wall of the vagina. The urethra and hymen mark the boundary between the external organs and vagina {ostium vaginas') (Fig. 4454). The hymen is a duplicature of mucous membrane, and forms the roof of the external genitals. When the subject is standing it lies nearly horizontal from front to back, and is arched forward from side to side (Fig. 4455). By far the most common form of hymen is that of a crescent, with the points directed toward the urethra. When the organs are closed these points unite to form a fissure. By sep- arating the labia the hymen is put upon the stretch and becomes a bow-like segment, slightly concave toward the front. The hymen grows thinner toward the free border. Its total thickness varies greatly ; usually it is thin and fragile, occasionally it is thick and tough. The thinner sort have a very delicate free edge, which is sometimes irregularly notched or fringe-like. This border is apt to be drawn tense. The thicker varieties are smooth on the edge and relaxed. Occasionally the hymen departs from the ordinary form. The horns of the crescent may pass toward the urethra, or even join below it, leaving an oval opening which is excentrically placed. The line of juncture of the horns is marked by a raphe. More rarely the open- genital absence of the hymen. The writer has met one case in which a band extended from the urethra back- ward, dividing the opening into two parts. The open- ing is said to be sometimes crib- riform. The hymen may be imperfor- ate, in which case it gives rise to trouble by retaining the menstru- al flow. * The folds and papilla? of the posterior wall of the vagina pass without a break upon the upper surface of the hymen, and fade gradually out as they pass toward the edge. The lower surface is like that of the external organs. Between its two mucous surfaces it contains fibres of elastic tissue, and often cavernous tissue and single bundles of muscular fibres. The hymen is nearly always ruptured at the first coitus.f The rupture may be single or manifold. It begins at the edge and passes outward, the location of the tear being between the folds which pass on to its upper surface from the vagina. These flaps heal and contract into emi- nences, the caruncula myrtifor- mes, which mark the entrance into the vagina. These carunculae are usually small rounded tubercules, symmetrically placed, and from two to four in number-more often the latter. They may, how- ever, vary greatly, both in length and breadth. They may be rounded or pointed, smooth or papular, and, according to the breadth of their bases, may touch one another or stand far apart. In old age they may disappear without leaving a trace. From the hymen the vagina extends to the uterus. It lies within the pelvis, and is con- nected with the rectum behind and the bladder in front. Its upper fourth is in contact with the peritoneum behind ; in front, the cul-de-sac of peritoneum which passes between the uterus and bladder is separated from it by a short interval. The levator ani muscles lie on each side. It is connected with the urethra and lower end of the rectum by a close tissue, from which the walls of the different canals cannot be sepa- rated. Therefore the walls of the vagina in- crease markedly in thickness downward. This is especially the case on the side of the rectum, the backward curving of the latter forming a wedge- shaped muscular column, which forms the common wall of the lower part of both vagina and rectum. As has already been intimated, the first part of the vagina, in virgins, passes almost directly backward, the hymen forming its lower wall (see Fig. 4454). At the outer border of the hymen it makes a sharp turn and Fig. 4455.-Frontal Section of the Female Genitals, through the Orifice of the Vagina. The right oviduct and ovary are removed. Lp, labia pudendi ; Cen, sections of the corpora cavernosa of the urethra ; H, hymen ; Cvp, posterior column of the vagina ; Va, vagina ; Oue, Oui, external and internal os uteri; Fv, fornix vaginae ; Lu, ute- rine labium; Ut, uterus; Od, oviduct; Lo, ovarian ligament; O, ovary ; Po, parovarium; *, Graafian vesicle ; *♦. corpus luteum. (After Henle.) Fig. 4454.-Median Section of the External Female Genital Organs of a Virgin. Cl, clitoris: Pc, prepuce; N, nympbae; H, hymen ; Fn, fossa navicularis; Na. navicula ; Ccc, Ccu. cavernous body of the clitoris and urethra ; *. venous plexus between these : Va. vagina: Cva, Cvp, columna vaginalis anterior et posterior ; S, sphincter ani muscle ; R, rectum. (After Henle.) ing is centrally located. When this opening is large the hymen may be reduced to a narrow fringed ring. Unless careful examination is made, this ring may escape obser- vation. Such cases have probably been reported as con- * ''A second hymen occasionally exists above the first " (Cazeaux). + In rare instances, however, as is well known in legal medicine, this does not occur. Such an event happened in a patient of the writer's, who became pregnant with the hymen intact. In such cases the hymen is unusually firm. 560 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vacclniuni* Vagina, passes upward and backward. The anterior wall also passes backward and then upward, but the first portion is more oblique, and the turn not quite so sharp as in the seven centimetres (2| inches), the posterior wall as about thirteen to twenty millimetres (| to | inch) longer. The width of the vagina is, on account of its great distensi- bilily, difficult to determine. It is constricted at its lower end, wider in the middle, and again slightly narrower at its upper end (see Fig. 4455). When left to itself it is closed, its walls touch one another, and its calibre in a cross section is a transverse fiss- ure. The shape of the fissure varies in different por- tions and with different ages. Its ordinary form is an H, the transverse portion being slightly curved forward and about twenty-four millimetres (1 inch) long (Fig. 4457). The side branches are moderately convex, the curvature being inwards. They may also be composed of straight lines which meet at an angle, whose apex joins the trans- verse portion. By this sort of folding the vagina accommodates the other pelvic or- gans and forms the most rigid column of support possible to the uterus. In children the transverse portion is very short and the sides are much inclined to it, so that a cross section approaches the form of a St. Andrew's cross. Very often the lines representing the dif- ferent parts of the H are irregular or wavy, projections of one side fitting into corre- sponding depressions on the other. Toward the lower end of the vagina a ridge projects from the anterior wall and another from the posterior wall. These are the columns of the vagina. The columns are not simply folds of mucous membrane; all the tissues are thicker, especially the mucosa or con- nective-tissue layer under the epithelium, which may reach a thickness of 2.5 mm. (-^ inch) or even more. As age advances the columns diminish in size and finally disappear altogether; the same result follows repeated labors or even frequent sexual intercourse. The anterior column is nearly always larger than the posterior, and is the last to disappear. One or both of thes< columns, especiallj the anterior, may b( subdivided by a fiss ure running length wise of the vagins (Fig. 4458). The anterior col umn may begin any where f rom the ori fice of the urethra tc 15 mm. (J inch) froir it ; it ends with the carina vagina. The posterior col- umn begins highei up the vagina thar the anterior, so that the lower and mos1 prominent part ol the anterior column lies in a depression below the origin of the posterior col- umn. The columns are often excentrically placed, so that when the vagina is closed they lie side by side. When they are not divided, a section of the fold is quadrilateral or elliptical, its height being about a third of its breadth. When divided, the folds may touch one another or be separated by a valley. The folds may diverge from be- low upward, or they may be separated below and con- verge upward (Fig. 4459). Fig. 4456.-Median Section of the Lower Part of the Buttocks of a Frozen Female Subject; Multipara. The intestines are removed. 1, Pubic synchondrosis; 2, peritoneum ; 3, outer muscular layer of the con- tracted urinary bladder; 4, inner layer of the same; 5, subperitoneal connective tissue ; 6, clitoris ; 7, vena dorsalis clitoridis ; 8, cross sec- tion of the deep transversus perinei muscle; 9, circular fibres of the urethra, anterior wall; 10, labium pudendi; 11, orifice of the urethra; 12, labia minora ; 13, longitudinal fibre layer of the urethra, posterior wall; 14, circular fibre layer of the urethra, posterior wall; 15, orifice of the vagina; 16, organic muscular tissue of the perineum ; 17, ex- ternal sphincter ani muscle : 18, internal sphincter ani muscle; 19, anus; 20, longitudinal muscular layer of the rectum; 21, internal sphincter ani; 22, external sphincter ani; 23, vagina; 24, anterior labium uterinum; 25, posterior labium uterinum ; 26, recto coccygeus muscle ; 27, sacrum ; 28, rectum ; 29, uterus. (After Henle.) case of the posterior wall. After turning, the course of the vagina is nearly straight, though it is constantly sub- ject to change, according as the bladder and rectum are full or empty. After the rupture of the hymen the posterior wall is straightened and the entrance to the vagina becomes conical or, to refer to our original simile, resembles the part of the boot between the instep and leg. The por- tion of the anterior wall in front of the angle of the turning part, formerly covered by the hymen, is now exposed when the labia are separated, together with a small portion of the posterior wall (canna vagina) (Fig. 4456). The uterus meets the upper end of the vagina at a considerable angle. The anterior wall of the vagina ends on the lower border of the anterior lip of the uterus ; the posterior wall curves around and behind the posterior lip and joins its upper border. The line of junction of vagina and uterus is called the fornix va- ginae. The length of the vagina is variously given by differ- ent authors, and there is no doubt that it varies consider- ably in different subjects; in negresses, for instance, it is longer than in whites, but the old measurements were certainly in excess of the truth. Henle's measurements, carefully made on the frozen subject, are probably very nearly correct. He gives the anterior wall as about Fig. 4457.-Cross Section of the Soft Parts of the Outlet of the Pelvis. Ua, urethra; Va, _ vagina ; R, rectum; L, levator ani muscle. (After Henle.) 561 Vagina. Vagina. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The columns may also be triple ; in that case the mid- dle fold is shorter than the two others but more promi- nent in the middle, so that the two others appear, in sec- tion, as appendages to the middle one. Toward the sides the columns usually fade gradually away, especially toward the upper end ; below, they are often steep, sometimes overhanging the base. The columns vary in height; in the dead subject they are from 7 to 15 mm. (-iao to A' inch) in height. During life they must be much higher. Besides the columns, there are close transverse folds, the so-called rugae or wrinkles. Henle calls them combs. These give the mucous mem- brane of the vagina its char- acteristic appearance. They are of two sorts ; one sort consists of a series of sharp- ened ridges which cover one another from above like tiles. Their free border is bent in a wave-like manner or notched. They are sometimes divided by deep fissures or deformed with wart-like projections which may be 0.6 mm. (-/0- inch) in height. Another variety consists of flat tubercles from 1 to 3 mm. (-/6- to | inch) in diameter, with a circular base, often changed by mutual pressure, and the confluence of single ones. An intermediate form consists of blunted transverse folds, as though consisting of fused tubercles. Tubercles and combs usually occur together in the same vagina, the tubercles appearing for the most part on the sides of the combs, as though continu- ations of the latter ; but in some cases one or other form is exclusively found. These structures are most prominent on and how'ever, great irregularity about this. The structures are often wanting on the columns themselves. Here they are sometimes represented by low folds and wrinkles; these wrinkles also sometimes occur on the columns in the interspaces between the combs. Fig. 4458.-Horizontal Sec- tion of the Anterior Wall of the Vagina with the Ure- thra (Ua). (After Henle.) Fig. 4460.-Perpendicular Section of the Anterior Column of the Vagina after Re- moval of the Epithelium. (After Henle.) The inner surface of the vagina, as well as the structure of its walls, becomes simpler in its upper part. When emptied of blood the wall is 1 to 2 mm. to inch) in thickness. It is of uniform density. It cannot be sepa- rated into layers by the knife, but, by the eye, two strata varying in cplor can be distinguished ; an inner, white (membrana media, Arnold), and an outer, more reddish (membrana mucosa vaginae anterior). These are the so- called mucous and muscular layers. Outside these there is, again, a more or less firm adventitia of connective tissue. The inner stratum, the mucous membrane, is composed of connective tissue covered with epithelium. The latter is a thick stratified pavement epithelium about 0.6 mm. (-/o inch) in thickness (Klein). The cells are very irregu- lar in shape and size, and are the largest in the body. The connective tissue contains much elastic tissue, which is collected into bundles that pass toward the sur- face. Vascular papillae project from the connective-tis- sue layer into the epithelium ; they are found on the eminences as -well as in the depressions. They are partly simple, partly compound. Some are pointed, some club- shaped. They average about 0.1 mm. inch) in height, but in single cases may be as high as 0.3 mm. (-/„ inch). They are said to be sometimes lacking in the parts bor- dering the os uteri (Fig. 4460). The outer layer (sometimes called middle layer) varies remarkably in different subjects ; it consists of connec- tive tissue with interspersed bundles of organic muscular fibres. Sometimes these fibres are present in scanty numbers, at other times they replace the connective tissue almost entirely. It is usually described as consisting of two layers, an internal longitudinal and an external cir- cular. This is not strictly true, for it cannot be separated into any such layers. Still, longitudinal fibres predomi- nate toward the inner surface, and circular fibres toward the outer. The longitudinal fibres are especially well de- veloped on the anterior wall of the vagina as far as this is attached to the wall of the urinary bladder. The mus- cular layer is intimately connected with the close-meshed venous net-work which surrounds the vagina, and mus- cular fibres penetrate in different directions into the inter- spaces of the net-work. The essential constituent of the columns is a caver- nous tissue with wide meshes. This tissue proceeds from a modification of the muscular layer into which the venous plexus w'hich surrounds the vagina sends out abundant branches, while at the same time the muscular bundles become thicker, and trabeculae run in different directions, especially toward the surface. The venous plexus which surrounds the vagina is usu- ally called erectile tissue ; but this is not strictly true, ex- cept on the columns, and, even there, not in the common sense of the word erectile. It forms an organ w'hich closes the vagina and offers some resistance, but which, Fig. 4459.-Vagina ; View of the Anterior Wall after Removal of the Pos- terior : A, with the folds of the anterior columns diverging upward; B, with the folds diverging downward. Ou. Urethral orifice ; Oue, ex- ternal os uteri; *. section of the fornix vaginas ; ♦*, carunculae myrti- formes. (After Henle.) near the columns, and gradually fade out above and to- ward the sides, where the mucous membrane becomes smooth. On the boundary the cones and folds become lower and farther apart, and finally disappear. There is, 562 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vagina. Vagina. unlike the resistance of true erectile tissue, is easily overcome by pressing the blood out of the organ. The variously shaped projec- tions above mentioned contain a plexus of large veins ; the connec- tive tissue between these vessels includes bundles of unstriped mus- cular cells derived from the mus- cular coat, as mentioned above. We have thus an arrangement sim- ilar to a cavernous tissue. A sec- ond plexus of veins is situated in the submucous tissue whose meshes ire elongated and parallel with the long axis of the vagina. The connective tissue in which the above-named plexus venosus vaginalis is situated-that is, the plexus outside the muscular coat-contains nu- the submucous layer. There are also numerous lym- phatic vessels connected in net-works in the muscular coat. The efferent vessels lead into a rich plexus of large lymphatic trunks with saccular dilatations situated in the adventitia. The nerve-branches form a plexus, in the nodes of which are contained ganglionic swellings. In the hu- man subject their termination in papillae has not been recognized, but in the rabbit the vaginal tunics are sup- plied with terminal bulbs and Pacinian bodies (Krause). The uterus is a thick-walled, hollow muscular or- gan, in shape somewhat like an hour-glass, flattened from before backward. The constriction is nearly in the middle, and divides the organ into two portions : the neck or cervical portion, and the body or corpus uteri. The neck is thickest in the middle and decreases above and below ; it resembles a flattened ellipsoid. The outer borders of the body are slightly curved, but Fig. 4461.-A Piece of Mu- cous Membrane from the Upper Part of the Vagina, furnished with Agminat- ed Glands. (After Henle.) it increases continually in breadth from the place of constriction to the upper portion or base and is broader there than at any part of the cervix. The general tendency of the organ is to diminish downward. The side borders along which the numer- ous vessels enter are not clearly distin- guished from the surrounding tissue. Only the upper portion, where it begins to turn slightly inward, is occasionally marked. The posterior surface of the uterus is convex from side to side ; the anterior is plain or even concave, following the cur- vature of the blad- der. The borders are rounded oif. From the two upper lateral angles pass off two tubes, the oviducts, through which pass the ova to find lodgement in the uterus. The part of the body above the entrance of the oviducts is called the base or fundus uteri. The upper border is slightly convex and joins the lateral borders at an acute angle. It lies free in the abdominal cav- ity, and upon it rest the coils of the intestines. In front of the oviducts, and a little below them, arise two mus- cular cords which pass to the abdominal rings-the round liga- ments (ligamenta teretia). Just behind and below' the ovi- ducts are attached the ligaments of the ovary. The uterus joins the vagina at its anterior wall. This wall passes straight to the uterus and joins it slightly above its lower ex- tremity. The posterior wall of the vagina passes by the extremity of the uterus, turns upon itself, and joins the merous bundles of un- striped muscular cells, de- rived from the circular stratum, and hence this plexus also resembles cavernous tissue. The mucous membrane of the va- gina is usually described as without secreting glands ; v. Preuschen, how- ever, has described mucous glands in it, lined at their fundus witli ciliated epithelium. " Henning also describes tubular glands in the mucous mem- brane, especially of the fornix and in- troitus vagina; in the rest of the organ they are very rare" (Klein). These observations lack confirmation. Notwithstanding the absence of glands, the vagina is bathed with an acid mucus. In some cases, at least, the vagina has organs which resemble the agminated glands of the small in- testine. Henle describes such struct- ures in the vagina of a girl eighteen years of age. They " were low prominences with circu- lar bases and a central depression 0.5 to 2 mm. to inch) in diameter. Part were single, part were arranged in transverse rows which, at the first glance, resembled the transverse folds of the anterior and posterior columns. Their favorite locations were the upper part of the vagina and the lips of the os uteri. Sections of the mucosa showed, in the centre of each of these agminated glands, a clear space filled by fluid and traversed by capillary vessels " (Fig. 4461). " There often occur in the smooth region of the va- gina, as also upon the uterine labia, erosion-like spots from 1 to 2 mm. (/g to inch) in diameter which probably occupy the place of destroyed agminated glands, as is the case with similar erosions of the intesti- nal mucous membrane " (Henle). In other cases also, patches of considerable size have been found, which were infiltrated with lymphoid cells, -the essential structure of what is called diffuse adenoid tissue. Klein describes plexuses of capillary lymphatics in the mucous membrane, and of large tubes with valves in Fig. 4462.-Uterus and Appendages; An- terior Surface. V, vagina ; U, uterus; M, os uteri; L, L, round ligaments ; T, T, Fallopian tubes ; O, O, ovaries; P, P, abdominal extremity of the tubes; 1, peritoneal fold covering the anterior surface of the uterus, uniting at the sides with the posterior fold to form the broad ligaments; 2, 2, ovarian liga- ments ; 3, 3, tubo-ovarian ligaments, (ilmil Beau.) Fig. 4463.-Section through the Middle of the Uterus and Upper Part of the Va- gina. (After Henle). 563 Vagina. Vagina. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. posterior portion of the extremity of the uterus opposite the anterior utero-vaginal junction. The vagina, there- fore, is a cul-de-sac. The uterus joins its anterior side a short distance below the extremity. The line of junction rises a secondary fold for the reception of the ovary. This fold deserves attention ; it is inclined at an acute angle with the surface of the broad ligament and forms a pocket with it. Its free border is below that of the broad ligament. The fold may be divided into three portions ; the first contains the ovarian ligament; the second, the ovary ; the third extends as a tense band between the ovary and the abdominal end of the oviduct. This third portion has a sharp free border ; it is called by Henle "the ligamentum infun- dibulo-ovaricum " (Fig. 4464). The length of the virgin uterus is from 6 to 8 ctm. (2 J to 31 inches). The transverse diameter at the fun- dus is 4 to 5 ctm. (If to 2 inches). At other places it cannot be esti- mated, on account of the venous plexuses at the sides. At the boundary of the body and cervix it is from 2 to 21 ctm. (f to 1 inch). The greatest antero-posterior di- ameter of the body is 2 to 3 ctm. (1 to 11 inch); that of the cervix is less. The weight is from nine to eleven drachms. After childbirth the uterus never regains its original virgin charac- ter ; the whole organ is increased in size, but the body increases more than the cervix. The con- striction between the body and neck is found still lower, and the whole organ becomes more decid- edly pear-shaped. In this condition the organ may be 9 to 10 ctm. (3f to 4 inches) long, 5| to 61 ctm. (21 to 2| inches) in transverse diameter, and 3 to 31 ctm. (11 to If inch) in antero-posterior diameter. The weight after childbirth is from three and a half to four ounces. The surfaces remain more strongly curved, the side borders become blunter, the angle which the side borders make with the upper border disappears, on account of the greater convexity of the upper border, and the boundary between. Fig. 4464,-View from Behind of a Lateral Angle of the Uterus (Ut), with a part of the Ligamentum Latum ; LI, the oviduct and ovary; Od, isthmus ; Od', ampulla of the oviduct; J, infundibulum ; Oa, ostium abdominale of the oviduct; Fo, fimbria ovarica ; O, ovary laid backward; Lo, ovarian liga- ment ; io, lig. infundibulo-ovaricum; ip, lig. infundibulo-pelvicum ; Po, parovarium laid bare by re- moval of part of the posterior lamella of the broad ligament; *, blood-vessel. (After Henle.) of the uterus and vagina is called the fornix vagina. The portion of the uterus projecting into the vagina is called its vaginal portion. These structures are surrounded by a peritoneal cov- ering. They are placed as though they had been pushed into a fold of peritoneum which was stretched across the pelvis from side to side, with the border directed upward and dividing it into two pockets, one in front and the other behind the ute- rus. The laminae are wider in the lower portion tnan tney are above. These folds are the broad ligaments. Anteriorly the peritoneum extends to about the level of the constriction which separates the body and neck ; here it is reflected on to the bladder. Behind, the peritoneum extends downward as far as the upper fourth of the vagina, forming a pouch between the rectum on one side and the vagina and uterus on the other {cul-de-sac of Douglas). In front, the connection of the serous coat with the muscular tissue is less close than behind, as it may be loosened for some distance wnn me Knne, more upon the borders than in the middle ; the line along which it can be detached forms an acute angle opening upward (Fig. 4463). Above this line of junction, the peritoneum grows inseparably to the tissue underneath. The apex of the triangular line of junction is about the middle of the uterus. On its posterior surface the peritoneum is close- ly attached to the body of the uterus, down to about the level of the internal os ; below this point it lies in low folds, in which run muscular fibres. These folds disappear when the uterus and rectum are separated. From the posterior lamella of the broad ligament there Fig. 4465.-Os Uteri in a Virgin, Fifteen or Six- teen Years of Age. mil Beau.) Fig. 4466.-Os Uteri in a Multipara, Twenty - five Years of Age. (Fmil Beau.) Fig. 4468.-Cross Sections of the Uterus. A, body; B, cervix; *, peritoneal covering. (After Henle.) these two borders is only marked by the insertion of the oviducts and the round ligaments. The uterus joins the vagina at an obtuse angle, but ex- actly what that angle is, is still disputed. If an opinion may be formed as to the position of the uterus from what is seen in the dead subject, it is extremely variable. It is seen, in sections of the frozen subject, lying parallel with the axis of the lower pelvis, or bent forward or backward at various angles. This would seem natural, for, as the organ lies immediately adjoining the bladder and rectum, Fig. 4467.-Os Uteri in a Multi- para from Thirty-five to Forty Years of Age. (£mil Beau.) 564 Vagina. Vagina. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tine or uterus fills the vacancy. The organ seems to have no power to support itself, but must fall either forward or backward, according as support is lacking. It is hardly just, however, to draw too positive conclusions from ap- pearances seen after death, for at least two conditions are then changed : the supports are relaxed on the one hand, and, on the other, the consistence of the tissue is changed. Whether during life the muscular bands which reach from the uterus to other organs-such, for instance, as the round ligaments- flex the organ or support it, is still a question. The filling of the vascular plexus which surrounds the uterus limits the space in which it can move. The wall of the uterus itself is probably not so stiff, after the muscular fibres have lost their tone in death, as dur- ing life. What the effect of filling its own vessels may be, whether to stiffen it or render it more pliable, is a ques- tion. Other things also have to be thought of, besides the uterus, when consider- ing its position ; for instance, the ute- rus is moved to and fro, at every res- piration, by the combined action of the diaphragm and the abdominal muscles. The uterus is also largely supported from below by the vagina, and any change in the character of that sup- port will alter the position of the ute- rus. Every gynaecologist knows that active contraction of the muscles of the vaginal wall-as, for instance, during sexual excitement-will draw the uterus downward. The truth seems to be that the uterus is in a nor- mal position when it is freely movable by normal forces. The extremity of the uterus which projects into the vagina is divided transversely, forming two rolls, the anterior and posterior uterine labia ; be- tween these is the os-a mere slit. Before childbirth it has rounded ends ; after child- birth it is elongated, and the ends become sharpened (Figs. 4465, 4466, and 4467). The posterior lip is thinner and longer than the ante- rior, although the anterior lip pro- jects more into the cavity of the va- gina. " The anterior lip overlooks, as a rule, the ostium uterinum about 5 to 7 mm. (ft to ft inch). The length of the posterior uterine lip measures, from the fornix vagina to the free border, about 18 mm. (J inch)." The uterine cavity, under normal conditions, is a fissure bounded by two surfaces, the front and back, which touch each other. Above and at the sides the surfaces join in a sharp line whose contour corresponds very nearly with the border of the uterus. The shape of the cavity, therefore, in a transverse or perpen- dicular section, is simply a line (Fig. 4468); in frontal section of the body of the uterus it is three-sided, with a blunt point directed downward. In virgins all the sides curve strong- ly inward ; in multipart they are nearly straight. The blunt point marks the connection with the cer- vical canal. This canal is an oblong, four-sided space, with the sides bulg- ing slightly outward ; the lower side of this space coincides with the ex- Fig. 4471.-Palm® Plicatae of the Cer- vix Uteri. Opening of the crypts seen at the base of the folds. (AfterHenle.) Fig. 4469.-Vertical Transverse Section of Nulliparous Uterus. 1, Ute- rine cavity ; 2, 2, commencement of the Fallopian tubes; 3, cervical cavity or canal; 4, internal os uteri; 5, external os uteri; 6, anterior wall of the vagina showing the transverse folds or rugee; 7, anterior column of the vagina, (fimil Beau.) every variation in the amount of distention of the one or other must change its position. It seems to be a matter of accident, when they are evacuated, whether the intes- Fig. 4470.- Outlines of Moulds of the Uterine Cavity in Different States. (After F. Guyon.) Natural size. A, in a virgin seventeen years of age ; B, in a woman, forty-two years of age, who had not borne children ; C, in a woman, thirty-five years of age, who had borne children; b, cavity of the body ; c, that of the cervix; i, isthmus or os internum ; o, os externum ; t, passage into the upper angle of the Fallopian tube. (After Quain.) 565 Vagina, Vagina, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. uterus is smooth ; that of the neck is divided into three portions-a narrow rim at the upper and lower border, which is smooth, and a middle portion, which has a wrinkled appearance. These wrinkles are called palmae plicatse.* They are comb-like projections of the mucous membrane, and cannot be spread out by stretching. They pass off to the right and left from two vertical ridges, one of which is situated in the anterior, the other in the pos- terior, wall. They are placed-one, the posterior, to the right, and the other, the anterior, to the left of the me- dian line, so that when the two walls are placed in appo- sition one fits into the other, and an outline of a cross section of the cavity is that of the letter tn. The folds often do not fit into one another, so that a section of the cervix shows open spaces. A considerable quantity of thick mucus also often lines the canal; this still further distends the open spaces (see Fig. 4471). The folds pass off from the central stem, like the branches of a tree ; the (Fig. 4471) lowest are nearly at right angles to the trunk, the upper at more acute angles, and the uppermost are nearly parallel to the stem. The trunk is a rounded ridge, the lower and more transverse branches are sharp and sometimes notched, and have their free border directed downward (Fig. 4472). The free border of the upper branches is convex, and projects into the uterine cavity. At the side angles of the cavity of the neck, where the two combs come to- gether, the branches sometimes separate Fig. 4472.-Portion of Cervix Uteri; enlarged nine diameters. (After Farr.) ternal os (ostium uterinum externum), the upper side with the internal os. The upper corners of the uterine cavity are the openings of the oviducts (Figs. 4469 and 4470). To the naked eye the inner surface of the body of the * Plic® palniat®; rug® penniformes; arbor vit®; lyra. Fig. 4473.-Uterus of a Young Virgin, dying during the Intermenstrual Period with the Posterior Wall removed. U, Body of the uterus; C, cervix'; VV. vagina; 00, ovaries ; TT, Fallopian tubes ; 1.1,1,1, sec- tion of the uterine mucous membrane; 2,2,2,2, section of the muscu- lature of the uterus; 3,3, Graafian vesicles; 4,4, corpora lutea. (ilmil Beau.) 566 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vagina. Vagina. and interlock with those of the opposite side. Toward the external os they become firmer, and join to form a net-work. The elevation of the combs may amount to 2 mm. inch) ; the number of the branches is in inverse ratio to their height. The free surface is also, as a rule, not perfectly plane, but has fine furrows which are visi- ble with a lens; only these are, in places, crowded to- gether so closely that their septa form a fine net-work. The wall of the virgin ute- rus, when emptied of blood, is 10 to 15 mm. (J to J inch) in thickness; after childbirth it may be as much as 20 mm. (f inch) in thickness. The muscular tissue forms by far the greatest part of the mass. The peritoneum is 0.05 to 0.06 mm. (s£0 to 4^0 inch) thick over most of its extent, but is somewhat thicker on the base. The mucous membrane which lines the body is, in ordinary conditions, from 0.5 to 1 mm. to A inch) in thickness ; during periods of special turgescence it may reach a thickness of 3.5 mm. inch). The mucous mem- brane of the cervix is 1 mm. (/s inch) or more in thickness. These different layers can usually be differentiated with the aid of the microscope alone. Sometimes the mu- cous membrane is thickened, and may then present a softer- looking appearance than it ordinarily does. Its color also varies in brightness. In a section of the body of the uterus the muscular coat is seen to be composed of three layers. The inner and outer layers are pale, and per- meated by fine vessels ; the middle layer is redder, and has great vascular openings (Fig. 4474). The outer layer is nearly as thick as both the others. It consists of two strata; an outer one, about 0.3 min. (/o inch) thick, of longitudinal fibres alone, under which is a stratum of regularly inter- laced longitudinal and trans- verse, or, rather, ring-formed bundles. Between these bun- dles are apertures formed by their crossing, which remain open. They are placed at tolerably regular intervals, and are occupied by vessels, for the most part veins ; their length corresponds with that of the longitudinal fibres. The diameter of the longitu- dinal bundles of this stratum amounts to from 0.03 to 0.05 mm. (g^o to soo inch). The longitudinal and transverse bundles are both notice- ably thicker in the deeper portions. The gaps for vessels are from 0.05 to 0.1 mm. to .inch) wide. The middle layer is also composed of crossed bundles of muscular fibres, but their regularity is disturbed by the vascular openings, which are surrounded by circular muscular fibres. The innermost layer is quite different from the others. The vessels are finer than in even the outer layer ; bun- dles of fibres cross one another in the most diverse ways, but approach continually the transverse direction. In this layer we find for the first time connective tissue, though in very small quantity. The inner layer also differs from the others by the smaller size of its muscu- lar fibre cells, the nuclei having a length of 0.006 mm. inch) and a breadth of 0.003 mm. inch). Immediately underneath the mucous membrane is a layer of longitudinal muscular fibres, 0.04 mm. (^^ inch) thick, from which isolated bundles pass up be- tween the glands (Henle). At the upper angles of the uterus the muscular fibres surround the oviduct in a circular direction. The oviduct passes through the muscular coat, retain- ing its individuality the whole distance ; it is connected loosely with the uterine walls by a little connective tis- sue which allows a small amount of independent move- ment. Toward the cervical portion the muscular coat di- minishes somewhat in thickness, and the direction of the fibres becomes less complex. They are here arranged in three layers ; the middle layer being composed of circular fibres, while the outer and inner layers are com- posed of longitudinal fibres. The longitudinal layer of the anterior side passes into a number of lamellae which partly lose themselves in the firm connective tissue of the urethra and vagina, and partly continue in the mus- cular layer of the vagina. The longitudinal fibres of the posterior wall radiate in the posterior uterine labium. The circular and inner longitudinal layers continue down to the external os. The inner longitudinal layer has a thickness about equal to that of the other two, even down to the exter- nal os ; there its fibres become lost among the circular fibres. From the posterior lip longitudinal fibres ascend to the transverse fold of peritoneum behind the uterus. The investigation of the microscopic structure of the uterine mucous membrane is attended with great diffi- culties, so that, even yet, writers arc by no means agreed in all points. The weight of opinion, however, seems to be that the body is lined with ciliated epithelium ; the cells, seen in a section perpendicular to the surface, are short, stout columns with granular contents and a large round or oval nucleus, situated in the centre. The top of the cell has a thick membrane or lid, marked with perpendicular striae somewhat like those of the cells of the small intestine, and is crowned with short cilia. These cells vary greatly in breadth, the larger ones being of nearly double the width of the narrow ones ; the height of the cells varies : 27.8 to 39 ^(yuo to inch) (Over- lach). Henle says, 0.03 mm, (g^ inch) (Fig. 4476). The epithelium rests upon a soft tissue which resem- bles that of the lymphatic glands and makes up the re- mainder of the mucous membrane. Its principal ele- ment consists of thickly crowded nuclei, from 0.006 to 0.008 mm. (t^o to inch) in diameter ; some of these are surrounded by a narrow cell-structure which may assume the form of rhombfc plates. The glands of the mucous membrane, and the blood-vessels which pene- trate it, are surrounded by one or more layers of these plates ; sometimes the plates are drawn out into fibres (Fig. 4477). A fine granular mass fills the interstices between the nuclei. Henle states that he has occasionally succeeded in demonstrating a fine net-work similar to that of the lymphatic glands, but much less distinct. A fibrous network may sometimes be seen passing across fissures between the granules, or projecting beyond the bor- ders of the section. Henle considers this to be elastic tissue. The whole of the mucous membrane of the body is beset with glands which are at some distance apart. For the most part the glands are simple and tubular ; some- times they are divided into two or more forks at the bottom ; sometimes the division reaches nearly to the mouths of the glands. They may be tortuous, especially if the mucous membrane is thick, and sometimes they Fig. 4474.-Section of the Wall of the Uterus. 1, Peritoneum ; 2-7, muscular layers; 8, mu- cous membrane. (After Henle.) 567 Vagina. Vagina. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. are turned up at the lower end in the form of a shep- herd's crook (Fig. 4478). The glands vary considerably in size, but whenever the mucous membrane increases in thickness the glands in- removed it is seen to lie against the flat cells formed from the nuclei which have been mentioned. These cells take the place of a basement membrane, and increase in thickness with the size of the gland. The cervix, like the body, is lined with cili- ated prismatic epithelium, but it differs from that of the body in several important particu- lars. . The cells are taller and more irregular in height; the nuclei of the several cells do not form a straight line, but lie at any point along the height of the cell. It is not uncommon for the cells to have two nuclei; this never occurs in the body. A characteristic pecu- liarity is found in the shape of the cell, which is like that of a vase ; the top is broad and tapers ab- ruptly down to a neck from which it swells out to form the body. From this point it narrows to spread out again into a broad foot- plate. There is, however, great irregularity in the shape of these cells. The top is sometimes much broader than the remainder of the cell, sometimes it contains a nu- cleus. It has a thick upper border marked with perpendicular stria- tions similar to the striations of the cells of the body ; perhaps the cilia project through these stria- tions. The nucleus is found at any point in the body ; the thickest part of the body corresponds with the situation of the nucleus. The foot-plate is a peculiar feature ; it is so firmly at- tached below that it usually remains when the cell is torn off. The height of these cells varies from 42.7 p. to 82 jU to inch). The average is about 56.5 Gio inch). The breadth of the foot-plate may reach 27.8 m (wow inch). The cilia are about 8.34 (jiAnr inch) in length, but may reach 9.43 m inch) (Over- lach). The columnar ciliated epithelium at the lower bor- der of the cervix passes into stratified pavement epi- thelium. The exact situation of this tran- sition has not been accurately ascer- tained. In Overlach's case it coincided with the sharp border of the os externum. The external layers of this epithelium con- sist of large rounded polygonal cells, like those already described in the vagina. Under- neath this is the Mal- pighian layer, com- posed, at the bottom, of one layer of cubical cells whose height slightly exceeds their breadth. Above this is a thick layer of polyg- onal cells shaped like the cells of the surface, but they are somewhat thicker. These cells are connected together by prickles ; the cells of the basal zone are also connected together, as well as with those of the layers above, Ly prickles. It may be worth while to remark that the prickles of the different cells do not fit into one another like cog- wheels, as was formerly supposed, but consist of minute fibres which connect one cell with another. In these cells the prickles are unusually large. crease in a greater ratio than the mucous mem- brane, becoming more tortuous the thicker the membrane. In a mucous membrane of 1 mm. inch) in thickness the diameter of the glands amounts to 0.06 to 0.08 mm. to inch). In a mucous membrane of 3| mm. inch) they would be 0.12 mm. (?io inch). Occasionally the open- ing is visible to the naked eye, and the surface of the mucous membrane has a sieve-like appear- ance. Once in a while the glands touch one another, but, as a rule, they are placed at distances of 0.1 to 0.2 mm. (2^ to r|y inch) apart; this difference is en- croached upon when the glands are enlarged. The glands are lined, probably throughout their whole length, with ciliated epithelium which resembles that of the surface, although it is often not easy to demonstrate the Fig. 4475.-Superficial Muscular Fibres of the Anterior Surface of the Uterus. A, A, round ligament; B.B, Fallopian tube; 1.1, fibres starting from the round liga- ments, tubes, ovarian ligaments, and broad ligaments, passing first trans- versely and then upward or downward to join the longitudinal fibres, 2.2, ; 3,3, 4,4, show the changes in the direction of the transverse and longitudinal fibres, (fl mil Beau.) Fid. 4477.-Horizontal Section of the Mu- cous Membrane of the Body of the Uterus. 1, Cross section of a uterine gland ; 2, opening remaining after re- moval of glandular epithelium; 3, two glands in contact; 4, blood-vessel. (Af- ter Henle.) Fig. 4476.-Epithelium of the Uterine Body, from the surface. *, Uter- ine glands ; cilia not represented. (After Henle.) cilia at their lower ends. The cells are from 8.34 n to 22.24 /u (aoloo to -n1^ inch) in length, and from 8.34 /x to 13.9 (rohnT to inch) broad ; the length of the cilia is 5.56 /x inch) (Overlach). If the epithelium is 568 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vagina* Vagina. The structure of all these cells is peculiar ; all prob- ably contain vacuoles whose contents cannot be stained. The vacuoles often form a ring around the nucleus and divide the cell into two portions: an outer layer, and a thin layer which surrounds the nucleus and is connected with it by narrow bridg- es. The width of the outer layer often amounts to one-tenth the di- ameter of the cell. The vacuoles are always separated from the nuclei by a layer of pro- toplasm, which is sometimes so thin that it is with dif- ficulty detected. Henle denies that there are pa- pillae under the ciliated epitheli- um of the cervix, and asserts that the papillae which have been de- scribed in this lo- cation are only the misunderstood partitions be- tween two sacs. The subject has, however, been several times re- studied since his time, and their presence is still asserted. Over- lach describes two sorts: "Filiform and wart-like, or, better, fungiform papillae." Ac- cording to Over- lach the filiform papillae are found only on the raised portions of the palmae plicatae. They are to be d i s t i n g u i s bed from the folds of the mucous mem- brane by their epithelium ; this consists of low cylinders quite unlike the tall cells of the other parts. The stroma of the papillae con- sists of a thick mass of small round cells with relatively large nuclei and a thin layer of proto- plasm. The epithelial cells on these papillae are from 6 to 13.9 m to mSur inch) high and about 11.12 p. inch) broad, while the epithelium in the neighborhood is about 27.8 M (900 inch) in height (Overlach). Filiform papillae are not found either above or below the palmae plicatae. Below the palmae plicatae are seen occasional fungi- form papillae which are covered by the ordinary tall cells of the cervix. The stroma of these papillae is similar to that of the filiform papillae. In the lower region of the cervical portion, which is covered with stratified pave- ment epithelium, are abundant, slender, filiform papillae ; these are embedded in the epithelial cells. These papil- lae are for the most part simple ; they are about 0.2 mm. (T|s inch) in height and 0.02 mm. (tAo inch) in breadth. At the bottom of the folds of the palmae plicatae, and concealed by the projecting parts, lie one or more rows of fine round, or somewhat distorted, openings parallel to the folds. These openings are for the most part sepa- rated from each other by narrow bridges. Most of these openings have a diameter of from 0.3 to 0.4 mm. (/y to /o- inch); here and there occur greater ones, which deep down are separated by a partition-wall (see Fig. 4471). These openings lead into simple blind sacs which are not much wider than the entrance, and their thickness corresponds with that of the mucous membrane. These crypts are lined with a continuation of the long epithelium of the cervix ; " still they are also clothed with cylindrical epithelium (of 0.02 mm. in height) where the free surface bears pavement epitheli- um " (Henle). Whether these structures are to be considered as glands or only depressions of the mucous membrane, is a question. They are filled with the mucus which lines the canal, and in all probability the mucus is se- creted by the lining cells. But the lining cells of the free surface also secrete mucus. Overlach has de- scribed cells of the free surface filled with granules, some of them distended so as to form beaker-cells, some also in the act of extruding a granular substance and, occasionally, a nucleus. Cells are also sometimes seen which are hollowed out at their upper ends and have neither cilia nor cell-cover. Besides the crypts, two sorts of glands are found in the cervix : one resembles the uterine glands and ap- pears to be a direct continuation of them ; another is pe- culiar to the cervix. The latter " are glands with short, broad ducts like the tapering neck of a short flower-vase, with a large glandular space up to 1 mm. (^ inch) in width and with, for the most part, very many large round pouches " (Overlach). The epithelium of the first sort of glands is the short, regular, ciliated cell of the uterine glands, with the sur- face even and the nuclei all in a row. The epithelium of the second sort is the long irregular cell of the cervix, with its uneven surface and the nuclei placed at unequal distances along the length of the cell. The upper of the three divisions of the cervix is by far the richest in glands of both sorts. Overlach found fif- teen glands of both sorts in one square millimetre of this portion. The second portion of the cervix, that of the plicae palmatae, contains only the uterine glands. The glands are found in the folds alone, the portion between the folds being free from glands, except the above-men- tioned crypts. In the third portion of the cervix, below7 the plicae palmatae, both kinds of glands are found, but more spar- ingly than above. The cervical glands are smaller and simpler in this portion than above ; the uterine glands, however, have a wider opening. The glands disappear at the external os, and the vagi- nal portion of the cervix is destitute of them, the struct- ures which have been described as such being probably the crypts before mentioned, or sections of the blood- vessels-either of which might be easily mistaken for glands. The ovulae Nabothi are frequent, but pathological, structures. They are found scattered throughout the palmae plicatae, and are especially frequent on the inner surface of the uterine labia. They occur singly or in groups. They are round sacs, and average 0.5 to 0.3 mm. (/o' to /o inch) in diameter ; when of this size they lie Fig. 4478. -Section of Mucous Membrane of the Uterus from near the Fundus. (Adapted by J. C. Ewart, from a figure by J. Williams.) a. Epithelium of inner surface ; 66, uterine glands ; r, interglandular connective tissue ; d, part of the muscularis mucosa?, with the ends of the glands, some of which are entirely filled by epithelium-cells. This specimen was pre- pared from the uterus of a young woman who was accidentally killed three or four days be- fore the exj>ected appearance of the catamenial flow. (After Quain.) 569 Vagina. Vagina. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. concealed in the mucous membrane and can only be seen in section. Sometimes they are larger, when they cause a bulging of the surface. They are filled with mucus or a colloid fluid and are lined with ciliated epithelium. They are supposed to arise from an accidental closure of the outlet of the crypts of the cervix, although this is not certain. The blood-vessels of the cervix differ remarkably from those of the body. The vessels of the body are notice- able for their large size, together with their thin walls. The vessels of the cervix, on the other hand, are remark- able for the great thickness of their walls ; this is true of both arteries and veins (Fig. 4479). In vessels whose The isthmus is narrow and of nearly uniform diam- eter. It extends transversely across the pelvis in a nearly straight direction. The ampulla is much larger, and trumpet-shaped; it is curved first backward, then downward and inward, and ends on the posterior lamella of the broad ligament by an open mouth which is directed toward the ovary. Sometimes the ampulla is very tortuous, giving the free border of the broad ligament in this place the appearance of a ruffle. The open end of the ampulla is remarkable as being the only place in the mammalian body where a serous cavity connects directly with a mucous membrane. The length of the tube varies between 10 and 16 ctm. (4 and 6J inches).* The two oviducts are usually of un- equal length. The isthmus averages 2 to 3 mm.^ to | inch) in diameter. The diameter of the ampulla is 6 to 8 mm. (| to J inch) or more ; occasionally it is con- stricted, especially at the outer end. The calibre of the oviduct increases in the same way as the exterior, but more rapidly. The opening into the uterus will with difficulty receive a bristle. A uterine sound or the blade of a pair of*dissecting scissors may be passed into the abdominal end. The calibre of the isthmus remains uniform until it passes into the am- pulla, f The uterine end of the oviduct, as has been already mentioned, may be followed as an independent tube through the thick muscular walls of the uterus, almost to its termination (Fig. 4480). The abdominal end terminates in an expanded ex- tremity, the margin of which is deeply divided, forming a number of irregular flaps, called fimbriae. Some of these fimbriae are pointed at their extremities, some are rounded, most of them are notched on their borders. Sometimes the secondary flaps are perforated by round- ed or angular openings; they may even form a net-work. The fimbriae, when spread out, radiate from the centre like the petals of a flower ; ordinarily they lie folded to- gether in two layers. Their number varies greatly ; their size is nearly proportioned to their number. Their length is between 10 and 15 mm. (t to f inch). One of these fimbriae is often nearly double the length of the others, and is also distinguished by the great size of its secondary fringes. This fimbria, called by Henle, "fimbria ovarica," leads toward the ovary ; it passes along the free border of the ligamentum infundibulo- ovaricum, being connected with this structure by its peritoneal surface, and is usually attached to the ovary slightly within its extreme outer point. The fimbria is apt to be symmetrical, and a line drawn from the point of attachment would divide it in the middle. Sometimes the fimbria is hollowed out into a channel. In some cases the fimbria does not reach the ovary ; in that case, the free border of the ligamentum infundibulo-otaricum "resembles a mucous membrane; it is also furrowed and furnished with a row of rounded appendages, occa- sionally notched, which are similar to the secondary notches of the fimbriae. These extend themselves upon the upper surface of the ovary " (Henle). Only rarely is there an interval covered with serous membrane between the tip of the fimbria and the ovary. Sometimes a second pavilion is found on the oviduct; this usually occurs near the pavilion at the end of the tube, but they have been found as far as the middle of the oviduct. Often it is an opening in the side of the tube ; sometimes it is situated on a short duct. Richard 1 Fig. 4479.-Horizontal Section of the Mucous Membrane of the Neck of the Uterus ; showing cross sections of the thick-walled vessels and of the lacuna;-♦,♦. (After Henle.) cross section is 0.01 to 0.04 mm. (-oVu to inch), scarcely a third of this space is taken up by the opening. In arteries of 0.3 mm. (-/□ inch) the wall is 0.06 mm. (4I5 inch); in veins of 0.15 mm. (t|^ inch) it is 0.02 mm. (r/so inch) in thickness. This thickness is made up almost altogether of circular muscular fibres. The course of the vessels is also unusual in the uterine labia, especially in the internal muscular layer. The arte- ries, here, give off trunks, at tolerably regular intervals, which pass directly toward the mucous membrane ; cap- illary vessels arise from these which pass up close un- der the epithelium and send loops into the papillae. From these capillaries veins arise which follow the course of the arteries and penetrate to the deeper tissues. In the territory of the plicae palmatae, the general di- rection of the vessels is always perpendicular to the sur- face. All the reasons for this arrangement are not quite clear. It would seem to facilitate the great distention to which the cervix is subject during parturition. A great relaxation of these vessels would gorge the cervix with blood and enable it to swell up like erectile tissue. That the cervix is capable of such erection is known to most gynaecologists ; the os, which at one time is so small as to only admit a uterine probe, will, at another time, as the result of some excitement, admit the tip of the finger. It may be well to call attention to the course of the uterine and spermatic arteries which bring blood to the uterus and ovaries. These vessels, within the ligamenta lata, are very tortuous, sometimes even spirally twisted, evidently designed to accommodate the various changes in the size and position of the uterus. The oviducts, or Fallopian tubes,* are two tubes ex- tending from the upper lateral angles of the uterus to the right and left in the duplicature of peritoneum which forms the broad ligaments. They may be di- vided into two nearly equal parts. The first of these divisions, the one next the uterus, has been called the isthmus ; the second, or outer one, the ampulla. The tube, as a whole, increases in diameter from the uterine to the abdominal end. * " Of forty oviducts measured by Barkow (Anatom. Abhandl., Breslau, 1851. p. 42) three gave a length of (i to 7 inches ; twenty-five gave be- tween 4 and 6 inches ; seven gave 3 to 4 inches; five gave 2 to 3 inches. Among eleven cases which Bischoff noted (Ztschr. fur rat. Med., N. F., iv., 129) the longest amounted to 195 mm. (7% inches); the shortest, 110 mm. (42/s inches) ; the average, 160 mm. (62/6 inches)" (Henle). t " Meckel computes the width of the ostium uterinum at half a line, the width of the ostium nbdominale at from 3 to 4 lines. Krause esti- mates the width of the ostium uterinum at from >/B to >/4 of a line, and the widest part before reaching the ostium abdominale at 2 lines. Huschke thinks the last measurement may be as much as three or four lines " (Chrobak, Stricker's Handbook). Such measurements are very uncer- tain, however, on account of the deeply wrinkled condition of the mu- cous membrane, which gives no certain point from which to measure. * Tuba, tuba uterina sive Fallopise, cornu uteri, meatus seminarius, Mutter Trompete, etc. 570 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vagina. Vagina. describes a case in which the second pavilion had two openings which were separated by a valve of mucous membrane from the opposite side of tire tube, which inter- rupted the calibre of the same. If an ovum entered the external pavilion it must certainly pass out of the first of the openings of the second pavilion. A second pavil- ion is pretty frequent. Henle,2 it is true, found it only on one side in a single case, but Richard found it five times in thirty cases, and Merkle found it four times al- together. A cross section of the opening of the isthmus, which to the naked eye appears like a point, is seen under the microscope to be a star-like fissure. This star-like appearance is caused by a longitudinal folding of the mucous membrane. The mem- brane itself is composed of three layers : First, epithelium ; next, a membrana propria ; and, last, a layer of organic muscular fibres. The cells of the epithelium "are conical and ciliated, and be- tween them are wedged in spindle- shaped or inverted cells." " At the base of the folds there are more layers of epithelium than at their top " (Klein). Frey says that goblet-cells are not found here. The membrana propria is com- posed of a dense feltwork, the fibres of which, by. preference, take a longitudinal direction. The muscular-fibre layer has about double the thickness of the connective-tissue layer. The epithelial cells have a height of 0.02 to 0.03 mm. (-tAtt to sfio inch). The whole mucous membrane has a thickness of 0.35 mm. (Vtf inch). This mucous membrane is sur- rounded by a firm layer of circu- lar muscular fibres which is wThite and shining on a cross section of the tube. The layer is somewhat over 0.4 mm. (^y inch) thick. Outside of this, and distant from it, is a layer of longitudinal fibres; these sometimes penetrate the cir- cular layer. Ordinarily the cells of this layer are not easily sepa- rated ; during pregnancy this is done somewhat more easily. Outside the muscular coats is an adventitia of connective tissue, rich in vessels. Through this ad- ventitia run numerous longitudi- nal muscular fibres. The ampulla resembles the isthmus in the structure of the two outer layers, except that there passes inward from the layer of circular muscular fibres here and there a layer of longitudinal mus- cles. The mucous membrane of the ampulla is also a direct continuation of that of the isthmus, but differs from it by numerous and, in parts, very complicated folds, which cannot beobliterated by stretching. The simplest of these folds resemble, in cross sections of the ampulla, tall slender villi (Fig. 4481). They may be either pointed or slightly club-shaped, and vary from elevations just perceptible above the general surface of the mucous membrane to 2 mm. (-^ inch) in height. A number of folds close together might easily be mistaken for a series of glands. The central portion of this fold is filled by a continuation of the connective-tissue layer of the mucous membrane. In the thicker folds the connective tissue is more spongy than in the thinner ones. These simple folds run in a longitudinal direction ; besides them are other and more complicated folds which run in a transverse or oblique, as well as in a lon- gitudinal, direction. They vary greatly in height, and bear, on their sides, secondary folds. Sometimes the secondary folds bear other folds, so that a cross section of one of them resem- bles a trunk with vari- ous branches (Fig. 4482). Seen from the sur- face the folds resemble long ribs; they are often connected with other folds running in various directions, and form honey - combed spaces of various shapes and sizes, some- times not more than 0.05 mm. (5^ inch) in diameter (Fig. 4483). The folds vary a good deal in different subjects; sometimes they leave the calibre of the ampulla free, but more often they close it almost com- pletely. In many cases the folds of opposite sides interlock so that it is difficult, in sections, to tell where the folds originate. Sometimes one fold appears to have grown to another, or to the wall of the oviduct, so as to make a cylindrical cavity. Usually, however, a careful examination will show that the fusion is only apparent, and that the parts can be separated. In some cases, again,the fusion does occur and real cavities exist; whether these cavities are open at both ends has not yet been determined. They must, of course, be open at one end, or accumula- Fig. 4481.-Section of the Lower Half of the Ampulla. The folds lie against one another and interlock from opposite sides. 1, Mucous membrane; 2, muscu- lar layer; 3, adventitia. (After Henle.) Fig. 4480.-Sections of the Fundus Uteri, passing from the middle (A) to- ward the upper lateral angle of the uterus to show how the uterine cavity passes into the oviduct. *, Oviduct; **, sharp bor- der of the upper angle of the uterus passing into the oviduct. (After Henle.) Fig. 4482.-Section of a Complicated Fold of the Ampulla with Numerous Secondary Folds. *, *, Spaces within the folds. (After Henle.) tions would occur in them. These openings are cov- ered with ciliated epithelium, and must be carefully distinguished from other openings found in the sub- mucous connective tissue. The latter' openings are lymphatic structures, similar to those which are found in the submucous tissue of the intestinal canal. They 571 Vagina. Vagina. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. contain a mesh-work of connective-tissue fibres, in which are- found lymphoid corpuscles. Near the blood-vessels at the base of the folds, and within the latter, are also found canal-like spaces ; these run lengthwise through the spongy tissue, and branch and divide there ; they are probably lymphatic struct- ures (Fig. 4484). The blood-vessels of the oviduct are very abundant; the trunks in the larger folds are often much convoluted, tube. Many facts seem to support this view ; as, for in- stance, in a case which has been reported of permanent closure of one oviduct, and yet an ovum from the ovary on the same side as the closed oviduct still finding its way into the uterus. The structure of the tube, on the other hand, would seem to be such as to offer the greatest resistance to the progress of the spermatozoa and prevent their passage out of the abdominal end of the tube. The meeting place of Fig. 4483.-Horizontal Section of an Ampulla of the Oviduct with Sec- ondary Folds. (After Henle.) Fig. 4485.-Uterus and appendages of human foetus at term. (After Richard.) a'. Pavilion of the left side ; a, the same of the right side (below it in this specimen is the remarkable variety of two separate accessory pavilions. 6 and c); d, Fallopian tube, exhibiting numerous sinuosities in its outer half; f, round ligament; e, ovary. (After Farr.) and even spirally twisted. They are often surrounded by the spaces before mentioned. The mucous membrane contains a rich net-work of capillary vessels. During menstruation these vessels are very greatly engorged.* The ciliated epithelium of the oviduct is continued on to the inner surface of the fimbriae and over the fim- bria ovarica as far as to the ovary ; in only rare instances is there a break in the continuity. No glands are found in the oviduct; the structures which have been described as such are, in all probabil- ity. folds of mucous membrane. It is not quite clear how the ovum is brought into the oviduct. The old theory that the fimbriated extremity grasps the ovary at the time of extrusion of the ovum, and so receives it into the open end of the tube, has no facts to support it, besides raising the difficulty of accounting for the wonderful direct- ing power which is to place the tube on the right spot of the ovary at the the spermatozoa and ovum is probably nearly always in the ampulla. The accident of abdominal pregnancy is so rare be- cause the spermatozoa have such great difficulty in escaping from the tube. The vagina and uterus change at different periods of life. Some changes in the vagina have been mentioned. In infants the cervical part of the uterus is more de- veloped than the body (Fig. 4485). " In a child of three years, in whom the entire length of the uterus is fifteen lines, the cervix measures eleven lines, the body only four lines. These dimensions do not materially differ from the uterus in the first year of life, nor do they much exceed those of the same organ at birth" (Farr).3 In the foetus and during early infancy the uterus is curved forward in an arc of about a third of a cir- cle. This curvature di- minishes as age advances, but does not entirely dis- appear until after repeat- ed pregnancies. Often there is little change in the organ until near the time of puberty. The body gradually en- larges until it equals and finally exceeds the cervix. It is probable that the uterus continues to en- large slightly in well- nourished womeh for many years, even if they have never borne children (Fig. 4470). The cavity of the ute- rus in childhood is nearly an equilateral triangle, but as puberty approaches the w\alls of the body become thicker and encroach upon the cavity, giving to it the strongly incurved adult out- line. If the woman has not borne children, this peculi- arity also increases slightly as age advances. The lining of the uterus in infancy lies in folds some- what like the palmse plicatai. They gradually disappear on the approach of puberty. Considerable doubt still exists as to the microscopic structure of the mucous membrane of the infantile ute- rus. Wyder4 states that in children the uterus is lined Fig. 4484.-Cross Section of the Mucous Membrane of the Ampulla. *, *, Spaces resulting from fusion of the folds; **, lymph-spaces in the folds. (After Henle.) right time to receive the ovum as it is making its exit. A much more plausible theory would seem to be that of ciliary action. When we remember that the intestines lie in contact with these structures, and allow only a thin stratum of fluid aboye the cilia, we shall easily see that ciliary action would have a powerful effect in carry- ing along light substances and bringing them into the * This engorgement, however, occurs after the rupture of the Graafian vesicle. 572 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vagina. Vagina. with cylindrical epithelium without cilia as far as the external os. Nothing is known as to the glandular structure. The walls are composed of undeveloped muscular tis- sue ; they consist of granules and cells in various stages of development, from the round granular cor- puscle to the elongated fusiform cell - all of which are embedded in a semitransparent formless matrix. After the meno- pause, the uterus ret- rogrades. The body atrophies until, in ex- treme age, it is scarcely larger than that of a child. The cervix re- mains more constant, but still atrophies somewhat, and the lips become thin and leave a wider opening between them. When a vaginal examination is made, the finger is received into a funnel-shaped opening. The os lies at the bottom of this funnel and is diminished (see Fig. 4486) so as sometimes to barely admit a small probe. On section, the walls appear thin and the cavity of the body, like that of a child, is an equilateral triangle. Lester Curtis. 1 Quoted by Dr. Farr. Cyclopaedia of Anatomy and Physiology. 2 Handbuch der systematischen Anatomic des Menschen. 3 Cyclopaedia of Anatomy and Physiology. 4 Wyder: Beitr. z. norm. u. path. Histiolog. d. menschl. Uterus- schleimh., Archiv. f. Gynaek., Bd. xiii., Berlin. 1878. VAGINA, ATRESIA OF THE. This term is often made to embrace a great variety in the degrees of de- parture from the calibre of the normal vagina. It sometimes is made to include-though erroneously-the narrowed condition resulting from an imperforate hymen, or from a double membrane obstructing the external orifice of the vagina, one of them, usually the external one, being the hymen. Ruysch, who lived 1638-1731, mentions these forms, but they do not constitute true narrowing of the vagina. The term should be confined, in great measure, to that condition of extensive agglutination of the sides of the vagina to each other by which they are united in a more or less solid manner into one.1 Sometimes, as in Dr. Ogier's case,2 there is nothing but a small pouch having some appearance of a vagina, and an examination by the rectum and the bladder de- tects, between these organs, only cellular tissue. Sometimes occlusion is not altogether complete, and passages of greater or less extent lead from the exterior to the uterus.3 Again, there may be apparently entire absence of the vagina, but a careful dissection will reveal one commencing at a greater or less distance from the labia. Sometimes the uterus, although it exists, can be reached only through the rectum.4 Sometimes, after a tedious and painful groping, in cases of a closed or absent vagina, no uterus is discover- able. The appearance of the external genitals is no safe guide to the condition of the internal organs. Sometimes there is congenital absence of both vagina and uterus, with full development of the external organs of genera- tion and of the mammary glands. On the other hand, the uterus and its appendages may be in normal condi- tion without any external evidence of their existence. My first case, published in the Canada Medical Journal, is an illustration of this. Occasionally there is normal development of all the ex- ternal organs, except the breasts. This is contrary to the opinion expressed by some authors, that t]ie develop- ment, the tension, and- the pain in the breasts are the usual accompaniments of the non-appearance of the menstrual flow determined by a natural obstacle in the vagina or at the vulva.6 As there is every variety and degree of completeness to be met with in atresia, so are there various shades and degrees of inconvenience and suffering ; and also, at certain periods and within certain ages, are there various degrees of danger. But inconvenience or suffering, or even danger, bear no direct ratio to the greater or less completeness of obstruction. The site of the obstruction and its nature markedly influence these. Some females become aware at the age of puberty, if not earlier, of an abnormal condition of things ; while some pass through single and sometimes married life without suspicion of obstruction. Especially is this the case if, as sometimes happens, the menstrual fluid escapes through the ure- thra (Coste and others relate cases of this kind6) or in any other vicarious manner. There are many instances on record where the wife, the subject of atresia, sufferingly, but uncomplainingly, has satisfied the sexual wants of the husband ; and I am familiar with a case where a lady, of high social stand- ing in Montreal, the subject of complete vaginal atresia, lived in loving attachment with her husband for seven- teen years, and neither husband nor wife suspected the latter's inaccessibility. I saw the lady in question for some local trouble, when she had been a widow a few years. When she submitted to examination there was scarcely any appearance of a vagina, but a slight de- pression alone existed. When told her condition, " Oh," she exclaimed, with naivete, "veuve et vierge encore; mais, c'est charmant! " She assured me with unaffected artlessness that neither her husband nor herself sus- pected her to be different from other women. The marital act, she said, seemed to satisfy the husband, and for herself, she added : " Ce n'etait pas bien amusant, mais il faut que la femme se soumette a tout." Cases like these are exceptional. The maiden, as a general rule, gives early indication of obstruction, and coitus with the wife is early recognized to be impossible. Causes.-The causes of atresia are various. a. Want of development. In these cases there is either entire absence of vagina, the raphe being pro- longed from the rectum to the urethra without interrup- tion, or a sulcus, pouch, or depression marks the site of the vagina.1 b. Accidental closure from excoriation of the lining membrane of the labia. c. Vaginitis, the result of simple inflammatory action. d. Early intercourse when the sexual organs are im- perfectly developed. e. Too frequent sexual intercourse.9 /. A too violent approach of the husband, resulting in severe inflammatory action.10 g. Traumatic injury,11 cases of which are met with, from time to time, in the practice of the medical prac- titioner as occurring from injury upon the pommel or other protuberant parts of a saddle, cuts from sharp or blunt instruments, such as the rung of a chair, or from a broken chamber-vessel, etc. As atresia is not commonly discovered till the age of puberty, the condition has generally to be considered in connection with the menstrual function, or, may be, with the question of marriage, or perhaps its annulment. When a young girl with all the outward signs of health experiences menstrual molimina without any appearance of menses, notwithstanding the use of emmenagogues, and when these phenomena are repeated with more or less regularity, when there are pains in the loins and hypo- gastric region, shooting pains down the thighs, occasional difficulty in passing water, wTith a feeling of tension in the breasts, vertigo, epistaxis, etc., an examination should always be made, and when obstruction is found to exist, immediate surgical interference should be suggested. For however free some cases are from danger, yet are the risks of delay very great. Dr. C. H. F. Routh re- lates 12 a typical case where a strong, healthy girl, fourteen years of age, but looking fully twenty-five, had violent menstrual molimina every five wreeks. All the external organs were well developed, but there was no trace of vagina, except a sort of caecum about half an inch in depth. The space interposed between the bladder and rectum seemed only one-eighth of an inch in thickness. Fig. 4486.-Os Uteri in Old Age. (After Farr.) 573 Vagina. Vagina. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Separation was carefully effected with the handle of the knife and the finger. When the uterus was reached it was tapped and a very thick crimson fluid welled out. A large gum-elastic catheter was substituted for the can- nula of the trocar and left in situ. The patient died on the seventh day, and an autopsy revealed the existence of an excessive dilatation of one of the Fallopian tubes with blood, and rupture of the other, with extravasation of fluid into the abdominal cavity. Several cases of this kind are to be met with in the " Annals of Surgery." The dread of a fatal issue should not be permitted to prevent an operation, especially if a gradual increase of swelling exists in the hypogastrium. Death following an opera- tion cannot be fairly attributed to it, but to a long reten- tion of the menses. This opinion has been clearly ex- pressed by Langenbeck,13 whose views on the subject may be fairly considered to be those of the profession in gen- eral. Cases have been reported more than once of women with atresia of the vagina in whom the external organs were well developed ; the bladder and rectum free from all obstruction; the mammae plump and well formed ; and the sexual appetite not deficient; but when a pas- sage was made by means of laceration and division, and the normal site of the uterus was reached, that organ was found to be absent, condensed cellular tissue occupying its place, or sometimes the wall of the upper part of the vagina was found to be formed by the peritoneum.14 Cellulitis in the former instance, or peritonitis in the lat- ter, is not unlikely to occur, with or without operation. Sometimes, when the uterus is present, and when it can be reached by a trocar introduced in the usual direction of the vagina, or by the knife aided by the finger through a vaginal cul-de-sac, even after the menstrual flow has been established, the patient may ultimately sink under the effects of a constantly recurring pyrexia.16 Sometimes after an operation, an extensive sloughing takes place which jeopardizes the life of the patient. Some years ago I met with a case of that nature : A young girl, eighteen years of age, presented all the ap- pearances of retained menstrual fluid, and an exami- nation revealed a small cul-de-sac, less than half an inch deep, in the region of the vagina. By incision and lac- eration through the puckered bottom, the os uteri was reached at one seance, when semi-coagulated blood came away ; but the patient continued in a critical condition for upwards of two months, from the constitutional dis- turbance consequent on extensive sloughing of connective tissue. Yet, notwithstanding the untoward results which some- times wait upon surgical interference, recourse must be had to the knife. As under the head of vaginal atresia every degree of impediment is to be considered, so also, when surgical interference is decided upon, the operation must be re- garded, in some instances, as presenting but slight diffi- culty or danger, and in others as presenting grave diffi- culties, and a very great degree of danger. I have on more than one occasion, while groping my way to the uterus, through a channel of my own creation, regretted that it had fallen to my lot to disturb the abnormal con- dition of things, and even immediate success in reaching a hidden uterus has been purchased by many weeks of anxiety attendant upon slow and halting recovery. Still, as the danger of not operating is often very great ; as a distended uterus is a formidable complication ; as the Fal- lopian tubes will not readily allow much distention ; as peritoneal inflammation may be lit up by the distended tube, or worse still, by its rupture and the passage out- ward through its walls, or perhaps through its fimbriae, of retained but altered menstrual fluid, surgical interfer- ence becomes a necessity. There is another view of the question which must not be lost sight of: Atresia of the vagina is an impediment to marriage, and no female, the subject of it, has a natu- ral right to enter into the married state. It annuls mar- riage ; or, rather, marriage is annulled de facto. According to the Jewish code, a man has valid cause for divorce from his wife if cohabitation with her is ren- dered impracticable or dangerous, either by constitu- tional defect, atresia, or by dangerous disease. Indeed, an ecclesiastical court is, according to Jewish teaching, as stated by Rabbi Meldola de Sola, compelled to en- force divorce in such a case, even if the party directly interested does not sue for it. But if the person inter- ested formally declares, in the presence of witnesses, that he is willing to live with his wife without cohab- itation, the divorce is not enforced. Living, as the Jews do, in various countries in which their ecclesiastical trib- unals have no civil power, they bow to the law of the country in which they reside, so far as to permit Rab- binical authority to wait upon parliamentary decree, as expressed by the regular courts of the land. The vari- ous laws regulating cohabitation, marriage, divorce, etc. -with w'hich many Christian men might do well to make themselves familiar-have been codified in the Eben Ha-ezer, a w'ork not yet translated, I believe. In those denominations of Christians in which the mar- riage tie is considered binding for life, atresia annuls it. Even the Catholic Church, which has always taught in every country and in every age that marriage can end only with the life of one of the contracting parties, the female, the subject of atresia, is obliged in conscience to make known her defect to the ordinary, who, on a solemn statement of two medical men that without an operation the consummation of marriage is impossible, and that an operation is hazardous to life, declares that the female is at liberty to submit to, or refuse, an operation ; but that on her refusal the man is at liberty to leave her and marry another. This is the only instance in which di- vorce is permitted by the Church and the divorced is at liberty to marry, not again, for the first marriage is con- sidered null and of no moral force from the beginning. Operation.-It is well to state that the vagina is not a mere mucous tube, through which it is easy to pass the finger or a blunt instrument, nor is it a tough, resisting tube, wdiich may be handled roughly with impunity. It is a musculo-membranous canal " remarkable for its di- latability," extending from the vulva to the uterus, and placed between the bladder and the rectum. It is cylin- drical in shape, flattened from before backward, and its w'alls are, in the natural state, in contact with each other. It is slightly concave on the side facing the bladder, and convex on the opposite side, the anterior wall being shorter than the posterior. The former is about four inches in length and the latter between five and six inches. Its relations to other parts are important: the anterior and posterior parts are covered by the peritoneum in their superior half, and are united-the former to the bladder, the latter to the rectum, by dense cellular tissue. The lateral regions give attachment above to the broad ligaments, and below to the levator ani muscles and the recto-vesical fascia. The cavity of the vagina is cylin- drical, terminating at the uterus by a circular cul-de-sac and at the labia by the sphincter vaginae. The interior of the vagina presents, in addition to the usual appear- ance of a mucous membrane, numerous elevations and plicae similar in aspect to those met with in the interior of the stomach, or in the intestines in a state of contrac- tion. On the anterior wall, commencing immediately behind the urethro-vaginal tubercle, are the anterior columns, which gradually taper and disappear. The posterior column occupies a similar position on the posterior wall. These columns are crossed by eleva- tions or ridges, which are less numerous and less promi- nent in the vicinity of the uterus, and which follow different directions, but become more regular in the inferior half of the vagina. These rugae are divided by furrows which give the mucous membrane the appear- ance of being studded by conical elevations. " The two columns are not exactly opposed, permitting a kind of dovetail approximation of the antero-posterior surfaces, and so more effectually closing the vaginal canal."16 The mucous membrane of the vagina is continuous with the membrane of the vulva. Its color, at first red, after- ward becomes grayish, and in the superior portion of the vagina the latter shade becomes modified by the existence of small livid spots which impart to the inter- nal surface, in this portion, a slaty color which is not met 574 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vagina. Vagina, with elsewhere. In the sinuses of the mucous mem- brane are found follicles, which are the source of the fluid which continually lubricates the interior of this canal. The secretion of these follicles is diminished and after- ward increased by inflammatory action. The submucous tissue is very pliant, and contains venous plexuses. " It is possessed of a high degree of elasticity and extensibil- ity " (Gussenbauer). The vagina receives its nervous distribution from the pelvic plexus, and derives its ar- terial supply from the anterior trunk of the internal iliac.17 The capacity of the vagina varies with different indi- viduals, and varies with the age and condition in the same individual. Its degree of sensitiveness, in particu- lar, is not the same in all. Each vagina, as each male urethra, has its individuality, so so speak, which must be taken into consideration by the operator. In a given case, when an operation is decided upon, an incision is made into the cul-de-sac, or pouch, if one exists, or into the perineum wdiere the vagina should be, and gradually, partly by incising, partly by tearing, a pouch more or less deep is created. The deepening of this pouch is continued in the same way, and a rectal bougie, or compressed sponge cut into proper size, pre- serves the patency. My earliest case was performed almost entirely by the knife. The haemorrhage was alarming. Subsequent cases have satisfied me that, after the first incision in the perineum, the greater part of the work can be continued with the finger and the handle of the knife. Most important is it that, when the vagina exists but when its sides have coalesced, the passage should be made between, and not outside of, the walls of the vagina, an accident which I have known to occur in the hands of a brilliant but impatient surgeon. The anterior wall of the rectum has been mistaken for the posterior wall of the vagina. I have now in my hospital a lady, through the anterior wall of whose va- gina a surgeon's knife made entrance into the bladder, the posterior wall of which had been mistaken for the an- terior wall of the vagina. Should an attempt be made to reach the uterus at one seance, or is it more prudent to carve the way gradually ? I am satisfied that where it can be safely done the former is often preferable. Dr. Routh, of London, seventeen years ago, claimed to have been the first to have formed a vagina, and tapped the uterus at one sitting.18 That pretension is seemingly disputed by Dr. Thomas Addis Emmet, of New York, who claims to have originated the plan of completing the operation of vaginal restoration or formation at one sitting ; of freely separating the tis- sues by passing the finger from one side to the other in the pelvis ; to have given free exit to the retained menses ; and to have washed out the uterus with warm water, to prevent blood-poisoning.19 But there are cases in which it would be almost im- possible to reach the uterus at one sitting. It is better, under such circumstances, to work gradually, preserving after each seance the patency gained. These cases, however, are not numerous. When the vagina is formed, means must be taken to preserve it, and this is troublesome in direct ratio to the difficulty of creating it. Sometimes bougies are used ;• sometimes a glass plug; sometimes, a Barnes's dilator. But the best means in each case will readily suggest themselves to the practical surgeon. When the uterus is reached, and is found to be imper- forate, should it be opened at once, or not until it is more or less swollen with the menstrual fluid ? Richet20 mentions the latter approvingly ; but the plan pursued by Emmet, of completing the operation at a single seance will find more followers. I have adopted a middle course, completing, when practicable, all that pertains to the vagina at one seance, and after a time, when its patency is assured, opening into the uterus. It is well, however, to bear in mind that even after successful restoration of the vagina and uterus to a nor- mal state, the menses may remain absent. Is the vagina formed by knife and finger and bougies likely to remain patent, so as to render coitus easy and painless ? In those cases which are the result of inflam- mation of the. labia and vagina, following protracted or instrumental labor, where bands of firm membrane ex- tend along or across the vagina, it is more or less prob- lematical. In congenital cases, however, there is greater probability of the patient being able to fulfil the duties of married life without difficulty, and often without suffering. In a case to which I have already alluded, where occlusion was complete, the patient subsequently was married, but not until a mucous canal, much like the normal vagina, and which permitted easy coitus, had been formed. In that instance the husband was never informed that the knife had preceded him. As a meas- ure of prudence it is advisable that the marriage state should not be entered upon until permanent patency of the vaginal inlet may be expected. Nor should any operation be undertaken in the married female wdthout something like a certainty of the non-existence of preg- nancy-even where physical impediment on the part of the female to the marital act is seemingly complete. I once assisted at an operation-undertaken at the urgent solicitation of both husband and wife-for the relief of atresia of the vagina, where coalescence of its walls was so complete and so firm that great difficulty was experi- enced in reaching the uterus by a channel which seemed to be the creation of the knife alone. Yet spermatic fluid had evidently preceded-and six months subse- quently a child, at full term, was ushered into the world to assert its existence prior to, and independent of all art ; and at the same time, happily, to prove that it had not been disturbed. Pregnancy in that case, was not, and could not have been suspected. Wm. H. Hingston. 1 De Haen: Ratio Medendi, quoted by Sabatier: De la Medecine Ope- ratoire, t. i. 2 American Journal, October, 1869, p. 585. 3 Transactions of the Obstetrical Society of London, vol. iv. * Op. cit. 5 Bulletin de Therapeutique, Juin, 1845, p. 223. 8 Journal des Connaissances Medicales, in Medico-Chiiurgical Review, vol. xxv., new series, p. 526. 7 Op. cit. 8 Loc. cit. 9 American Journal of the Medical Sciences, October, 1853, p. 365. 10 Op. cit.. January, 1853, p. 86. 11 Numerous cases. 12 Transactions of the Obstetrical Society of London, vol. xii. 13 Langenbeck's Bibliothek, vol. iv., part 3. 14 Medico-Chirurgical Review, vol. xviii., p. 449. 16 Ibid,, vol. xxxii., from Bulletin de l'Academie. 18 Condensed from' Savage. Anatomy of Female Pelvic Organs. 17 Loc. cit. 18 Transactions of the Obstetrical Society of London, vol. ii. 19 American Journal, October, 1878, p. 490. 20 Traite d'Anatomie Chirurgicale, p. 852. 21 Lauverjat: Nouv. meth, de pratiquer Foperation cesarienne. De la Motte: Traite complet des Accouch., 627-33. Velpeau: t. 2, p. 211, etc. VAGINA, CONGENITAL MALFORMATIONS OF THE. Development of the Vagina.-A knowledge of the mode in which the vagina is developed is essential to a proper understanding of its congenital malformations. The lower portions of the two Mullerian ducts coalesce to form the vagina, and by the ninth week of embryonal life the intervening septum disappears, and this union is complete, although the appearance of the cervix and the differentiation of the genital passage into uterus and vagina cannot be said to take place before the fifteenth or sixteenth week. In the nineteenth wreek of foetal existence a slight projection of mucous membrane makes its appearance on the posterior wall of the en- trance to the genitalia, just above the point of union of the vagina with the uro-genital sinus, and a little later a smaller projection at a slightly higher level may be seen on the anterior wall. These elevations subsequently unite laterally, and thus form the hymen, which, by the twentieth week, is fully developed. Varieties of Congenital Malformations.-The vagina may be entirely absent ; it may be more or less completely closed by a transverse, or divided by a longi- tudinal, septum ; though not seriously misshapen it may still be too short or too narrow ; or it may communicate with cavities from which it should properly be separated. There are yet other errors in development, which are. however, of less import. A. Absence of the Vagina.-When there is total failure in development of the lower .portions of the ducts of 575 Vagina. Vagina. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Muller the vagina is entirely absent, and only a thin septum intervenes between the bladder and the rectum, in which some little connective tissue, but no muscular elements, are discoverable. A fibrous strand or cord may, however, indicate the situation which should be oc- cupied by the vaginal tube. When the Mullerian ducts are developed, except at their very lowest extremities, or are not prolonged downward far enough to open into the a d i t u s uro-genitalis, then only the most in- ferior portion of the vagina is wanting. Absence of the vagi- na is usually associated with someother marked mal-development, such as absence or a rudi- mentary condition of the uterus. The condi- tion of the uterus will determine the existence or non-existence of re- tained fluids. In absence of the vagina the urethra is found to be abnormally relaxed. If there is haemato- metra, an operation de- signed to create a pas- sage where the vagina should be located is imperative, and even when only a very rudi- mentary uterus can be discovered, and there is no retention, the gen- eral health of the individual is often markedly improved after operative interference is instituted, and the uterus has been known to take on active growth. When there is sufficient space between the bladder and rectum, a vagina can be made by stretching and tearing the intervening tissues with the finger, aided by the use of blunt-pointed scissors, if great resistance is encountered. A sound in the urethra, and the finger of the operator or of an assistant in the rectum, are useful guides. The operation should be completed at one sitting, and the passage should be made larger than it is thought desir- able to have it subsequently remain. Undue contraction is prevented by the use of a vaginal plug of glass, and the cicatricial tissue which forms over it is said to resemble very closely normal mucous membrane. When the uterus is well developed, and there is reten- forms a sac filling the pelvic cavity. The uterus at first is undisturbed, and rests upon the summit of the dis- tended sac. Ultimately the cervix, and even the uterus, if no outlet is found below, become dilated. The tubes likewise suffer, but the blood discovered in them is by some not regarded as an overflow from the uterine cav- ity, since the uterine ends of the tubes are often closed, and the blood is located in small diverticula or sacs near the fimbriated extremities, and is said to originate in haemorrhages from the mucous membrane of the ovi- ducts themselves. The blood may, however, subse- quently escape into the peritoneal cavity from the fimbriated ends of the Fallopian tubes. Atresia Vaginalis.- In atresia vaginalis the obstruction (or obstruc- tions, for there may be several, located one above the other, and separated by layers of different kinds of re- tained fluid) is generally found in the lower third of the vagina. T h e thickness of the atresia varies in different cases, and whatever may have been its original di- mensions, pressure from the fluid accumulation above produces some- times a remarkable de- gree of thinning. Thus the obliteration may be 1.2 inch thick, or of membranous-like delicacy. In atresia vagi- nalis, however, we do not find the elasticity and disten- sibility met with in atresia hymenalis. The occluding membrane, made up largely of connective tissue, is of a firmer texture and greater thickness, and yields less read- ily beneath the superincumbent 'weight. As a result of this, the lower part of the vagina and the vulvar orifice are seldom dilated, and the former is not uncommonly narrow and cone-shaped, although attempts at coition may materially modify its shape, while the occluding diaphragm viewed from below may appear quite flat. It is very important, in view of proposed operative in- terference, to ascertain the seat and thickness of the oc- cluding membrane, and this is best done by the various combined methods of examination, a catheter or sound placed in the bladder being employed to assist the finger in the rectum or vagina. Above the obstruction, as in atresia hymenalis, mucus or blood accumulates. The seat of the atresia, and the activity and fre- quency of the menstrual function, determine largely the quantity of the accumulated blood ; but, as has been pointed out, nature, discovering an obstacle to escape, retards in some way the amount of blood effused, so that it is never as great as one would expect to find it, considering the number of periods that have occurred, and is always less in con- genital atresia than in the acquired condition. It is probable, also, either that the uterus is in an immature and inactive condition, or else that the fluid elements of the accumulated blood have been largely absorbed. The peculiar characteristics of the retained liquid would seem to support this last assumption, for it is found to be dark reddish-brown in color, and of a thick, tenacious consist- ence, the mucus mingled with it preventing coagulation. Microscopically it is found to contain shrivelled blood- corpuscles, and extravasated blood-pigment, with flat epithelial cells, mucous corpuscles, and granular debris. As in atresia hymenalis, the genital tube above the point of obstruction dilates as the retained fluid accu- mulates. At first the vagina, then the cervical canal, and Fig. 4489.-Atresia Hymenalis. (Hart and Barbour.) Fig. 4487.-Absence of Vagina with H®m- atometra. a, Closed os externum ; b, os internum. Fig. 4488.-Glass Vaginal Plug. (Hart and Barbour.) tion, but no vaginal passage can be formed, Battey's operation may be indicated. B. Atresia of the Simple Vagina.-In this condition the occlusion of the vagina is absolute. The obstruction may be seated at the hymen-atresia hymenalis, or at some point within the vagina proper-atresia vaginalis. Atresia Hymenalis.-Atresia hymenalis is the most common variety of vaginal atresia. The duplicature of mucous membrane constituting the hymen here forms an obstruction, which, although thinner and more elastic than the atresias situated above in the vagina, yet may be considerably thickened and of almost cartilaginous toughness. As menstrual blood accumulates, the hvmen bulges downward, and the vagina dilates above, until it 576 Vagina. Vagina. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. finally the uterine cavity become filled and expand often to a remarkable degree ; the distended vagina will, how- ever, always constitute the major part of the tumor. If the liquid is mucus, the conditions known respectively as hydrocolpos and hydrometra develop ; if blood, then the terms hsematocolpos and haematometra are employed. Fortunately, the walls of the dilated portion of the va- gina, although overstretched, do not become thinned. On the contrary, they hypertrophy, especially their muscu- lature, and the condition known as " excentric hyper- trophy " is thus developed. The vaginal walls internally may be thrown into folds although the sac be greatly distended. Occasionally, in new-born children, the folds of mucous membrane on opposite walls of the vagina become united, forming a thin, transparent diaphragm, which soon ruptures spon- taneously, and is seen no more. The origin of the obstruction in atresia hymenalis has been variously explained. It is said that the fusion of the lower ends of two solid Mullerian ducts will produce this abnormality, or that there may be an overgrowth of the fold of mucous membrane which constitutes the hy- men and a union of its free edges toward the centre of the ring. Foetal inflammation may likewise produce an agglu- tination of these same free edges after the hymen has been com- pletely formed. Numerous hy- potheses have likewise been ad- vanced to explain the origin of atresia vagi- nalis. Either the lumen of the vagina at some point has never been established, as when the Mullerian ducts as solid cords have united, but have failed to become hollowed or tun- nelled at the point in question ; or else, after a nor- mal formation of the vagina by proper coales- cence and perfo- ration of these ducts, its walls, for a variable dis- tance, become united one with the other, as the result of an in- flammation dur- ing intrauterine life. And further, the idea has been suggested that, in cases where there is but one septum, the canal above the septum may belong to one Mullerian duct, and that below to the other. In explanation of the fact that atresias are most often seated in the lower third of the vagina, it should be borne in mind that the walls of the vaginal tube are very closely approximated just above the seat of the hymen, and agglutination is thereby rendered easy. Atresias of the vagina are important only as interfer- ing with menstruation and coition. . Hence, although exceptionally before puberty these occlusions may give rise to inconvenience or suffering (as in certain cases of profuse secretion of mucus and the formation of a hydro- colpos, a condition rarely of significance in adults), yet in the majority of cases it is not until the establishment of the menstrual function, and, more rarely, when graver rudimentary conditions exist and the catamenia do not appear, not until after marriage, that symptoms mani- fest themselves and a physician is consulted. Certain well-known general conditions may likewise postpone the ushering in of the first menstrual period, and then if an accumulation occur it will be of mucus and not of blood. In atresia of the hymen or of the vagina proper, when puberty arrives the usual disturbances which precede and accompany the catamenia are noticed, but there is no discharge. At the time of the next period these disturb- ances are somewhat accentuated, and, as the fluid accu- mulates, gradually change to suffering, which is expe- rienced now during the inter-menstrual period as w'ell. The tumor produces pain and a feeling of weight in the pelvis, and by pressure or traction upon the bladder and rectum interferes with micturition and defecation. There is sometimes, too, no little constitutional disturb- ance. The amount of fluid and the consequent size of the tumor determine in large part the intensity of suf- fering, which is also influenced by the general condition of the patient. Usually, after menstrual molimina have been noticed for three successive months, a tumor begins to be appa- rent, although it may not be noticed until a much later period, and this swelling gradually enlarges until it bulges at the vaginal inlet and causes a perceptible in- crease in the size of the abdomen. Certain conditions previously described may however, retard its develop- Fig. 4490.-Atresia Vaginae-Lower Third, oi, Os internum ; oe, oe. dilated os externum ; c, dilated cervical canal; v, vagina ; s, loca- tion of the atresia. (Hart and Barbour.) Fig. 4491.-Excentric Hypertrophy. (Hart and Barbour.) ment, and the sac may never attain very great propor- tions. If menstruation has never appeared and the accumula- tion of mucus has not been excessive, it may be that futile or unsatisfactory attempts at intercourse first re- veal the existence of an atresia. Yet if the atresia be elastic or high-seated, repeated efforts at cohabitation ultimately form a fairly roomy canal, or, if the dia- phragm be low or unyielding, intercourse may be car- ried on through the urethra or anus. It is extraordi- nary how greatly the urethra may become dilated under these circumstances, and it is still more singular that in- continence of urine so seldom results. Occasionally sterility first induces a patient to seek medical advice. Spontaneous rupture of the occluding membrane and evacuation of the retained fluid are rare in both forms of vaginal atresia ; they occur in only one per cent, of cases of atresia vaginalis. And, indeed, although a source of temporary relief, this natural effort at cure is of some- what questionable value. Pyo-colpos and pyo-metra almost invariably result, and the danger to the patient is, if anything, aggravated. Yet if spontaneous perforation does not occur, and no surgical procedure looking to the emptying of the sac is instituted, the outlook is extreme- 577 Vagina. Vagina. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ly unfavorable. Rupture of some portion of the dis- tended genital tube, or of a blood-sac in the oviduct, is almost sure to occur, or else without rupture a grave peritonitis may develop. The symptoms observed at puberty, and repeated periodically afterward, which have already been de- tailed, are quite characteristic, and, with the accompany- ing physical signs of a gradually increasing retention- tumor, leave but little doubt as to the diagnosis. It is true that amenorrhcea and abdominal enlargement may, and sometimes do, give rise to the impression that preg- nancy exists, but this is rapidly dispelled by a local ex- amination and a careful inquiry into the history of the case. In view of the serious nature of the malforma- tion in question, the physician is justified in insisting at least upon an examination of the rectum and ab- domen, if not of the genitals, in all doubtful cases. And this examination should be undertaken early and be performed carefully; for although the recognition of a vaginal atresia is a matter of no great difficulty, yet it is not always easy to determine the exact seat, and more especially the thickness of the obstructing membrane, which are matters of great importance when surgical interference is attempted. The various combined manual and digital methods of exploration are the means generally employed, and a sound or catheter of some resistant material, placed in the bladder, often assists in arriving at a definite opin- ion. In children the persistence of dysuria may, after simple remedies fail, suggest the necessity fpr an exam- ination ; and in adults dyspareunia and sterility, in a case where menstruation has never occurred, likewise require investigation. To differentiate between atresia hymen- alis and atresia vaginalis is not always so easy as one would suppose. In atresia hymenalis, if there be retention, the sac distends the perineum and protrudes from the vulvar orifice. The obstruction in atresia vaginalis is thicker and less elastic, and there is not so much likelihood of distention of the lower vagina and separation of the vul- var fissure ; but if it be seated, as is usual, in the lower third of the vagina, the sac may bulge through the geni- tal outlet, the hymen being seen adherent to it like a fringe. However, in atresia vaginalis the lower part of the vagina is often narrow and cone-shaped, and the diaphragm itself may appear flat. Atresias of the vagina which are located at a higher level are more difficult to delimit accurately, but are less likely to give rise to con- fusion with imperforate hymen. It is not always easy in a given case to decide whether an atresia is congenital or acquired. Even in children injury and subsequent inflammation of the vagina may produce occlusion, although stenosis, rare as a congeni- tal condition, is more likely to result. The existence of a rudimentary state of other portions of the genital apparatus, and the absence of tissue ir- regularities, cicatricial bands, and the remains of de- structive inflammation, point to the congenital nature of the affection-. Atresia of the hymen is very rare as an acquired condition. The prognosis, in cases of vaginal atresia with reten- tion, is almost without exception unfavorable, and this is especially the case when the fluid consists of menstrual blood. Where nothing is done, a fatal termination is invariably to be expected, through rupture of some part of the sac, or as a result of septic infection or peritonitis, independently of rupture. If perforation of the occlud- ing membrane and evacuation of the cavity do occur, pyo-colpos and pyo-metra follow with rare exceptions, and the danger to the patient, though less imminent, is hardly less certain. Even in spite of the most active treatment, the existence of a large sac secreting pus, which often is in free communication with the peritoneal cavity, is a constant source of apprehension, and a ter- mination by no means favorable is to be anticipated. In every case of atresia with retention it may be safely said that surgical intervention is urgently required. But even this is not free from danger or difficulty. For immediate rupture of a blood-sac in the Fallopian tube may introduce a complication of the greatest gravity, or septic peritonitis may subsequently develop. In atresia hymenalis an operation is likely to be followed by a better result than in atresia vaginalis. While the greater number of the congenital malforma- tions of the female genitalia appeal only to the student of development and of pathological anatomy, vaginal atresias possess great clinical interest and are of the ut- most practical importance. It is true that in a certain proportion of cases of vaginal atresia relief is sought be- fore puberty is reached, and in other instances not until sexual intercourse proves to be difficult or impossible, and conception fails to occur; yet in the majority of cases of atresia, where suffering follows the establish- ment of the menstrual function and is dependent upon retention of the menstrual fluid, surgical intervention is urgently demanded. Almost without exception the con- dition of the patient is not recognized until this time, or else the obstruction could be divided before stasis had begun or before it had become considerable. The most satisfactory results are to be looked for when an opera- tion is undertaken w'hile there is yet no haematometra. Although the methods of operating vary according to the nature of the obstruction and the taste of the op- erator, yet the indications are always the same. In every case an opening must be made through the occluding tissue, (at a time midway between the two menstrual periods), sufficiently large to permit the free egress of the retained fluid, and this opening must be maintained in order that the sac may be thoroughly emptied and kept empty. In atresia without retention the same general plan of procedure is necessary, so that the vaginal tube may be kept sufficiently patulous to offer no obstacle to intercourse, conception, and delivery. Hymeneal atresias may be incised or punctured, and the opening thus made can be immediately or subsequently enlarged with the linger. Atresias of the vagina which are simply due to an ad- hesion of its w'alls are sometimes easily broken down, with the finger alone or with some blunt instrument. But if the atresia is due to a pronounced rudimentary condition of the genital canal, bloodless dilatation is hardly possible. In such cases the obstructing tissue must be carefully and slowly divided with a knife, or, preferably, with blunt-pointed scissors and the finger, a silver catheter guarding the urethra and bladder, and an assistant's finger the rectum, until the retention tumor is reached. Breisky, of Prague, w ho minutely describes the method of operating in high vaginal atresias, accom- panied perhaps with atresia of the cervix, advises that as soon as the sac is encountered it should be punctured opposite the site of the cervix, or if this cannot be found, at the lowest part of the vault of the tumor, with a long- handled lancet-shaped knife, the blade of which is sur- rounded and protected by a cannula. As soon as the blade has been projected from the cannula into the tumor, and the opening has been enlarged laterally, the knife is withdrawn and the cannula is pushed for some distance into the sac. The blades of a dilator, especially designed for this purpose, are next introduced alongside of the cannula, and the opening into the tumor can be enlarged in any direction, to any extent, or with any degree of rapidity that is deemed desirable. After this dilatation a German-silver tube is introduced to serve for drainage, and likewise for the introduction of antiseptic fluids, and the dilator is removed. Whatever form of drainage-tube is employed, it should always be of some resistant ma- terial, and should be provided with large fenestrations. As the walls of the retention tumor subsequently contract, a tube smaller than the one first used should be substi- tuted. Although this mode of operating is based upon sound principles, and is intended to prevent any injury being done to the surrounding hollow organs and peritoneum, to enable the surgeon to control the rapidity of the escape of the retained fluid, and to maintain after the operation a free communication with the sac, yet it is quite prob- able that the same results could be achieved without the aid of the special instruments described, and with a greater degree of simplicity in manipulation. 578 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vagina. Vagina. The prognosis in cases of neglected vaginal atresia is unfavorable, nor is a more hopeful issue always to be anticipated after operation. Like many other gyneco- logical procedures the danger here is out of proportion to the magnitude of the operation itself ; for even punct- ure of a thin hymeneal septum may be followed by a fatal result. The untoward accidents which may accompany or fol- low measures instituted for the relief of atresia vagina- lis are : 1, injury of neighboring organs or of the peri- toneum ; 2, rupture of tubal blood-sacs ; and 3, septic infection. The first of these dangers is not to be anticipated in operating upon the imperforate hymen or upon vaginal atresias of moderate extent, but where there is a con- siderable defect of the vaginal tube, and the atresia is broad and deeply seated, it requires the greatest care, es- pecially when sharp-pointed instruments are used, to avoid wounding the urethra, bladder, rectum, or peri- toneum. Rupture of the tubes may follow operative interference in even the simplest forms of vaginal occlusion. The Fallopian tubes, distended with blood, or containing di- verticula, or sacs filled with blood, are very prone, when the menstrual function has been established for some time, and there has been considerable retention, to form adhesions with surrounding tissues or organs. When the retained fluid is evacuated, and the distended genital canal collapses and contracts, great traction is exerted from below upon the fixed, thinned, and friable tubal wall, and rupture is very apt to occur. Increased pres- sure of the abdominal walls, blood forced by uterine contractions into the tube, and even contractions propa- gated from the uterine to the tubal ■wall, are said to in- crease the probability of this untoward accident. Rupt- ure of the tube is a most unfortunate complication, to prevent which efforts have been made to alter slowly the size and position of the overfull uterus and vagina by withdrawing the fluid gradually through a small trocar puncture, or by several successive tappings. It is cer- tainly wise to proceed slowly, and to withdraw the greater part, if not all, of the retained fluid through a small opening, which is to be enlarged after evacuation is com- pleted. In this way changes in pressure occur slowly, and the genital canal has adequate time to adapt itself to its new position and surroundings. But the entire opera- tion should be concluded at one sitting, or otherwise, while avoiding rupture of the tube, we court danger through septic infection, and subsequent disintegration of the tubal walls may occur as a result of this process. Brei- sky suggests that in some cases it might be wTell to per- form abdominal section and remove the hsemato-salpinx, or incise and drain it, if such is known to exist, before the operation upon the atresia is attempted. Septic infection, the third of the complications already mentioned, may be caused by absorption from the divided surfaces of the atresia, and the actual cautery and gal- vanic current have been used instead of the usual cutting and puncturing instruments in order to obviate this dan- ger. But such an origin is somewhat questionable in view of the greater liability of the contents of an incom- pletely emptied sac to undergo decomposition, and the much greater importance which this factor assumes. It is septic decomposition and absorption which increase so signally the risk of repeated punctures and gradual evacuation. Emmet long ago showed the fallacy of this procedure, and the principles which he then urged upon the profession have now been accorded universal accept- ance and approval. We should evacuate the cavity slowly if tubal rupture is anticipated, but, nevertheless, always at one sitting. Subsequent risk of decomposi- tion within the sac is diminished by providing for ade- quate drainage. The sac immediately after operation may be thoroughly irrigated with an appropriate solu- tion thrown into it under low pressure, and not so hot at first as to stimulate uterine contractions ; but if the entrance of air is prevented, or only sterilized air is ad- mitted, the danger to the patient is materially lessened. When the operation is performed with the spray and other antiseptic precautions, and the outer end of the drainage-tube is wrapped in some absorbent material impregnated with an efficient germicide, the outlook is rendered exceptionally favorable. Under certain cir- cumstances it might be judicious to postpone washing out the canal until after evidences of decomposition have become apparent, in the meanwhile being careful to se- cure adequate drainage. Irrigation is always indicated when pyo-colpos and pyo-metra are recognized. When the immediate danger to the patient is over, the physician is confronted with the problem of how best to keep patulous the opening that has been made. The tendency of artificial passages through extensive atresias to close is remarkable; various plank have been sug- gested to obviate this difficulty. The use of the glass tube, which can be introduced into the vagina by the patient, and can be worn for as long a time as is desir- able, is especially commended by Emmet. Breisky, on the contrary, prefers dilatation with the fingers or spec- ulum, to be begun eight days after the operation, and to be repeated at suitable intervals. If the divided edges can be covered with a flap of skin or mucous membrane, as lias been done in exceptional instances, an excellent result is assured. Cohabitation, if the patient be mar- ried, materially assists subsequent efforts to keep the canal open. Puncture of a htematocolpos through the rectum or bladder should only be mentioned to be con- demned. (For further details in regard to this subject, consult the preceding article, entitled "Vagina, Atresia of the.") C. Congenital Stenosis of the Simple Vagina.-While atresia of the vagina means complete, stenosis implies only partial, occlusion of that canal, so that menstrual blood can find an exit, and conception can take place, things impossible in the former and more rare condi- tion. As in atresia, the hymen or the vaginal canal above it may be affected, though congenital stenosis of the hymen is uncommon. There may be a septum perforated with openings so small as only to become apparent when the menstrual blood trickles through them, or bands of tis- sue extending from one portion of the vagina to another, or again, spiral or ring-shaped folds projecting from the vaginal surface. Pronounced stenoses are not commonly encountered where the remaining portions of the genital apparatus are normally developed. The same causes which produce atresia of the vagina, though operating less actively, occasion stenosis of this canal, namely, foetal inflammatory processes occurring late in embryonal development, and overgrowth of the hymeneal folds. In this condition there may perhaps be temporary amenorrhcea when the stenosis is very pronounced, fol- lowed by dysmenorrhoea from forcible contractions of the vagina and uterus ; but since there is always some opening for the escape of menstrual blood there is no development of a retention tumor nor of the painful and alarming disturbances incident thereto. Cohabitation may be interfered with, but there is no insuperable ob- stacle to conception, and while labor is occasionally made tedious and difficult, the characteristic tissue- changes of pregnancy often render the structures soft and dilatable. Still, in certain cases, without surgical intervention delivery cannot be accomplished, and even rupture of the vagina during labor has been known to occur. The diagnosis is easy, as a rule, although it may some- times be difficult to find an opening, and the condition is hence mistaken for an atresia. It is, however, not im- possible to confound acquired with congenital stenosis, and a spasm of the muscles of the pelvic floor may lead one into error. For obvious reasons the prognosis in stenosis presents none of the grave aspects that characterize atresia of the vagina. When to lessen the difficulties attending coition, and to increase the probabilities of conception, it is desirable to enlarge the strictured vaginal canal, this may be accom- plished by the use of tents, sounds, dilators, and the 579 Vagina. Vagina. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. like, but the results are never so satisfactory as when the edges of the occluding bands or folds are incised, and dilatation by speculum or antiseptic tamponing is after- ward systematically employed. Cohabitation alone often ultimately achieves the desired end, and during labor the advancing head accomplishes an extraordinary de- gree of dilatation. Yet it is never safe at this crisis to rely entirely upon nature's efforts to overcome the ob- struction, for the most ontoward accidents have been known to occur. It is best during delivery to divide at once any obstructing band which seems likely to mate- rially delay the progress of the child, though incision should always be made as superficially as possible. D. Divided or Duplex Vagina.-In this condition the vagina is divided into two lateral halves, rarely of equal dimensions, by a more or less perfect septum, consisting of two folds of mucous membrane, separated by a little muscular and connective tissue. This partition may be complete, or may be perforated by a number of open- ings, or its presence may alone be indicated by a band or by bands of tissue connecting the upper, middle, or lower portions of the anterior and posterior vaginal walls. With double vagina the uterus is usually also double, but may be single, and there may be a portion in each half of the vagina, or the uterus may have two openings in one side and none in the other. When the uterus is single and the vagina double, only that half of the latter is suitable for coition which ends in a cul-de-sac above; and in one-horned uterus, with atrophied second horn, the side of the vagina which corresponds to the atrophied half of the uterus is generally found in a very rudimen- tary condition. There may be atresia of both halves of a duplex va- gina, although one side-in a vast majority of cases the laterally, but may push the septum or band before it, delivery being thus impeded. When there is atresia of both halves of a duplex vagina the symptoms will be almost identical with those accom- panying occlusion of the simple canal. When, however, only one-half is obstructed, moliminal disturbances will occur with retention in the obstructed half (haematocolpos and haematometra lateralis), but a menstrual discharge will regularly escape from the patent portion of the tube, and in the inter-menstrual periods a catarrhal out- flow will occur. The diagnosis is facilitated by remembering that in this condition there are present all the symptoms accom- panying atresia of the simple vagina with the exception of amenorrhcea ; the menstrual flow regularly recurs and the retention tumor that is developed has a distinctly lateral situation. This latter fact may lead the ex- aminer to confuse hsematometra and liaematocolpos later- alis with periuterine haematocele, with cystic enlarge- ments of the ovary and Fallopian tube, or with soft uterine myomata. But if the atresia is seated near the vaginal outlet, no such error is likely to arise, and famil- iarity with the history of the case will usually solve any apparent difficulties. The same dangers attend atresias of the double vagina that are present in obstruction of the simple canal. Rupt- ure of the Fallopian tubes may occur, or after spontane- ous perforation of the occluding diaphragm, pyo-colpos and pyo-metra may develop with subsequent involve- ment of the tubes and pelvic peritoneum, or the patient's general health may suffer seriously from the long-con- tinued suppuration and purulent discharge. The septum can be divided with scissors without much risk of haemorrhage even during labor, when it offers, or seems likely to offer, any serious obstacle to delivery, or in the non-pregnant female when intercourse is difficult or conception impossible. E. Faulty Communications with other Cavities.-Re- membering that in the embryo the uro-genital tube and the intestinal tube terminate in a common conduit- the cloaca-a depression on the external surface of the ovum, the genesis of the abnormalities in question is easily explicable. In the normal course of development a septum (completed in the tenth week of intra-uterine existence) divides the uro-genital sinus in front from the rectum behind. If this septum does not appear the cloaca persists, there is no anus, and apparently the rec- tum empties into the vagina a short distance above the hymen. To this condition the strange name atresia ani vaginalis has been accorded ; while if the communica- tion is below the hymen, it is called atresia ani hymenalis or vestibularis. The simple term persistent cloaca would more accurately describe both abnormalities. The open- ing of the intestinal canal into the cloaca may be small, and if not actually possessing a sphincter, may yet be able to resist the involuntary passage of faeces and flatus, which are voided periodically and at will. If the com- munication be large, however, the patient suffers from those symptoms which characterize the more extensive forms of perineal laceration. Numerous other abnormal communications have been observed, as, for example, an opening from the vagina into the normally formed rectum, from the vagina into the urethra or bladder, or between a ureter and the vagina. Again, the ileum, colon, and vagina have been found opening upon the surface of an extroverted blad- der. The sinus uro-genitalis may persist as a long and nar- row passage, so that the urethra opens, apparently, not into the vestibule, but into the vagina. The causes of these faulty communications are largely arrests in development occasioned by fcetal inflammatory processes; but in the production of persistent cloaca (atresia ani vaginalis or vestibularis) hereditary influence seems to have some force, since this condition has been known to have been present in several members of the same family. For the relief of this last condition the perineum should be divided from before backward, the end of the intes- Fig. 4492.-Double Uterus and Double Vagina, with Left Lateral Haema- tocolpos and Hieniatometra. (Emmet.) right-is alone occluded as a rule. As a result of this, bilateral or unilateral hsematocolpos may develop. Spon- taneous perforation of the obstructing membrane and evacuation of the contained fluid, and rupture of tubal blood-sacs, occur more often here than in the case of atresia of the simple vagina. Duplexity of the vagina results from a persistence of the septum between the Mullerian ducts, which should have completely disappeared by the end of the twelfth week of embryonal life. Coalescence of the two ducts of Muller begins not far from their points of outlet, be- tween the lower and middle thirds of the future genital tract, and extends upward and downward, but more slowly in the former than in the latter direction. A single vagina with a double uterus is hence a more com- mon condition than a double vagina with a single womb. The septum of a duplex vagina may interfere with coitus, and during labor the descending foetal extremity may not follow either canal, displacing the partition 580 REFERENCE HANDBOOK OF TIIE MEDICAL SCIENCES. Vagina. Vagina. tine is to be sutured in the middle of the incision thus made, and the remainder of the wound closed by stitches. The abnormal opening into the vagina will often close spontaneously. F. Blind Canals or Inversions of Vaginal Mucous Mem- brane.-Occasionally lacunae of the vagina attain unusual dimensions and are recognized as blind tubes, sometimes large and long enough to admit the little finger, lined with smooth mucous membrane and lying parallel to the long axis of the vagina, or they are deflected into the peri-vaginal connective tissue. The point of exit of these tubes is usually near the vaginal outlet at the sides of the columna ruga posterior. G. Infantile Vagina.-Sometimes the vagina, though perfectly developed, from an arrest of growth in child- hood, fails to attain adequate dimensions, and retains its infantile character throughout later life, being too short, too narrow, or both. Uterus fcetalis and uterus infantilis are not infrequently associated with this condition. Literature. Breisky : Die Krankheiten der Vagina, Deutsche Chirurgie (Billroth and Luecke), lx., 14, Stuttgart, 1886. Emmet: Principles and Practice of Gynecology, p. 188. Philadelphia, 1884. Hart and Barbour : Manual of Gynecologj'. p. 484. Edinburgh, 1886. Winckel: Diseases of Women, p. 102. Philadelphia, 1887. George Woodruff Johnston. CYSTS OF THE. There are two kinds of vaginal cysts : those which contain liquid, and those which contain air. A. Cysts of the Vagina containing Liquid. Path- ological Anatomy.-Opinions differ as to the frequency with which cysts of the vagina are encountered. While certain observers have met with a large number of cases of this affection, others have been less fortunate ; and it is generally believed that, while not phenomenally rare, vaginal cysts are yet by no means common. Cysts are seated almost as often on the posterior as on the anterior wall of the vagina, and but rarely on the lat- eral walls. Still, when the tumor is large it encroaches upon portions of the vagina sometimes far removed from its point of origin, which it may be difficult to identify. Again, it is quite possible for cysts to be present simulta- neously on opposite walls of the vagina. Vaginal cysts are encountered most frequently in the lower third of the canal, although it is not uncommon to find them in the upper third ; the middle third is least often affected. Cysts of the vagina, when small or very deeply seated, project but little above the surface of the vagina. The superficial and larger growths are, however, quite appar- ent, and form globular or ovoid tumors rising sharply above the .plane of the surrounding vaginal wall. The mucous membrane overlying the cyst may preserve its normal color, but when greatly stretched, loses its characteristic wrinkles and becomes smooth and glossy, while it presents a whitish, bluish-white, or greenish- white appearance, that has been likened to the outside of an ovarian cystoma, or to a distended knuckle of intes- tine. When a cyst prolapses and protrudes through the vul- var fissure, the mucous membrane covering it exhibits the same epidermoidal change which affects the vaginal walls under like circumstances, or it may become in- flamed and show superficial ulcerations. The latter con- dition is seen when cysts lie directly opposite each other in the vagina. Cysts of the vagina grow slowly. In certain instances they increase in size up to a certain point, and then re- main stationary. Even when all the conditions favoring growth are present, a considerable time-perhaps many years-may elapse before they begin to attract attention. When the walls of the cavity in which the fluid is effused are elastic and the rapidity of this effusion is great, de- velopment will be correspondingly active. The pro- longed hyperaemia of pregnancy imparts new energy to the growth of cysts, as likewise does excessive sexual in- dulgence, or inflammation of the vaginal tissues. As has been said, these vaginal tumors may never at- tain very great proportions, but occasionally they reach an enormous size. Vaginal cysts, in their further development, are influ- enced by the resistance offered by the vaginal walls and their fascial attachments, by the force of gravity, and by the pressure originating in the adjacent and overlying hollow organs-the bladder and intestines. In conse- quence of the action of these negative and positive forces, cysts have a tendency to extend first toward the lumen of the vagina, and then downward toward its outlet, since these are the directions of least resistance. . When seated upon an elastic and yielding base, the tumor will in time become pedunculated, but this is not likely to occur in the case of a cyst of the anterior wall, on account of its firmer attachments. Occasionally, when traction is great, the whole vaginal wall to which the cyst is affixed may prolapse and protrude for a vari- able distance beyond the vulvar fissure, and the remain- ing wall and uterus also, in aggravated cases, may take part in this descent. The prolapse is rendered more pro- nounced by standing, walking, coughing, crying, and by efforts at micturition or defecation ; but in most instances, when the patient assumes the recumbent posture the growth, spontaneously or by the aid of a little pressure, slips back and disappears within the vaginal canal. Cysts of the vagina ordinarily give to the touch the impression of a soft, elastic, and fluctuating tumor, but occasionally they feel quite hard, and almost like a fibrous growth. In consequence of bruising between the thighs on walking, or as a result of injuries received during labor, inflammation of the sac may occur, and the cyst is then changed into an abscess. With or without antecedent inflammation a cyst may rupture, spontaneous cure fol- lowing ; or the opening may close and the sac refill; or, lastly, the opening may remain patulous, and become the "terminal extremity of a sinus lined by unhealthy granulations, and discharging continually a fetid, puru- lent fluid. In endeavoring to study the anatomy of vaginal cysts exhaustively, with a view of throwing more light upon their etiology, the older observers investigated the con- tained fluid with great care. With the same object in mind, in more recent times, the internal investment of these tumors has been examined. The outer aspect of cysts of the vagina is clothed with the normal vaginal epithe- lium. Besides this, any or all of the tissue elements of the vagina may be found in the cyst wall, its thickness depending upon the number of these tissue layers pres- ent, and the latter upon the locality where the accumula- tion originates, and upon the degree of pressure which it exercises. On account of the peculiar bluish colora- tion of the vagina, the wall of the cyst in many cases ap- pears to be thinner than it really is. Although in some instances it may be so attenuated as to be quite translu- cent, yet in others the sac is so thick and resistant that it fails to collapse even after puncture and evacuation. From actual measurement it would appear that 0.5 mm. (^o inch) is the minimum, and one ctm. (f inch) the maxi- mum, thickness of wall attained. As a rule, the interior aspect of vaginal cysts, which may be either smooth and shining, or rough and covered with papillomatous outgrowths, is provided with an epithelial investment, although cases are recorded in which such was wanting. This investment may consist of two distinct varieties of epithelium, and should the cyst be lined in the beginning by one variety, it is quite possible for this to be changed into another by the me- chanical pressure of the contained fluid. Cylindrical cells may thus be flattened and made to assume a pave- ment form, and by multiplication of the upper strata, a many-layered squamous epithelium is made to replace the original variety. With these facts in mind, and remembering that the other anatomical elements of the cystic wall may be ma- terially modified by pressure, it will readily be seen how futile would be the attempt to classify cysts of the vagina upon a purely histological basis. 581 V a^ina. Vagina. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Several schemes for the proper classification of vaginal cysts have been proposed, none of which is entirely sa- tisfactory. Whether the tumor originates in the vaginal wall or in the perivaginal tissue, its subsequent growth and the changes induced in its environment make it im- possible, after a certain size has been reached, to trace back its origin. And when we come to consider what or where this starting point is, we are overwhelmed by ingenious theories. The most natural assumption is that the vaginal glands become obstructed, and fluid accu- mulates within them, leading to the formation of reten- tion cysts of appreciable size. A hypenemic or inflamed condition of the tissues of the vaginal wall would natur-. ally induce an increased and altered secretion from these glands, and the accompanying cell proliferation about the ducts of outlet, and denudation within, would first dimin- ish the calibre of the peripheral extremities, and ulti- mately occlude them. This inviting theory receives a severe blow at the hands of those who aver that the vaginal mucous membrane contains no glands. Other anatomists, many of them in the light of specially undertaken investigations, believe, on the contrary, that glands are invariably present. To decide off-hand in a matter of this kind would be presumptuous. A much safer course would be to follow those who admit that glands are found, but who consider them exceptional formations. That certain vaginal cysts are developed in the manner above described would seem almost incontestable. It has been suggested, again, that cysts of the vagina are simply dilatations of the lymph channels which are found in the mucous, submucous, muscular, and exter- nal fibrous layers of the vaginal wall, and in some in- stances such a mode of origin may be assumed as almost certain. It would seem, from investigations recently made, that Gartner's ducts are occasionally found in the adult human female. Their persistence in certain of the lower ani- mals has long been recognized. These tubes, situated toward the sides of the anterior vaginal wall, may become distended with fluid and give rise to one form of vaginal cyst. The absence of any terminal opening, the devia- tions at the point of exit of the ducts, the great varia- tions in calibre which they exhibit, and the plugs of epithelial debris occasionally found in them, lead to the obstruction, which utimately ends in cyst formation. When several cysts are found seated one above the other at the side of the anterior wall of the vagina, it is prob- able that they have originated in localized dilatations, either of one of Gartner's ducts or of an undeveloped duct of Muller. It is also held that fluid may accumulate in the de- pressions between two neighboring folds of vaginal mu- cous membrane, which, through inflammation, have become adherent to each other by their free borders. Between no two species of vaginal cystic enlargements is it so difficult to draw the line as between those which are called respectively interstitial and perivaginal cysts. They both originate in the same kind of tissue, and are made up of the same structures. The spaces which are found in the loose connective tissue immediately beneath the vaginal mucous membrane, and in that surrounding the vaginal walls, are oftentimes stretched by indiscreet or excessive sexual intercourse, by pregnancy, and by labor, and serum or blood is effused within them. This undergoes certain 'well-known retrograde changes, and by the irritation of its presence produces a condensation of tire surrounding tissues and the formation of a proper capsule. A large number of accepted authorities believe that all vaginal cysts originate in this manner, while others limit the process to such tumors as are large, have thick walls, over which the mucous membrane glides freely, and which are seated in the lower portion of the genital canal. Finally, it should not be forgotten that in some cases a urethrocele is almost a cyst, there being only a minute communication with the urethra which may first con- tract and ultimately close, and that dermoid and hydatid cysts are sometimes found in the vagina. Contents.-Considering the many different sources from which cysts of the vagina may be derived, we are prepared to find a great variation in the quantity and quality of the contained fluid. But after all it is very questionable, when we consider the great alterations which the contents of vaginal cysts suffer from changes, chiefly of an inflammatory nature, taking place within the sac, whether the examination of the contained fluid can teach us anything. With the exception of the es- sential elements of dermoid or hydatid collections, noth- ing significant of the nature of a cyst is likely to be found ; for, as has been proven, the contents of cysts of the same construction may be different, and those of dissimilar cysts the same. But one case is recorded, so far as we know, in which a calculus was found in the sac. Etiology.-Cysts of the vagina are found most fre- quently between the ages of twenty and thirty, but have been discovered in the new-born and in the aged. They are sometimes congenital, but otherwise their formation is promoted by those causes which produce hyperaemia or inflammation of the vagina, or relaxation of its con- nective tissue strata or environment, with coincident ef- fusion of blood or serum. Consequently this variety of new-growth is found quite often in prostitutes, and in those who have had many pregnancies, and tedious or difficult labors. But among a multiplicity of possible causative agents, it is next to impossible in a given case to select the most potent. Symptomatology.-As a rule, cysts of the vagina are of no great clinical importance. As growth is slow, and some tumors never attain a large size, it is quite possible that their existence may be entirely unsuspected, and their discovery be purely accidental. No characteristic symptoms attend this form of vaginal tumor. Occasionally, when the cyst is inflamed, pain on pressure is complained of, and when prolapsed, bearing down pains and the sensation of the descent of some- thing within the genital passages, leads the patient to seek medical advice. A feeling of weight and dragging is not uncommon, the functions of micturition and of defecation are interfered with, and coitus is often ren- dered difficult. Many of the functional derangements to which -we have alluded are accentuated-indeed, in some instances are only manifest-when the cyst is large ; during the general pelvic congestion accompanying the menstrual epoch ; after standing or walking ; or, finally, when the cyst becomes prolapsed and protrudes through or beyond the vulvar fissure. Vaginal cysts usually neither cause sterility nor interfere with the progress of labor. But when the growth is large, unyielding, or immovable, or when rupture of the sac is not produced by the descend- ing foetal extremity, labor may be prolonged or rendered difficult, and even impossible, until the cystic sac is punctured or incised, its contents evacuated, and the ob- struction to the passage of the child is removed. Diagnosis.-The recognition of cysts of the vagina is usually easy. Occasionally they have been mistaken for cystocele, urethrocele, or rectocele, and tampons, pes- saries, etc., have been employed. A careful bimanual examination, with rectal and vesical exploration, will, in most cases, clear up the diagnosis at once. Evacuation of the bladder or rectum has caused many apparent cysts to disappear. Perhaps the greatest difficulty is found in distinguish- ing cysts of the vagina from vaginal hernia, and from cysts of the vulvo-vaginal glands or their ducts. With regard to the former, it has been observed that in vaginal cysts there is no impulse on coughing ; they simply be- come more prominent, are forced down along with the whole of the pelvic contents, are dull on percussion, and irreducible. From cysts of the glands of Bartholin, those of the vagina may be differentiated by the fact that the latter invariably originate within the vagina at a point more or less removed from the labia minora. Prognosis.-Cysts of the vagina disturb function, and occasionally offer an impediment to delivery, but are tu- 582 Vagina. Vagina. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. mors of a benign nature, and it is very rare that they as- sume any pathological importance. From those growths which originate in dilated lymph-vessels, extended lymph- angiectasis, it is said, may develop, and this may become a source of danger in subsequent pregnancies. Treatment.-Operation is unnecessary in every case of cyst of the vagina. For those tumors that are large and cause trouble, there is no choice ; and in young women it is best to interfere, even when the growth is small and produces no symptoms, for future difficulty and danger may be thus avoided. When a woman is entering upon the period of sexual repose, unless she is annoyed or suf- fers, the presence of the cyst may be disregarded. Surgical procedures may be instituted at any time. In some instances, an operation has been performed during pregnancy, without there being any interruption to ute- ro-gestation ; or just before or during labor, either be- cause the cyst is then recognized for the first time, or because it offers, or seems likely to offer, an impediment to delivery. An almost countless number of operative methods have been proposed and practised, alone or in combina- tion. There is some choice among them ; that which is easiest of performance, freest from suffering or danger, and most likely to be radical in its results, is to be pre- ferred. It is especially in private practice that we desire to avoid the necessity of repeated attempts at cure. The following plans of treatment are to be enumer- ated : 1. Simple puncture. Puncture of the cyst and the withdrawal of the contained fluid is useful as a diagnos- tic resource, and answers very well in the treatment of very small and superficially located tumors; but the punctured opening may close, the fluid reaccumulate, or an abscess form. 2. Puncture followed by the injection of an irritating fluid-tincture of iodine, carbolic acid, etc. We seek, by the injection of some irritating fluid into the sac, to create an adhesive inflammation of its walls, and a con- sequent obliteration of its cavity. This plan of treat- ment is generally recommended, and is preferred to all others by many authorities. It is not always satisfactory in its results, being rendered entirely useless when in- flammation already exists, and is apt to be followed, es- pecially in deep-seated cysts, by a too active and too ex- tended inflammatory process. 3. Simple incision. Cysts may be incised in the long axis of the vagina, or in a crucial manner, with the knife or actual cautery, care being exercised not to pass be- yond the limits of the tumor and wound any of the ad- joining hollow viscera or the peritoneum. A finger in the rectum, or a sound in the bladder, may be used as guides. Simple incision may suffice, but is not always effective. 4. Incision, followed by an effort to alter or destroy the lining membrane of the sac. After incision of the vaginal aspect of the cyst wall, applications of iodine, carbolic acid, nitrate of silver, the actual cautery, and tampons of cotton, charpie, etc., have been employed to alter or destroy the secreting membrane lining the sac, and set on fool inflammatory processes. The immediate object sought is usually achieved, but the subsequent cicatrization is often incomplete, the cyst cavity commu- nicating with the vagina by a suppurating track. 5. Incision of the cyst, followed by excision of the borders of the wound, or the removal of a part or the whole of the projecting portion of the sac. This is a sim- ple and effective procedure, but is not infrequently ac- companied or followed by sharp haemorrhage. In large, thick-walled cysts, this method is particularly applicable. 6. Excision of the whole or a part of the cyst wall, followed by the application of some irritant to its inte- rior. This mode of treatment, like some that have gone before, in which an effort is made to establish in- flammation in the sac with a resulting adhesion of its walls, or obliteration of its cavity by granulation and cicatrization, is generally followed by disappearance of the cyst; yet there are many objections to its employ- ment. It is painful, frequent applications are often nec- cssary, serious inflammation of the surrounding tissues may be caused, suppuration is prolonged, and a cicatrix is left behind. The patient is subjected to more suffering than was experienced from the presence of the tumor. 7. Enucleation or extirpation of the entire sac has been attempted. This is a somewhat laborious undertaking in large, thick-walled, and deep-seated tumors ; the rupt- ure of the cyst, which usually occurs, and the accompa- nying haemorrhage, add not a little to the difficulties of the operation. In many instances, the attempt at ex- tirpation has been abandoned in favor of some other simpler procedure. If it is successful, the edges of the resulting wound may be approximated by sunk and superficial sutures, drainage being provided for at its lower angle. This operation is difficult, and sometimes dangerous, and has no compensating advantages. 8. Schroder's operation. This is altogether the best method of treating cysts which cannot be cured by puncture or incision. The operation consists in the re- moval by scissors of all that part of the tumor that pro- jects above the surface of the vagina, and the union by sutures of the vaginal mucous membrane to the tissue lining the cyst. The sac is thus turned into the vagina. The epithelium which invested the inner surface of the sac is soon indistinguishable from that which covers the rest of the vaginal mucous membrane ; the cup- shaped cavity becomes flattened out, and no trace of the tumor remains. 9. There yet remains to be mentioned treatment by ligature and section of the pedicle in the case of pedun- culated cysts, through drainage and the seton. So far as we know, but two cases in which an opera- tion was performed in the treatment of a vaginal cyst terminated fatally. In one of these, a cyst, seated in the posterior fornix of the vagina, was removed, and, al- though the peritoneum was not injured, a fatal periton- itis resulted. In the other, solid nitrate of silver was twice applied to the interior of the sac, and the edges of the wound were subsequently excised ; here also peri- tonitis followed. B. Cysts of the Vagina Containing Air.-Syn- onyms : Colpohyperplasia cystica ; vaginitis emphysem- atosa ; emphysema of the vagina ; colpitis vesiculo-em- physematosa. Although instances of this affection had been pre- viously described, Winckel was the first to study it care- fully and to direct to it the attention of the profession. Certainly, by whatever name we designate this condi- tion, it is a most curious one, and while of no practical importance, we look in vain for a pathological analogy. Air-cysts of the vagina generally occur in crowded groups in the upper portion of the canal. They are hemispherical in shape, though occasionally umbilicated, are transparent, of a gray or yellow color, and vary from the size of a pea to that of a grape. The surrounding vaginal surface is hypersemic, inflamed, or cedematous. Although occasionally observed in the non-pregnant, and even in the unmarried, air-cysts are most usually en- countered during the course of utero-gestation. They have been discovered as late as the forty-sixth day of the puerperium. On the introduction into the vagina of the examining finger, a perceptible emphysematous crepitation is some- times evoked. When punctured the cysts collapse, and gas escapes with an audible sound, accompanied perhaps by the flow of a few drops of a thin serous fluid. They do not refill after puncture. These cysts are, almost without exception, very super- ficially seated. They do not always appear to have the same anatomical structure ; sometimes they are provided with a proper wall; at other times they seem to be mere clefts in the superficial connective-tissue stratum of the vagina, fibres from which project into their cavities or divide them up in a trabecular manner. Occasionally they have within a perfect epithelial in- vestment, though sometimes this is defective or entirely wanting. Cysts have been found lined throughout with giant cells. 583 Vagina. Vagina. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The mode of origin of air-cysts of the vagina is very obscure. Whether they are but dilated glands, distended connective-tissue vacuoles, or ectasic lymph spaces, it is a difficult matter to determine. Each theory has its ad- vocates, and it would seem, from the different microscop- ical appearances which the interior of cysts exhibit, that any or all of these suppositions might be correct. The contents of these cysts have been studied with ex- traordinary care and patience. In some instances, an analysis of the gas has shown it to have a composition identical with that of ordinary atmospheric air, or of air less four per cent, of its oxygen ; while one observer maintains that it is trimethylamin, which is present, it is said, in the healthy vaginal secretions of pregnant women. It has been averred by some that the gas develops in the cystic spaces ; by others that it finds an entrance from without, or that cocci entering set up decomposi- tion in the fluids already present. From the almost ever-present inflammation of the va- ginal texture, and from the microscopical examination of the walls and environment of the cysts, it is believed that the affection is, in its essence, an inflammation ; but this theory has its opponents as well as its adherents. Those who consider this condition an emphysema deny the existence of any inflammatory factor. The impor- tance of the local changes induced by central circulatory obstruction is acknowledged by all. On reviewing all of the theories which have been ad- vanced to account for this unique condition, it may be said with reason, we believe, either that air-cysts of the vagina have the most diverse origin, or else that their primary structure is subject to the most pronounced al- terations. The stretching and compression of the vaginal walls during labor and puerperal changes generally cause the disappearance of air-cysts of the vagina, although, as has been pointed out, they may persist long after delivery. No treatment except that of the accompanying vaginal catarrh is indicated. Litebatube. Breisky : Diseases of the Vagina, Deutsche Chirurgie, lx. (Billroth and Leucke). Stuttgart, 1886. Winckel: Diseases of Women, p. 146, Philadelphia, 1887. Johnston, G. W.: A Contribution to the Study of Cysts of the Vagina, etc., American Journal of Obstetrics, xx., 1144. New York, 1887. Qeorge Woodruff Johnston. VAGINA, TAMPON OF THE. Custom has established the use of two words to signify the placing of cotton or other similar substance in the vagina, tampon and tam- ponade, with the following distinction : Tampon signifies the complete packing of the vagina to stop or avoid uterine haemorrhage ; tamponade is used to indicate a limited amount of cotton or other substance for purposes other than haemostatic. The history of the tampon is very obscure. It is a sim- ple, oommon-sense procedure, and at the same time a very efficient one. It doubtless suggested itself to many minds, and was practised in a more or less crude form till the use of the speculum, and especially Sims's specu- lum, developed it into somewhat of a scientific process. The Tampon.-The use of the tampon originated in the idea of placing something in the vagina to facilitate the formation of a clot. It was first practised by loosely stuffing in a handkerchief, napkin, roller-bandage, or a few wa,ds of cotton. Such tampons are more or less ef- fective in stanching for a time the external flow of blood. But in a short time the tampon becomes satu- rated and haemorrhage again becomes apparent. To Dr. Emmet we owe the thorough and efficient method of tamponing the vagina as it is now used, or should be used. His method is based on the idea of pressure. And while the stoppage of all haemorrhage depends upon formation of clot, the pressure thus pro- duced carries the uterus high in the pelvis, compresses all the pelvic vessels, and transfers the formation of the clot from the vagina up into the uterus. To properly tampon the vagina a Sims speculum is in- dispensable. As Munde very forcibly remarks : " Every practitioner who takes, and is liable to meet with, cases of uterine haemorrhage (and what practitioner is not ?) from miscarriage, polypi, polypoid endometritis, fibroid uterus, or cancer, should not only possess a Sims spec- ulum, but know how to use it and how to tampon the vagina so securely that not a drop can escape so long as the tampon is retained." When the haemorrhage is free it may be necessary to tampon the cervical canal as far as the tampon can be forced into it. This will prevent the escape of blood from the uterus, which, by accumulating or forming a clot within its cavity, stimulates the uterus to contract and so control the haemorrhage. There is no danger of the uterus enlarging to accommodate the clot as it in- creases in size, except directly after delivery, post partum, and when this is to be feared other methods of inducing contraction of the uterus must also be resorted to, as ergot, applications of cold, pressure through the abdom- inal walls, constitutional stimulants, etc. If there is reason to believe the haemorrhage is pro- duced by something within the uterus, as retained pla- centa, or polypus, that can be removed at the time, of course such indication is to be acted upon first. But frequently these cases of haemorrhage occur in the night, or some other reason for delay in operating exists, or the patient may be so reduced that the first indication may be to prevent further loss of blood. Under these condi- tions resort must be had to the tampon. The best material for the tampon is plain cotton squeezed out of carbolized water and flattened out into disks one-half the diameter of the palm of the hand and about one-half inch thick. This is better than absorbent cotton, as it retains its elasticity, and so by its expansile power increases the pressure. It is well to have five or six also squeezed out of alum-water, of the strength of an ounce to the pint. These are the first to be used about the cervix and fornix vaginae. The bladder must be emptied either naturally or by catheter, and if the case is not too urgent to permit time for it, the rectum should be unloaded by enema. The patient is placed in Sims's position, the Sims spec- ulum introduced, and the cervix brought well into view. All coagula and fluid blood are wiped away with ab- sorbent cotton held in dressing forceps, and the vagina is hastily swabbed out with bichloride solution, 1 to 5,000. If the os is patidous and the haemorrhage free, it may be well to pass the applicator, wrapped with absorbent cot- ton and dipped in iodine, to the fundus. If a decided impression on the uterus seems necessary, the cotton can be slipped off and left in the uterus as the applicator is withdrawn ; but care should be taken to leave the end of it protruding from the os. The uterus will be stimulated by this means to contract, and probably to force out the cotton. In some cases one or two small plugs can be packed into the cervix. This will assist materially in stanching the flow. One of the disk-shaped tampon balls is now placed over the os, another posterior to the cervix, one on either side, and one in front. These are not rolled up into balls, but are spread out and moulded to the vaginal fornix by pressing them all about with the dressing-forceps in one hand, and a stiff probang stick, or another pair of closed dressing forceps in the left. This completes one circle or layer of the tampons. Another layer is to be placed upon this in the same way, crowding the disks well in against the cervix till the fornix is filled out flush with the external os. Disk after disk is thus placed around the cervix in a circle and well packed down. The last disk inserted is successively held in place by the rammer in the left hand till another can be inserted; in this man- ner the pressure is at no time relaxed. As the walls of the vagina stretch, and the diameter of the canal increases, a circle of disks is placed around the central one ; then another concentric circle outside of that, and so on till the vaginal wall is reached, always making the pressure at first toward the centre. But as the lower section of the vagina is reached all the press- ure is made toward the hollow of the sacrum, the final disks in each layer being tucked in against the anterior 584 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vagina. Vagina. vaginal wall. The whole process is similar to that em- ployed by a dentist in filling a dental cavity with gold- leaf. No great force is used at any time in the proceed- ing ; but by firmly packing down each disk of the elastic cotton, the vagina can be gradually distended, if neces- sary, till the tampon fills the entire calibre of the pelvis. The process is continued till the solid tampon reaches the floor of the pelvis and the arch of the symphysis. The speculum is now removed, great care being exercised not to dislodge the tampon. The point of the speculum should be directed well toward the back, and allowed to slip along the floor of the pelvis. Sometimes the space the cervix or interior of the uterus. When so over- looked they are apt to be the cause of septic infection, oc- casioning a chill, rigors, and a rise of temperature. Tamponade.-The tamponade is not so formidable an affair. It is in constant every-day use for the treatment of all kinds of uterine difficulties. It is employed for various purposes, the most important of which have been enumerated by Munde under eight different heads, as fol- lows : 1. As a carrier for the application of medicinal agents to the cervix and vagina ; 2, as a means of retain, ing certain substances introduced into the uterus in theii proper position-such as pledgets of cotton, tupelo tents, stem-pessaries ; 3, as a means of retaining the uterus or a prolapsed ovary in position ; 4, as a mechanical sup- port and stimulus to the pelvic vessels and alterative to the pelvic tissues by means of pressure ; 5, as a pro- tective to the ulcer- ated, inflamed, or swollen cervix or vaginal walls, to prevent friction and an increase of irritation ; 6, as a means of dilating or sep- arating the vaginal walls-a substitute for a hard or dis- tensible dilator-in constriction of the vaginal canal after operation for vaginal atresia or stenosis, in vaginismus and spasm of the levator ani muscle ; 7, as a haemostatic (I have already considered this subject under the head of Tampon, but there is another use of the tamponade or tampon that I deem worthy of special mention, and there- fore shall consider it as the 7th, viz., to hasten expulsion in unavoidable miscarriage); 8, as an absorbent of vaginal and uterine discharges, which are thus prevented from touching the external or sound parts, and as a protection of the sound parts from caustic substances applied to the uterus or cervix. The same tamponade may fulfil the purposes indicated by several of these headings. At the same time each is distinct and important. As a carrier of medicinal agents the tamponade has come into almost universal use. The best material is the ordinary unglazed cotton batting, as sold in the shops, done up in colored tissue-paper, at fif- teen cents a roll. The absorbent cotton, plain or borated, is extensively used. But when saturated with glycerine or moistened with the vaginal discharge it packs together too solidly, and has no elasticity. The absorbent cotton is used mainly as a mop in the dressing-forceps for cleans- ing and drying out the vagina, and as a vehicle, when wound on an applicator, for making intra uterine appli- cations or painting the vaginal vault. Other materials are used, as suits the fancy or particu- lar notion of the medical practitioner. Chief among them are tow, marine lint, wool, oakum, sponges ; of these the sponge is the least desirable, while the cotton fulfils every purpose, is easily procured, is cheap, and, in fact, is the most generally used. If some disinfectant, as carbolic acid, boroglyceride, or iodoform, is always used in the material with which the pledgets are loaded before being applied, the cotton needs no further preparation than to be made up into tampon balls ready for use. These tampon balls should not be made with too great nicety as regards looks. They pack together better and so retain their place in the vagina better if they are somewhat irregular in outline. The best way is to pull or tear off the cotton from the end of the roll, without unrolling it or removing it from its paper wrapper, in little masses of varying size, about two inches long and an inch thick, and without folding in the edges any more than enough to secure it all with the string ; then to put a thread about it, when it will be ready for use. The purpose of the string is to enable the pa- tient to remove the tamponade herself. It should be long enough to project well out of the vagina, and strong enough not to break when traction is made upon it. For this purpose the neatest and simplest material to use is Clark's white cotton thread, No. 12 or 14. When used Fig. 4493.-Sims's Tampon Extractor; with closed and open screw. (After Munde.) thus left by the speculum cau be filled in with two or three extra disks. When the vagina is thus packed there is no possibility of haemorrhage. The amount of cotton used and the thoroughness with which it is packed must vary with in- dividual cases. A slight degree of pressure is sufficient in some cases, and the extreme degree of thoroughness alone suffices in others. It is necessary in all cases to confine the patient to bed, and when the tampon is large an anodyne is required. The pressure is especially painful about the neck of the bladder, and if this persists in spite of the anodyne some of the disks in this region can be removed in an hour or two without impairing the integrity of the tam- pon. When this becomes necessary there is usually re- tention of urine and the patient has to be relieved with the catheter. The tampon should not be allowed to remain longer than twenty-four hours. At the end of this time it has usually become soaked along one side, at least, with the bloody secretions. It is then more or less offensive and must be removed. It may be that it has done its work and is no longer neces- sary, or if not, it is no longer of any avail and should be replaced by a fresh one. It is most advisable, as recommended by Munde, to keep on hand, in a well-stop- pered bottle, a supply of absorbent cotton which has been soaked in some styptic and al- lowed to dry, as solu- tion of the subsulphate of iron(one part to three of water), or alum (one part to twelve). This can be applied directly to bleeding surfaces, as in cancer, previous to application of the tam- pon. If Sims's speculum is essential to the placing of the tam- pon, Sims's screw tampon extractor is quite as important for its removal. By means of this instrument the first few pieces of cotton are removed without the use of the speculum. The external parts are separated by the left hand, and the screw, guided along the finger, is screwed into the disks, and they are removed one by one till the pressure is somewhat removed from the perineum. Then the speculum is introduced ?. short distance, and as the cotton is removed it is slid farther and farther in till it has reached the full depth of the canal and the vagina is emptied. Great care must be exercised in removing the tampon pledgets not to overlook one, especially about Fig. 4494.-Tampon Pledget. 585 Vagina. Vaginismus. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. double it is sufficiently strong to withstand any strain that may be required. A convenient way is to cut off the thread about fourteen inches long ; then, catching it by the middle point, pass the two strands around the pledget, slipping them through the loop and drawing it up tight enough to securely hold the cotton. It is time- saving to make up a supply of these at convenient mo- ments or to have the nurse do it. A number of these pledgets are saturated with the medicament from day to day, ac- cording to the number to be used, and kept securely covered to avoid evaporation. The cylindrical tam- pon pledget is in com- mon use, rolled hard and used dry to retain the medicated one in place, or used alone saturated with the medicament. These are made by cutting the cotton into strips about two and a half inches wide, and firmly rolling them till they at- tain the diameter of about one inch. They should then be secured by a thread tied as before about one end. The old-fashioned kite-tail tampon was made by tying a number of pledgets one after the other on a string. This was easy of removal, and in that respect was a suc- cess ; but it was apt to get badly tangled and was awk- ward to handle. Foster's lamp-wick tampon was a great improvement on this, and is an excellent device. The ordinary old- fashioned lamp-wick, as it comes wound in balls, is the material used. It is cheap, elastic, and absorbent; is .readily introduced and has the merit of being as easily removed by the patient. Usually a single strand of the wicking is tucked into the vagina through a speculum ; but when the ostium vaginae is capacious several coils of the wicking may be gathered into wads and inserted one after the other without breaking the strand. When enough has been introduced the wick is cut off two or three inches from the vulva, leaving the end thus pro- truding. To remove it the patient pulls on the project- ing end and thus unwinds the mass within the vagina, drawing it through the vulva in a single strand. Medicinal Agents.-Glycerine is the most universal medicament used on the tamponade, and with it are com- bined alum, tannin, fluid extract of eucalyptus, boroglyc- eride, carbolic acid, boracic acid, according to the indi- cations. The tampon pledget may be dusted with a dry powder, bismuth, alum, tannin, or iodoform, or it may be smeared with an ointment. One or two medicated pledgets are to be inserted, and these are held in place by one or more dry ones. It is important to bear in mind in using the tamponade that the patient must be informed that she has a specified number of pledgets of cotton in her vagina, and instructed how to remove them. The custom is to remove the tam- ponade at the expiration of twenty-four, thirty-six, or at the most forty-eight hours. No sudden traction should be made on the thread lest it break. It must be drawn steadily downward toward the perineum, and when any astringent has been used on the pledget it is well to instruct the patient or nurse to pass her finger into the vagina alongside of the cotton and allow a little air to enter as the pledget is withdrawn. Otherwise the cotton acts like a piston in a pump, and may drag down the tissues above, even to the extent of retroverting the uterus. Passing in the syringe tube alongside of the cotton and injecting a little water will also prevent this unpleasant circumstance. When several pledgets have been introduced it is a good plan to tie a knot in the string of the one to be with- drawn first, two knots in the second, and so on. Unless some distinction of this kind has been made the patient cannot know which string to draw first, and is as apt to make traction on the uppermost pledget as on the lowest. In the vast majority of cases of periuterine trouble and inflammation of the appendages the nearest point of ap- proach to it in the vagina is the part posterior to the cer- vix. The nearer the medication can be applied to the seat of the disease the more efficacious it will be. The logical deduction of these premises is that the medicated tam- ponade in the vast majority of cases should be placed behind the cervix, as shown in Fig. 4496. In spasmodic and inflam- matory conditions of the bladder, in acute ovaritis, or in tenderness of the uter- ine ligaments, it frequently affords relief to support and steady the uterus, even when it is in normal posture. The most common applica- tion of the tamponade as a pessary is that made to retain the uterus in a normal posi- tion when first reduced from a retro-displacement. The uterus, under these circum- stances, is apt to be tender, and the surrounding tissues are too sensitive to tolerate a hard pessary. Indeed, where the circumstances will permit, a cure can be attained much more readily by persevering with the tamponade than by resorting to a pessary. When the retroverted uterus is bound down by adhe- sions, the frequent applications of the glycerine tampon- ade, by its pressure and alterative action, will produce a stretching and absorption of the adhesions, and grad- ually allow replacement of the organ. In partial or complete prolapse of the uterus a large astringent tamponade will often give more relief than any other support. If the vaginal and uterine supports are much relaxed, it may be necessary to retain the tam- ponade by a T-bandage. In rectocele and cystocele the tamponade is most serviceable. The astringent puckers up the vaginal walls, and ultimately restores their tone to a greater or less extent. In 1878, Taliaferro, of Georgia, described a method of using the tamponade to relieve subinvolution, areolar hyperplasia, descensus, and other dislocations of the uterus, with adhesions, chronic pelvic peritonitis, and cellulitis. His method simply introduced the element of pressure into the treatment already in use, thus stimu- lating circulation and hastening absorption in the same way that a snug roller bandage hastens the absorption of an exudation into the tissues of the leg. He places the patient in the knee-chest posture, and elevates the perineum with Sims's speculum. A few medicated pledg- ets are then packed into the fornix vaginae with long dressing-forceps, and upon them a solid column of tightly packed loose balls of wool or cotton is built, down to the floor of the pelvis. This column is flat antero-poste- riorly, but reaches from side to side the full width of the vagina ; or it may be varied in shape to make pressure where most desired. Various methods have been devised by which the pa- tient might be enabled to apply the tamponade herself. These methods are all sadly deficient. Few women have the dexterity and knowledge of the parts to enable them to apply a tamponade in themselves with any degree of efficiency, either through a special contrivance or a bi- valve speculum. The idea is a delusion. To accomplish any beneficial results it must be applied carefully and intelligently, and with an eye single to the object to be accomplished in each individual case. Bibliography. Emmet: Principles and Practice of Gynecology. Mnnde : Minor Surgical Gynecology. Foster: New York Medical Journal, 1880. James R. Goffe. Fig. 4495.-Cylindrical Pledget. Fic. 4496.-Proper Application of Cotton Pledgets. Ordinarily only two are necessary, viz., the one posterior to the cervix and the one next to it. (After Mund6.) 586 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vagina. Vaginismus. VAGINISMUS. This was defined by the late Dr. Sims 1 to be " an involuntary spasmodic closure of the mouth of the vagina, attended with such supersensitive- ness as to form a complete barrier to coition." Hart and Barbour2 refer to it as " a painful reflex contraction of the muscular fibres surrounding the vaginal orifice-just as laryngismus is applied to the same condition." They add that " Marion Sims first drew attention to this condi- tion ; " the error of this statement will presently be made manifest. From Winckel3 we learn that the diseased condition which has received the name of vaginismus " is doubtless the result of structural changes in the hymen, or in its vestiges, contact with which, or even the fear of contact, causing such violent contractions of the muscles of the pelvic floor that a digital examination is impossi- ble unless the patient is anaesthetized." This definition is especially to be commended because it recognizes that other muscles, in addition to the vaginal sphincter, are involved in the abnormal contraction. But it excludes those cases in which vaginismus results from a urethral caruncle, a vaginal, or anal fissure, or ulcer, from ute- rine or ovarian disease, etc., and therefore, though strict- ly correct, does not correspond with the common use of the term ; scientifically it is accurate, but practically it is deficient. Furthermore, there is a variety of vaginismus in which spasmodic contraction involves the canal, not at its out- let, but some distance-usually four or five centimetres, or somewhat more-above ; this is much rarer than that commonly known as vaginismus ; it has been, by some, distinguished as vaginismus superior. It has been intimated that the disease was known be- fore Dr. Sims's important contribution. Demarquay,4 who has given a very full bibliographical index of the literature of the subject, attributes the first reference to it to Chambon, in his " Traite des Maladies des Filles," 1785 ; but upon consulting the passage indicated the claim will not be found just. Chambon, in considering the injurious effects of astringent vaginal injections em- ployed for leucorrhoea, observes that the parts subjected to the action of astringents become so firm and rigid "that they present an obstacle to the usage of marriage, and there result at least severe pain and tearing from co- ition." This is all, and the condition of contraction mentioned could not be called vaginismus. Burns, referring to the vaginal sphincter, said :6 " This sphincter is sometimes spasmodically contracted, and the nerves so sensible that pain is felt in coitu, and at last some degree of permanent circular stricture is pro- duced. The cure in all stages is division in a lateral di- rection of the affected parts." Vinay 6 states that Du- puytren, and especially Lisfranc, described a peculiar state of the genital organs, its chief character being pain ; for Huguier, on the other hand, contraction is the predominant element, and he described it in 1834, under the name of spasmodic contracture of the sphincter of the vagina, an affection which has a marked analogy with spasmodic constriction of the anus, which may be essen- tial or symptomatic, but which is in almost all cases caused by the different varieties of herpes or eczema. Fabre in an article1 upon spasm of the vagina, states that in some cases it may be so severe as to oppose the introduction of the extremity of the little finger. Gream, in a paper8 on " Some of the Causes of Sterility Remediable by Me- chanical Treatment," narrates the case of a lady who had been married ten years without complete intercourse ever having occurred ; upon examination he found the orifice of the vagina so rigid that considerable force was necessary to introduce the finger, and its introduction seemed to cause great suffering. Without referring to many other contributions to the subject of vaginismus, though not called by this name, prior to Dr. Sims's paper, the following extract from a paper by Sir James Y. Simpson, presented to the Edin- burgh Obstetrical Society, November, 1860, is given.9 The paper was entitled " Vaginodynia, or Painful Mus- cular and Fascial Contractions along the Vaginal Canal; " the concluding part of the extract is that which is essential to the present purpose. Sir Janies, re- ferring to a patient suffering with vaginodynia, whom he had recently seen, observed that "she had never allowed her husband to approach her, so that in her the morbid condition must have been present before marriage, al- though she had never been in a position to be made aware of its existence. Instances, however, like this last oftener belonged to a class of cases where apparently the stricture was not, as in the preceding class, in the course of the vaginal canal, but wTas situated at its very orifice, independently, apparently, in most, of all disease there except supersensibility and spasm of the sphincter of the vagina, but traceable in others to hyperesthesia of the mucous surface of the vulva or vagina, resulting from irritable eruption or other morbid states of these mucous surfaces." The last sentence indicates that the great Edinburgh teacher had met with the disease described by Sims at a later date as vaginismus, but it is a mistake made by a recent writer to state that he called it vaginodynia, for that term he applied to contraction, not at the entrance, but in the course of the vaginal canal, an affection corre- sponding to the variety of vaginismus denominated by Hildebrandt vaginismus superior, and which will be de- scribed presently. In the fifth edition of Churchill's work on " Diseases of Women," 1864, the author, adopting the term vaginis- mus, and quoting from Sims's description, observes : " That this affection, or some modification of it, is known to all extensively engaged in obstetric practice, I do not doubt ; it is probably owing to its supposed deli- cacy that it has obtained little or no notice in books. It has come before me so repeatedly, and I have so con- stantly seen it the cause of ill health and unhappiness, that I should feel it wrong to omit all notice of it in this edition." Dr. Sims, therefore, did not first* draw attention to this condition, but he furnished a most accurate description of it, and gave it a name which has met with general professional acceptance-the substitution of that name by vulvismus, as has been done by a French surgeon, is certainly a great error of fact, and the abbreviation of it to vaginism, recently made by an American physician, is a trivial one of doubtful taste ;-and he described a plan of treatment that is important in some cases of the dis- ease, though Huguier and Michon anticipated him in at least partial division of the vaginal sphincter.10 The common form of vaginismus will be first consid- ered, and then that which is both absolutely and compara- tively quite rare. Sudden and severe pain when the vaginal orifice or ad- jacent parts are touched is the characteristic symptom of vaginismus ; and instantly following the pain there is such contraction that the introduction of the penis or of the finger is impossible, or if in some cases such intro- duction is made, it is by violence, and at the expense of severe suffering ; or if the touching be continued in a bad case of the disease, opisthotonos may result,11 the woman may become insensible, and hours elapse before she recovers from the condition consequent upon the ir- ritation. Sims 12 refers to the fear such a patient has of an examination, saying " she is like a timid, nervous per- son who has once had a pointed instrument thrust into the exposed pulp of an inflamed nerve in a decayed tooth." Further, he says that the sensitiveness is at all parts of the vaginal outlet, and that the gentlest touch with the finger, a probe, even with a feather, produces great agony. Duncan believes that in a woman suffer- ing from vaginismus there is not only spasm of the vol- untary muscles concerned, but also a painful spasm of ♦In the just published work by the late Bernutz, "Conferences cli- niques sur les Maladies des Femmes," the author observes : " The word vaginismus is of recent date, introduced into pathology by M. Sims; but it should be known that the affection to which he has given this name, was vaguely indicated at the beginning of the century by Guillemot; then clearly pointed out by Huguier, Dupuytren, Lisfranc, Hervey de Chegoin, Scanzoni, Debout, Simpson; finally, briefly but ably describedby Michon, who reported eleven cases before the communication of the American surgeon to the London Obstetrical Society. It may be stated that he has rendered common the knowledge of this affection, and has made known its rather great frequency and its difficult curability, but no right of discovery belongs to him." 587 Vaginismus. Vaginismus. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the involuntary muscular fibres of the uterus proper. He also states that he has seen two cases of vaginismus in which the pain and aching were felt on one side only. Syncope and convulsions may follow attempts at coi- tion, according to Barnes.13 Change of position or washing the genitals may cause an attack of vaginismus (Thomas); it may result from a lascivious dream, the pain awaking the patient (Duncan). In most cases the subjects of the disease are women who have been recently married, or, if married, for some years sexual intercourse has never been accom- plished, and ill health or sterility is the cause of the se- cret being revealed. In some instances, however, the vaginismus has first occurred after coition has taken place freely for months, or for years, and the disease then comes, in consequence, for example, of vaginitis. In still rarer instances women, after having borne one or more children, are affected, as in a case reported by Wright in the British Medical Journal, 1875. Similar cases have been observed by Depaul, and others. Its occurrence in the virgin seems possible from Schnegie- rief's report1 of a case. While sterility is almost the invariable result of vagin- ismus, a few instances have been reported in which im- pregnation occurred, although intromission was impos- sible. Such instances are those of Scanzoni, Packard, and v. Preuschen. In the case14 of the last named, a mar- ried woman, five months pregnant, suffered so greatly from obstinate vomiting and hysterical spasms that abor- tion became necessary. In this case a bougie could not be introduced, because of contraction of the vaginal sphinc- ter, until the patient was brought under chloroform. In the vaginodynia of Simpson, the vaginismus supe- rior of Hildebrandt, the contraction occurs at some dis- tance above the vaginal entrance; it might be called hour- glass contraction of the vagina, for there is ample space both above and below a ring-like narrowed portion. In a few instances the contraction is voluntary, so that the woman at will can prevent complete introduction of the penis, or after it has entered retain the organ. Hilde- brandt, in 1872, described15 the case of a married woman in whom there was during coition a ring-like muscular contraction at the upper portion of the vagina around the base of the glans penis, for a time making its withdrawal impossible. He regarded the strong contraction of the levator ani as the cause of this condition. He gives two illustrations, the first showing the anal levator at rest, the second in action. Sims, in his " Uterine Surgery," refers to a constrictor muscle at the upper portion of the vagina which he was confident the anatomist would one day dissect and de- scribe. Budin,16 adopting the view of Hildebrandt, asserts that the superior vaginal constrictor of Sims is none other than the anal levator, a muscle which may con- tract under the influence of the will, but which most frequently contracts during coition without the con- sciousness of the woman. He has reported some inter- esting cases of the affection, one in which the action of the muscle was voluntary, so that coition might be pre- vented or arrested, as the woman chose, and others in which this action was a serious obstacle to labor. One form, at least, of the affection-was observed long before the contributions of Hildebrandt, Simpson, Budin, and others in recent years. Schurigius, in " Gynaecologia Historico-Medica," 1730, has several pages under the title " De cohaesione in coitu," and refers to reports of this accident made by Borellus, Diemerbroc, Paullini, and others. He gives the expla- nation of it proposed by Riolanus, and which was also held by Plempius and by Diemerbroc, viz., that if the penis were very long, and the os uteri relaxed by recent menstruation, the former might enter the os, and the latter contracting retain it for a time-retineatur et con- stringatur, ut in canibus simul junctis ei coharentibus accidit. One of the authors referred to calls the affection a spasmodic contraction of the female genitals, and an- other describes a case in which the cohesion was re- lieved by the application of cold water: quern nexum advocatus medicus affusione aqua frigida protinus dissol- verat. The diagnosis of vaginismus is not difficult. If the affection has existed for some time it is probable there is more or less marked deterioration of health; the pa- tient is pale and thin, and she may have become more or less hysterical. She consults the physician because of the cruel suffering she has at attempted intercourse, or from her desire to have children, or because threat- ened by her husband with divorce. When an exam- ination is proposed she shrinks from it with trembling and tears, and it is only in consequence of the entreaties and the commands of others that she yields, finally, reluc- tant consent. Placed upon the examining chair or table she shows fear and anxiety ; the lower limbs, projecting in front, are, as Bernutz has said, rigid like bars of iron, the knees drawn together by the contraction of the custo- desvirginitatis, and there is also contraction of the muscles of the perineum. Promising and trying to be obedient, brave, and patient, she, in response to the physician's request, separates the limbs, and may permit a visual examination of the external sexual organs, and the la- bia majora and minora may be gently drawn apart; but the moment an effort is made to pass the finger into the vagina, or even if the vaginal orifice is gently touched, the pain, the spasm, and the restlessness will probably forbid any further examination without the use of an an- aesthetic. If the finger should overcome the resistance, it may be so tightly encircled by the contracting muscle that, as in a case reported by Sims, it becomes numb. Navarro has given an instance of a married woman suf- fering from intermittent vaginismus, and her hueband stated that the penis became numb from this contrac- tion. There must be hyperaesthesia and contraction to con- stitute vaginismus, and hence cases where ohly one of Fig. 4497.-Fibro-papillary Hypertrophy of the Hymen in Vaginismus. (Winckel.) these elements is present should not be called by this name. It is to be remembered, too, that vaginismus, although the name implies a neurosis, is rarely an idio- pathic but usually a symptomatic affection, and there- fore it is not enough to recognize its presence ; we must also endeavor to find its cause. Winckel, whose views as to the true nature of vaginismus have been given, has recently found that there were important structural changes in the hymen in cases of the disease. _ In gen- eral these changes are thickening of the epithelium and fibro-papillary hypertrophy (Fig. 4497). Sims stated that the most perfect cases of vaginismus he had seen were uncomplicated with inflammation ; but he adds that he had met with several cases in which there was a redness or erythema at the fourchette. But it must be remembered that this great American pioneer in synecology regarded the disease as chiefly neurotic. On the other hand, Scanzoni found in thirty-four cases inflammation at some part of the vaginal entrance, and he regarded this not as casual, but as causal, aud believed 588 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vaginismus. Vaginismus. that it resulted from traumatic violence during the first attempts at sexual intercourse. Now it must be evident that each of these views is too exclusive, and we must combine them in order to comprehend the truth. Further, fissures of the vaginal entrance-usually situated at the upper portion-ulcers, urethral angioma, and fissure, certain diseases of the uterus or ovaries or their displacement, vulvitis, anal fissure, etc., have been observed as causes of vaginismus. It may be, as Demarquay has said, such etiological rich- ness brings confusion, or one may ask with Winckel, why should we classify under one name and from one symptom, which is even by no means common to all, so many wholly distinct affections which can be differenti- ated anatomically and microscopically, and for many of which we have far better names, e.g., angioma, lupus, and oophoritis, names which indicate the seat and nature of the affection ? Nevertheless vaginismus not being a disease, only a symptom-but a symptom in many cases, however various its etiology, requiring direct treatment -we cannot in the present state of oui' knowledge, and in obedience to therapeutic requirements, dispense with the recognition of the many causes which may lead to it. The treatment of vaginismus consists, first, in absolute rest for the genital organs, all attempts at coition being strictly forbidden. Next, the hyperaesthesia of the parts should be lessened by local means. Among these means may be mentioned warm hip-baths, pencilling the sensitive surface with a solution of nitrate of silver, of .chloral, or of carbolic acid. Tarnier and Siredey advise iodo- form in powder ; but probably the best local sedative is a solution of cocaine, four to eight grains to the ounce of water. This last application has proved, in my experi- ence, especially successful in the vaginismus of recently married women. Having by some one or more of these means obtunded the sensibility of the parts, and relief not following, careful examination is to be made for a local cause, other than excessive sensibility, of the affec- tion. That cause being found, whether it be fissure, ulcer, angioma,.inflammation, etc., is to be removed. Possibly the cure of the pain and spasm will thus be accomplished, and no other means be required. But if other means are necessary, dilatation may be tried. This is either abrupt or gradual. The former may be accom- plished by the introduction of the thumbs into the vagi- nal orifice, the patient being anaesthetized, and separating them until the resistance is overcome by rupture of some of the fibres of the sphincter of the vagina, just as a sim- ilar operation for stretching the anal sphincter in fissure of the anus is employed. Another method is to use a bivalve, trivalve, or quadrivalve speculum, which is closed for introduction into the vagina, and then the blades being opened, the instrument is suddenly with- drawn. A third method is to use the Sims speculum, the patient lying upon her side, and the sphincter is stretched by strong retraction of the perineum ; this is especially recommended in the treatment of vaginismus superior. Most practitioners prefer gradual dilatation, spontaneous fracture of the instrument may occur, greatly to the consternation of the patient, possibly to her injury, while the instrument is in the vagina ; such an accident did occur to one of my patients. The parts are to be benumbed by the application of cocaine before the dilator is introduced ; it should be retained for half an hour, and one of a larger size em- ployed each succeeding day, until the dilatation is suffi- cient. The presence of the dilator helps to obtund the sensibility. But if the hymen be diseased, or if there be sensitive tubercles occupying its site after its rupture, the hymen or the tubercles should be removed, as advised by Sims. For the removal of the hymen the fol- lowing direction is given by Sims: "Plac- ing the patient (etherized) on the back, with the thighs well flexed over the ab- domen, the orifice of the vagina is to be forcibly dilated by fingers or instrument. Then seize the hymeneal membrane with a delicate pair of lock-forceps just at its junction with the urethra on the left side, and, putting it on the stretch, clip, with properly curved scissors, till the whole is removed in one continuous piece." In some cases the exsected piece will show two openings, one for the vagina, and the other for the urethra, as is seen in the accompanying illustration from Sims. Winckel speaks of his excising the entire urethral ori- fice in some cases. The hemorrhage, which may be considerable, is usu- ally venous, and can be arrested by pressure ; but if an artery bleeds ligation is advisable. In order to prevent the formation of a resisting cicatrix from the healing of the surface from which the hymen has been removed, v. Preuschen14 advises sutures, and Mann 11 speaks favor- ably of the continuous catgut suture. But Sims did not stop with the removal of the hymen -that was only the first step in the operation-he also divided the vaginal sphincter. After the completion of the exsection his further directions are as follows: " Then pass the index and middle fingers of the left hand into the vagina, separate them laterally, so as to dilate it as widely as possible, putting the fourchette on the stretch ; then with a scalpel cut through the vaginal tis- sue on one side of the mesial line, from above downward, terminating at the raphe of the perineum. This cut forms one side of a Y. Then pass the knife again into the vagina, still dilating with the fingers as before, and cut superficially in like manner on the opposite side from above downward, uniting the two incisions at or near the raphe, and prolonging them quite to the perineal integument. Or these vaginal incisions may be made, one on each side of the raphe, and parallel with it, termi- nating a third of an inch or more apart, on the perineal surface. The bleeding, usually trifling, is arrested by the introduction of the vaginal plug. I have had two cases where it was necessary to resort to the iron-cotton tampon for twenty-four hours. Generally the dilator is introduced at once. It is made usually of glass, some- times of metal or ivory. I prefer glass because it is eas- ily kept clean, and being transparent we can see the cut surface, and indeed the whole vagina, without removing it. Its introduction is attended with a sense of soreness, but with none of the peculiar agonizing suffering so characteristic of the original disease." The dilator is secured in position by a T-bandage, and is worn for two or three hours in the morning, and again in the after- noon or evening ; it is used for two or three weeks, or longer, or until the parts are entirely healed and the sen- sitiveness from the operation has disappeared. Dr. Emmet, who regards an operation as rarely nec- essary,18 gives the following directions for its perform- ance : " The patient is placed on the back, with the limbs drawn up ; after etherization a speculum is intro- duced under the arch of the pubis, so as to bring the posterior wall of the vagina into view. The index-fin- ger is introduced within the anus, and the sphincter is Fig. 4499.-Exsect- ed Piece of Hy- meneal M e m- brane, showing the two Open- ings. (Sims.) Fig. 4498.-Sims Vaginal Dilator. and this is best effected by means of the dilators devised by Sims. A series of these, progressively increasing in size, should be employed : they are usually made of glass, though they may be of vulcanite or of metal; if made of the former, the practitioner must carefully examine the instrument before its introduction, in order to know that it is without flaw and properly annealed, otherwise 589 Vaginismus. Vaginitis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. forced up against the posterior wall of the vagina. It is then easy to divide with scissors the fibres encircling the vagina on each side, just within the fourchette, and about three-quarters of an inch apart. This does not al- low a prolapse of the vaginal wall, but permits an equal extent of dilatation of the outlet by the glass plug." Bernutz urges the importance of complete exsection of the hymen, or of the myrtiform caruncles, and then ab- rupt dilatation of the vaginal ring, either with the fingers or with a bivalve speculum. Referring to the second part of Sims's operation, he states that it has been re- jected by French surgeons, but has secured, in the hands of the American surgeon, some successes, not only tem- porary but permanent, which he believes ought to be at- tributed to the violent perturbation produced in nervous women by the operation itself, just as one has seen sci- atica cured by cauterization of the lobe of the ear. Winckel does not employ incisions of the sphincter, but after the exsection of the hymen introduces a tampon of salicylated cotton, which is not made to fill the vagina, but simply to press upon the part operated upon. " Af- ter the wound has healed, if the patient still be anxious and sensitive, she should be given a Sims dilator and in- structed in its use, so that she may methodically dilate the vaginal orifice until she has courage to submit to sexual intercourse, which will usually result in preg- nancy." If the vaginismus has existed for some time, and the patient's health has become deteriorated, it is important to administer tonics, and further to promote her restoration by a wise hygiene, which might include bathing, pleas- ant social surroundings, travel, going to the seashore or to the mountains at a suitable season, and agreeable mental occupation. Theophilus Parvin. 1 Transactions of the London Obstetrical Society, vol. iii., 1862. 3 Manual of Gynecology. 3 Diseases of Women. 4 Traite clinique des Maladies de 1'Uterus. By Demarquav and Saint- Vel, 1876. 6 Principles of Midwifery, seventh edition, p. 41. London, 1828. 6 Nouveau Dictionnaire de Medecine et de Chirurgie pratiques, tome trente-huitieme. 7 Bibliotheque du Medecin-Practicien. 1842. 8 Lancet, 1849, vol. i. 9 Edinburgh Medical Journal, 1861. 10 Manual pratique des Maladies des Femmes. By Eustache. Paris, 1881. 11 Clinical Lectures on the Diseases of Women. Duncan, third edition. London, 1886. 13 Clinical Notes on Uterine Surgery. New York, 1869. 13 Diseases of Women. 14 Transactions of the London Obstetrical Society, vol. xvi. 16 Real-Encyclopiidie der gesammten Heilkunde, 1883. v. Preuschen in his contribution to the Encyclopaedia describes vaginismus under the name of reflex cramp of the muscles of the pelvic floor. 16 Billroth's Ilandbuch der Frauenkrankheiten. 17 Obstetrique et Gyn6cologie. 18 American System of Gynecology. 19 Principles and Practice of Gynecology. VAGINITIS. Definition.-Vaginitis is an inflamma- tion of the mucous membrane whicli lines the vaginal canal. It appears in all grades of severity, from a simple blush of color, with slight heat and dryness, to the most virulent inflammatory action with its attendant constitu- tional symptoms. No period of life is exempt from it. It is met with in young girls, in women during the child-bearing period, and in women who have passed the climacteric. It is most important to distinguish the two varieties- simple or non-specific, and specific or gonorrhoeal. They differ primarily in their cause or etiology, and in their remote effects ; the one when uncomplicated being at- tended with only a certain amount of personal discomfort and a limited impairment of general health, while the other may involve, in its later manifestations, serious in- flammatory action within the peritoneal cavity resulting in chronic invalidism and even in death. For convenience of description the subject will be con- sidered under two heads : Simple or non-specific, and spe- cific or gonorrhoeal. Simple vaginitis demands consid- eration under three heads, as it appears : I. In girls prior to puberty; II. In unmarried women ; III. In married women. Vaginitis tn Children.-Vaginitis in young girls between the ages of three and seven, and even later, is a very common affection. It usually shows itself in the form of a chronic catarrh. But it may vary in severity from this mild subacute inflammation to one attended with copious discharge and pain, with swelling and ex- coriation of the labia. The vulva and vagina, as far as can be seen, are sensitive and red, and even the buttocks and inner surface of the thighs may be inflamed and irri- tated. Causes.-It most frequently occurs in weak or strumous subjects, and results from lack of cleanliness. It may arise from "taking cold." Seat-worms are a frequent cause, owing to the intense itching they excite, which induces the patient to rub and scratch the parts, usually with dirty hands and finger-nails. Or these parasites may find their way into the vagina and inflame the parts by their presence. Self-abuse must also be reckoned among the causes of this disorder and should be ever present in the mind of the physician when consulted for this trouble, especially if the case is an aggravated one or persistently refuses to yield to treatment. Gonorrhoeal poison is also the occasional cause. There is a vague notion which persists among the depraved and ignorant classes that contact with virgin genitals will cure a case of clap ; and cases have been known where such cure has been attempted. Such examples, however, must necessarily be rare. More often it is communicated by water-closets, soiled linen, or towels. Dr. J. Lewis Smith records the case of a young man who was under treatment for gon- orrhoea, when his two nieces, four and six years of age, respectively, both became infected with specific vaginitis, probably from the towels. Purulent ophthalmia, which is usually considered the accidental accompaniment of specific vaginitis, may itself be the origin of the vaginal affection. They are recipro- cally dependent. The exanthemata are frequently accompanied and fol- lowed by a vaginal catarrh, due either to the direct action of the disease upon the membrane, as occurs in otorrhoea, or to the reduced conditon of the vital powers. Treatment.-The parts should be bathed frequently in warm water and all excoriated surfaces smeared with a protective ointment. Astringent injections thoroughly administered with a glass or hard-rubber syringe are usu- ally necessary, and in some instances must be continued for days and weeks. Tannin or alum solution (five per cent.), sulphate of zinc (two per cent.), nitrate of silver (one per cent.), are all efficient injections and should be administered twice each day. I have found a combina- tion of iron and potash in the usual proportions for a gar- gle very satisfactory : Tinct. ferri chlorid., 3 ij.; potass, chlorat., 3 j.; glycerinae, $ ss.; aq. ad § iij. When ascarides are present a dose of castor-oil should be given, to be followed for several days by daily injec- tions in both rectum and vagina of salt water, lime water, or infusion of quassia. In the meantime the general hy- giene and nourishment of the child, together with appro- priate tonics, must not be neglected. Caution must also be given regarding the danger of purulent conjunctivitis and ophthalmia from the infectious discharge. When masturbation is present, of course the child must be put under proper surveillance and restraint. Vaginitis in Unmarried Women.-Simple vaginitis is rarely a primary affection, being secondary to some inflammatory condition in neighboring organs of the pelvis. As a rule, it begins and continues in a subacute form, the most marked symptom being the catarrh, but this may at any time take on the character of a violent acute inflammation. On the other hand, the acute form may be excited primarily by some special cause and gradually pass into the chronic. It is important to de- termine early in the treatment of the case whether the inflammation be primarily in the vaginal mucous mem- brane or whether it be induced there by the irritating qualities of a discharge coming from some source beyond the vagina ; viz., the cervix, the uterus, the Fallopian tubes, or even a pelvic abscess. Thomas mentions the fact that he has seen two cases of profuse and obstinate vaginal discharge regarded as the result of vaginitis which were in reality produced by pelvic abscesses which emptied their contents into the upper part of the vaginal 590 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vaginismus. Vaginitis. canal. He says : " An element in such cases calculated to mislead the superficial examiner is the fact that vagin- itis does really exist to a limited extent as the result of the purulent flow from the abscess." Etiology.-When primary, in unmarried women, the most frequent cause is " taking cold." It may arise from undue retention of the menstrual discharge behind a too constricting hymen, where, through contact with the air, it undergoes decomposition and so becomes a source of irritation. Self-abuse is an occasional cause. Anaemic young women with a nervous erotic tempera- ment will often have a constant leucorrhoea with an irri- tated condition of the vulva and vaginal walls due simply to the vitiated condition of their general health. In our large cities the shop-girls or clerks are the class of pa- tients in which this condition is most often found. The custom of compelling these girls to stand constantly, long hours in succession, in the cramped and narrow spaces behind the counter in crowded stores breathing vitiated air is most disastrous. But to this is added the still more vicious rivalry among themselves (and I speak of it here because, although not confined to them, it seems universal with them and they are a large and increasing element of the female community) to attain what fashion regards as the forme exquisite. To this end they draw the corsets tight, crowd the viscera down into the pelvis, and so keep up a constant passive congestion of all the pelvic organs. This nature attempts to relieve by an in- creased secretion of the glands and membranes, producing the leucorrhoea and eventually a subacute inflammation. Diabetes is an occasional cause of vulvitis and vagini- tis. Accompanying this disease is usually an intoler- able itching of the vulva and mons veneris. Through scratching for its relief and the constant bathing of the labia with urine there is set up an inflammation of the vulva reaching sometimes well into the vagina. It is very intractable, on account of the ever-present irritant. Vaginitis in Married Women.-In married women, especially those who have borne children, simple vaginitis is not uncommon. In addition to the causes common to all women, as cold, want of cleanliness, pediculi, as- carides, diabetes, etc., they are subject to much more frequent uterine difficulty, to lacerations of the cervix and the diseased condition attending it, to violence to the vaginal membrane through rough or excessive in- tercourse-each and all of which may be the original cause of vaginitis. Mechanical irritants are a frequent cause, such as pessaries, which abrade the mucous mem- brane or simply act as irritants, and accidental contact of irritating substances used for application to the uterus, as chromic acid. " Three of the most virulent cases that I have ever seen," says Thomas, " were caused by contact of a solution of chromic acid with the vaginal walls in making an application to the uterus." The most frequent cause is an irritating discharge from the cervix or uterus. In these cases the irritation usu- ally commences at the vulva, where the secretions come in contact with the air, thus establishing an inflamma- tion which gradually travels back throughout the entire extent of the vagina. This may be seen thus originating as a patch on either side of the entrance to the vagina or sometimes as a ring encircling the entire introitus. Symptoms and Treatment.-The subjective manifesta- tions vary with the intensity of the inflammation. In very mild cases the patient is conscious simply of a leu- corrhoea with slight itching or burning. A careful examination both by touch and by sight with a Sims' speculum is most important. By this means the amount and extent of the inflammation can be learned, its primary or secondary nature ascertained, and the cause usually determined. Treatment can then be directed with intelligence and some degree of scientific accuracy. As the affection in this form is usually secondary, it de- mands only palliative treatment, the main efforts being directed to the original cause. Cleanliness, together with the soothing and astringent effect of heat, both of which are obtainedbythe hot-water douche, are usually sufficient to relieve the symptoms. Recovery is hastened by brush- ing the inflamed tract thoroughly with a solution of nitrate of silver, twenty or thirty grains to the ounce. This disease is frequently aggravated and, indeed, some- times induced by the poor quality of glycerine used on vaginal tampons. This is frequently a source of great annoyance, as it is not generally understood. In an acute attack the clinical features differ very lit- tle, and in some cases not at all, from the specific form of the disease. The description of both is therefore em- braced in the one account given under the head of Spe- cific Vaginitis. The treatment of both is also similar, and will be considered together. Specific Vaginitis.-Synonyms: Gonorrhoea in the female, Gonorrhoe, Vaginite, Blenorrhagie, Blenorrhoea, Elytritis. Definition.-Gonorrhoea in the female is an inflamma- tion of the genital and urinary passages, characterized by a purulent discharge which has been produced by contact of an infecting substance as the result usually of sexual intercourse. It may run a very acute course and then be- come chronic. It may be subacute in its inception, and slumber in this chronic state for years or until aroused to an acute form by some disturbing element. In an acute case, when first seen, the inflammation is usually coex- tensive with the entire visible mucous membrane of the genital tract, but it maybe limited in extent and confined to the vulva, the urethra, the vagina, or the cervix uteri. Hardy, Remy, and, more recently, Bumm, have pointed out the fact that the membrane lining the canal of the cervix uteri may be the original seat of the disease, the virus being absorbed by the cervix directly from the penis during the copulative act. Indeed, the last author maintains that the cervix is, as a rule, the primary seat of all gonorrhoeal inflammation. He says : " Gonorrhoea never occurs primarily in the vagina, but usually spreads thence from the cervix, or, more rarely, from the ure- thra. The stratified pavement epithelium forms so good a protecting tissue that the gonococci cannot effect an entrance unless changes which render the more delicate layers accessible have occurred. Surfaces covered with cylindrical epithelium, viz., the interior of the cervix, are not so resisting." The frequency with which the cervix is involved and the persistence of the affection in this locality mark it as a most favorable ground for the inception of the disease. The anatomical structure of the mucous membrane, as pointed out by Bumm, makes his d priori argument seem reasonable. In opposition to it, however, stands the testimony of the great majority that the most com- mon seat of the disease is the vagina. The tendency of the disease, whatever locality it may invade first, is to extend throughout the entire tract of mucous membrane, from the vulva throughout the va- gina, passing through the uterus, into and through the Fallopian tubes, and invading the ducts of all the glands opening along its course. Source of Contagion.-There is no doubt regarding the identity of the disease in the two sexes. The gonor- rhoeal discharge from an individual of one sex, when ap- plied to the genital mucous membrane of the opposite sex, produces a similar discharge with the same intense and protracted symptoms. But cases occur in men after intercourse with women who upon subsequent examina- tion present no sign of the disease. And Ricord (and all his host of admirers and followers have insisted on the truth of his statement) declared that a man could acquire gonorrhoea by intercourse with a woman who did not have it-" give himself the clap." While the authority of this great teacher has caused his theory to be maintained, and while it affords an easy and convenient explanation in many obscure cases, it seems far more reasonable, in the light of our present knowledge, to believe that the actor in this scene was afflicted with a latent gonorrhoea which by this act was converted into an acute form. Milton, in discussing this point, says: "That true gonorrhoea was ever thus set up in a man never previously infected I must, judging from experience, respectfully decline to believe." " True gonorrhoea requires no idiosyncrasy, no ale or champagne, no excess, no weakened condition of the 591 Vaginitis. Vaginitis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. urethra for its development, but simply intercourse with a female [or male] having a gonorrhoeal discharge. No abrasion of the membrane is necessary. Simple contact of the virus with the membrane is sufficient to establish the disease " (Van Buren and Keyes). It is impossible always to trace the source of the dis- ease in an individual case. Everyone is naturally anx- ious to relieve himself of suspicion. Prostitutes espe- cially cultivate the notion that gonorrhoea can be caused by an innocent leucorrhceal or menstrual discharge. But however much the relation of cause and effect may be obscured by false histories, and however hidden the di- rect source of the contagion, the best authorities of to-day are agreed that there is a specific contagium in gonor- rhoear discharge, that it is a virus sui generis and pro- duces results that are likewise peculiar to itself; in other words, that gonorrhoea alone can produce gonor- rhoea. What the essential causative element of the virus may be will be discussed under the next section. The Gonococcus.-In 1879 Neisser, of Breslau, de- scribed a micro-organism which he claimed was the ever- present essential element of gonorrhoeal virus, and named it the gonococcus. He also established the fact that this parasite is identical with one which is found in purulent ophthalmia neonatorum. Previous to this, efforts had been made to capture a germ that might be held responsible for the vicious pro- clivities of gonorrhoeal discharge. In 1844 Donne dis- covered in gonorrhoeal pus, and described, an infusorial animalcule which he named Trichomonas vaginalis. He announced that he had discovered the guilty party. But numerous advocates arose who were able to establish an alibi, and Donne was forced to renounce his convictions. In 1868 Salisbury described a cryptogam (Crypta gonorrhoea) which he announced as the true bacillus of gonorrhoeal discharge. His account is quite full and complete, and there are grounds for believing he de- scribed what Neisser rediscovered and named the gono- coccus. Many careful investigators in the field of bacteriology have confirmed Neisser's observations, and many others have denied them. The difficulty in the way of a gen- eral acceptance of Neisser's microbe has been the claim that the same micrococcus is present in pus from sources other than gonorrhoea. Moreover, in many cases of gonorrhoea, especially in women, other bacteria exist so similar in size and shape, and even in the manner of multiplying by fission and the formation of diplococci, as to render recognition of the gonococcus uncertain. But more recent and thorough experimentation in making cultures of this organism and applying to it various methods of staining have brought out its distinguishing characteristics with great exactness. Moreover, the be- lief in the gonococcus is constantly gaining adherents and is being practically used at the present time by some of our best observers. Neisser described the gonococcus as follows : It is large and rarely found single, is round at first, then be- comes somewhat oval, occurs usually in pairs lying close together and within the protoplasm of the pus-cell as well as on its surface, showing a constriction through its long diameter, or, having already separated, showing a pair or diplococci. These in turn multiply by fission in a line at right angles to the previous constriction or line of separation, and so continue in parallel lines in sets of twos, fours, or multiples thereof. A magnifying power of 500 diameters is sufficient to detect readily the gonococcus, but an oil-immersion lens, with power of 1,000 or 1,200, is much more satisfactory. A drop of pus is placed upon the glass slide and spread into a thin layer by pressing or rubbing with another slide which has been placed upon it. This is then dried in the air or by passing it rapidly back and forth in the flame of an alcohol lamp, keeping the smeared side up. A drop of the gentian-violet solution, or methyl blue in aniline-water, is now placed upon it for a moment, then washed off with a gentle stream of water from a wash- bottle. A few drops of Gram's iodo-iodide liquid are then applied for a few minutes. After this has been washed off, a cover-glass is placed upon it and it is ready for observation. The nuclei of the cells are seen darkly tinged with purple and the outline of the cells and granular contents faintly tinted, while the groups of cocci are clearly seen as clusters of minute black dots arranged as described above. Scattered sets of dots have no significance, but dots arranged in twos, fours, or multiples thereof are the specific gonococci. As a rule, this is the only micrococ- cus present in the thick purulent discharge of an acute case. But in chronic or latent cases, especially in women, as has been said, other bacteria are found which by the method above given cannot be distinguished from the gonococcus. Dr. Roux proposed to the Academy of Medicine, in Paris, a method of staining in these doubtful cases that has the virtue of simplicity and, as he claims, also that of exactness. He discovered that the gonococ- cus, unlike all other bacteria, did not remain permanently stained by Gram's iodo-iodide liquid when the slide was subsequently treated with alcohol. Therefore if there is doubt about the genuineness of the micrococci as observed on the slide as above prepared, the cover-glass is removed and the specimen washed with absolute alcohol till the color is thoroughly re- moved. The cover-glass is now replaced and the slide again examined. If there be an absolute disappearance of the gonococci which have been previously observed they are surely those of Neisser. If, on the contrary, they, as well as the other previously observed bacteria, persist and retain their color they are spurious. Significance of the Gonococcus.--Is its presence an in- fallible proof of the specific nature of a discharge ? Koch's test of the specific nature of a given organism lies in the fulfilment of three conditions : 1. That one and the same form of spore be always found in a given disease. 2. That this be easily recognized morphologically or chemically, as well as by its behavior to coloring materials. 3. That the disease may be artificially established in a healthy individual by inoculation with pure cultivations of these spores. In regard to the first condition, Keyes says : " I have never yet examined a thick purulent discharge which I believed for other reasons to be gonorrhoeal, without finding it loaded with gonococci." Indeed, its universal presence in gonorrhoeal pus is not disputed. The point of contention has lain in the fact that it was present in pus from other sources. In reference to this, Sternberg remarks that, like the infectious elements of other dis- eases, this may be a widely distributed and usually harm- less organism requiring special conditions and environ- ments to acquire specific pathogenic powers. The second condition is fulfilled by the gonococcus, in its behavior under coloring materials according to Roux's method, as well as morphologically. In addition to this, it has the property of penetrating living tissues- a distinguishing characteristic pointed out by both Bumm and Widmark. The third requirement has been fulfilled by the gono- coccus under the experiments of many careful observers ; viz., Bokai, Welander, Bockhardt, Leistikow, Konig- stein, and others. While it is impossible to describe these experiments with any degree of fulness, it may be of interest to glance hastily at a few of the most con- spicuous. Welander found gonococci present in the urethral dis- charge of twenty-five women. He was able to discover the source of contagion in each, and found gonococci in the urethral discharge of each of the twenty-five men. He took matter containing gonococci from the urethrae of three of these women and applied it respectively to the urethrae of three different men ; and on the third day each man had a characteristic gonorrhoeal discharge con- taining in each case an abundance of gonococci. Bock- hardt applied a culture-fluid of the fourth generation to the urethra of a paralytic, forty-six years of age, whose urethra was known to be free from disease. On the third day thereafter there was redness at the meatus and a discharge of pus containing gonococci which continued 592 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vaginitis. Vaginitis. till the twelfth day, when the patient died of hypostatic pneumonia. On the other side of the question Sternberg was un- successful in his efforts to establish gonorrhoea in the healthy urethra of three men with the culture-fluid of the ninth generation. And De Amicis insists that he has produced blennorrhagia in healthy urethra by injections of ammonia, and that in the discharge thus established he has found diplococci on the sixth day which he could not distinguish from those found in urethritis with an undisputed history of contagion. In reply to these statements it can be said that Stern- berg's negative results cannot weigh against the many positive results of other observers. And De Amicis differentiated his micro-organisms simply by their mor- phological characteristics. Roux's staining-test was not applied, nor was the characteristic feature of penetrating living tissue noted. Sattler and Haab, among the ophthalmologists, and Kroner, a gynecologist, and likewise Oppenheimer, have made careful investigations looking to the establishment of the identity of gonorrhoea and ophthalmo-blennorrhcea neonatorum. Kroner found the gonococci present in sixty-three out of ninety-two cases of the latter disease which he had observed. The vaginal secretions of twenty-one mothers, in the eyes of whose infants gonococci had been found, were also ex- amined by him, and every specimen contained gonococci. In the majority of the cases these were the only bacteria found. The vaginal secretions of eighteen mothers, in the eyes of whose infants no gonococci had been found, were free from the gonococci. Oppenheimer found gonococci present in the secretion from the upper portion of the vagina in thirty out of one hundred and eight pregnant women examined by him. Practical Significance of the Gonococcus.-Is the gono- coccus a reliable diagnostic sign ? While the majority of practitioners rely upon the clinical features for diagnosis, the presence of the gonococcus in all urethral or vaginal discharges raises the presumption at least of its specific character. The absence of the gonococcus is equally convincing of its non-specific nature. Keyes says : "I have frequently examined urethral discharges, and in- tensely purulent ones at that, and, failing to find the go- nococcus, have pronounced the source of alleged conta- gion non-virulent, and the patient to possess a discharge which he could not communicate to another, and have not yet been proved to be wrong." At the same time an abundance of gonococci may exist in urethral discharge and that person practise sexual inter- course repeatedly without inducing the gonorrhoea in the female. The wise practitioner, under such circumstances, will advise caution in practising intercourse, especially in marriage. Drs. Bryson and Burnett, from observa- tions of one thousand three hundred and ninety-four cases of gonorrhoea, draw the following conclusions : There is no case of high inflammation without the pres- ence of the gonococcus ; in cases diagnosticated, from absence of the gonococcus, as non-specific urethritis pa- tients had been granted permission to marry and the wife had remained well; in cases in which the gono- coccus was present in the discharge, men had married, contrary to professional advice, with unfortunate results Latent Gonorrhoea.-The serious nature of gonorrhoea in women and the importance of early recognizing its presence, except for the purpose of avoiding contagion, lias been sadly neglected. The idea of gonorrhoea has been so intimately associated with urethral trouble that unless that feature of the anatomy was affected no anx- iety was experienced. As the acute symptoms rarely continue longer than ten days or two weeks, and then subside, without leaving a urethral stricture in their train, this affection in women has been thought a com- paratively simple and harmless affair. But since Dr. Noeggerath, in his now classic paper, pointed out the latent propensities of this vicious disease, attention has been more carefully centred upon it, and it is now receiving some of the consideration which its impor- tance demands. The fact is recognized that after a par- tial advance toward recovery the disease may linger for years, and, by gradually extending itself, be the cause of cervical catarrh, endometritis, salpingitis, ovaritis, sterility, and the oft-repeated attacks of peri uterine in- flammation with which its victims are afflicted. But these unfortunate sequelae not only follow an acute at- tack in which due warning of their impending arrival has been given, but they may be the first indication of trouble, so insidious is this disease in its latent form. Dr. Noeggerath's views regarding the frequency of gonorrhoea in women were so extreme, and he insisted so strenuously on sterility as its inevitable consequence, that his paper met w'ith almost universal dissent. This was in 1872. But the pendulum is now swinging back. Some of his most bitter opponents are now giving cordial assent to his theory, and the careful observer is daily recognizing cases in his practice which illustrate the condition he so graphically described. He says that gonorrhoea, though apparently cured, may exist both in the male and in the female an entire life- time in alatent form ; that this latent form may be trans- mitted to the female, to continue there quiescent for an indefinite period, or, travelling along throughout the mucous tract, excite serious uterine, peri-uterine, or peri- toneal inflammation, or at any moment burst forth into acute gonorrhoea. He undertakes to show that the wife of every husband who at any time of his life before mar- riage has contracted a gonorrhoea, with very few excep- tions, is afflicted with a latent gonorrhoea which sooner or later brings its existence into view through some form of disease of the uterus or its appendages. While we may not give assent to the universality which Dr. Noeggerath claimed for this form of the affec- tion, it embraces such a large class of cases that it is most important to recognize it, and I cannot do better than place before the reader Dr. Noeggerath's graphic description of a typical case. Mr. M , a merchant of New York, formerly a com- mercial traveller, like almost every one of his tribe, ac- quires a gonorrhoea. The treatment recommended by a renowned specialist is carefully followed, and the affec- tion cured in two months. Two years later this gentle- man marries a healthy, robust young girl. Three months later the woman begins to complain of backache and general malaise ; it becomes difficult for her to attend to the common household affairs ; the usual promenade, in- stead of being a pleasure, becomes fatiguing. Menstrua- tion, which appeared hitherto without any premonitory symptoms, is now connected with backache, more pro- fuse than usual, and followed by a white discharge. By and by the desire to urinate becomes more frequent, and is occasionally accompanied by burning at the meatus. The white discharge gradually extends from one period to the next. About eight weeks later a pain is felt in the left side of the abdomen, which suddenly increases, upon an unusually severe exertion, to such an extent that the patient has to take to her bed. At the same time the dysuria is increased, the discharge becomes profuse and of a greenish-yellow color, like matter. The physician attending her recognizes an acute attack of perimetritis. A year after this she consults me for sterility. I find her suffering from general weakness, backache, pain in the left side, increased before the now scanty menstrua- tion, and a muco purulent discharge. On examination the uterus is found in right latero-ver- sion and anteflected ; the left vaginal roof, or parts above, hardened and contracted ; the uterus, soft, succulent,very tender on being gently pushed into its normal position, great tenderness of posterior cul-de-sac, cervix of a high color, os surrounded by a thin rim of eroded tissue, dis- charging a tenacious yellow mucus; both outlets of Cowper's glands eroded to some distance and painful to the touch. In the history of this patient we find no trace of the existence of acute gonorrhoea either before or after mar- riage ; but a condition very like it, if not truly gonorrhoea, is being developed during the acute attack of perimetritis. The patient has never been infected, in the accepted 593 Vaginitis. Valerian. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. meaning of the word, but she gradually develops a con- dition which wre usually observe as the result of an at- tack of acute gonorrhoea. These cases of latent gonorrhoea are distinguished from simple leucorrhoea as follows: If the upper part of the vagina be filled with a copious, glairy, greenish-yellow glue which adheres to the cervix tenaciously on attempting to remove it, gonorrhoea is present. And even when the discharge is scanty, pellucid, white, or of a pale-straw color, it is gonorrhoea, if the five following conditions also exist: 1, If there is also a red, eroded, narrow rim about the os ; 2, if there are signs of present or past peri-uterine inflammation ; 3, if there is catarrh of the vulvo-vaginal or peri-urethral glands attended with condylomata in the fourchette or around the urethral orifice ; 4, if the dis- charge is very difficult to relieve ; 5, if it has developed soon after marriage in an otherwise healthy woman with- out other morbific cause. These clinical features are quite sufficient for a diag- nosis ; but if, in addition to them, the gonococcus be pres- ent, the cause of the trouble is at once made clear. Thus latent gonorrhoea accounts not only for a large percentage of the manifold troubles embraced under the terms peri-uterine and pelvic inflammation, but there is no doubt that some of the cases of puerperal fever sup- posed to be due to septic poison are really caused by a latent gonorrhoea; especially those cases in which the in- flammation is circumscribed and the general septic con- dition is absent. Symptoms.-The patient's attention is early attracted, usually from three to five days after the impure inter- course, by a sense of heat and burning in the vagina. This is followed by aching and weight in the perineum, a throbbing pain through the pelvis, a profuse purulent and offensive discharge, frequent desire to micturate, and swelling of the labia. A severe attack will be ush- ered in by a chill and sharp rise of temperature-103° to 104° F.-anorexia, nausea, and general nervous excitation. The mucous surfaces about the vulva become excoriated, and the inflamed parts so sensitive that motion becomes very painful. If the nymphae are large they may swell to such an extent as to protrude beyond the labia and become constricted, a condition analogous to paraphi- mosis. Accompanying the discharge an almost intolerable itch- ing about the vulva sets in. This is usually worse just when the patient gets warm in bed and wishes to settle down for the night, and leads her to scratch and tear her person for relief. As a rule the poison finds its way into one or both of the ducts of the vulvo-vaginal glands, which open just in front of the lateral carunculae myrtiformes. Thence it may invade the gland and set up an abscess. This is extremely painful when once the capsule is put upon the stretch, and continues so till relief is afforded by the bursting of the abscess or artificial evacuation. All cases are not so severe. Instances occur in which the redness, swelling, and sensibility are but slight, and the discharge scant. Physical Signs.-Upon exposing the parts the labia are found swollen and tense, the mucous surfaces smooth and red, or abraded and livid in color, sore and sensitive to the touch. As the labia are separated a flow of puru- lent matter of a creamy or greenish color, sometimes streaked with blood, is seen exuding from the vagina. In cases as they present themselves at the public clinic this discharge may bathe all the external parts, excoriate the perineum back to and around the anus, irritate the integ- ument on the interior aspect of the thighs, and become mingled with the hair of the mons veneris, where it dries in yellowish crusts. The clothes are also soiled and stained with this yellowish discharge. To the touch, when digital examination is possible, the vaginal canal is found hot, the papillae and rugae rough and prominent. The introduction of the speculum is always painful, some- times intolerable, and should be managed with great care. When exposed to view through a speculum (and,Sims' speculum should always be used) the vaginal membrane presents a swollen, roughened appearance, the color varying in different cases and in successive stages of the disease from a bright red to a deep livid or leathery color, with patches here and there denuded of their epithelium, forming superficial abrasions. This usually extends throughout the entire canal, including the vag- inal surface of the cervix. About the external os is an inflamed granular ring of tissue, and hanging in the os is a mass of muco-pus. If a pessary has been worn, the im- print of it, when removed, still remains in the mucous membrane, and may be marked by abrasion. The urethra may or may not be involved, the scalding which attends micturition being frequently due to con- tact of the urine with the excoriated vulva. When, however, the lips of the meatus are swollen and irritated, and pressure by the finger along the canal of the ure- thra from behind forward causes pus to appear in the mea- tus after the parts have been carefully cleansed, its pres- ence there is certain. Formerly the involvement of the urethra was regarded as a diagnostic sign, but this is not reliable. Sometimes urethritis is a complication of sim- ple vaginitis, and sometimes it is absent in the specific form. Diagnosis.-The differentiation of this disease from simple acute vaginitis is extremely difficult, and in some cases impossible, by its clinical features alone. If a his- tory of recent suspicious sexual contact or intercourse can be obtained, in conjunction -with the well-known clinical manifestations, the question, for all immediate practical purposes, is settled. But there is no denying the fact that everyone, no matter how shy he may be of giving assent to the supreme importance of the gono- coccus, feels much more certain of his diagnosis when the presence of the bacteria is known. Prognosis.-Can an acute case of gonorrhoea be abso- lutely cured ? There is abundant evidence to prove that cases are so cured, and the physician is justified in as- suring a patient that, with proper treatment, the prob- abilities are that such will be the result in her individual case. But the virus has the property of penetrating so deeply into tissues, and the abundant crypts and folli- cles and ducts and glands afford so secure a lodging- place for the poison that the question of its total eradi- cation is beyond all ken. The more recent the attack and the more limited the area of infection the more fav- orable the prognosis. Treatment.-The importance of stamping out the dis- ease promptly cannot be over-estimated. Whatever line of treatment is pursued must be followed up with the greatest thoroughness, persistence, and attention to de- tail. Granting the causative feature of the gonococcus, the use of the most efficient germicide is the indication par excellence. Oppenheimer has made successive experiments to de- termine which parasiticide is most efficient against the gonococcus. His method of experimentation was to cul- tivate the gonococcus in sterilized blood-serum, the mi- crococci developing on bits of thread suspended or laid in it. Different substances were then applied to the so- lution and their effects noted. Alum, bismuth, and ace- tate of lead were absolutely harmless, as were also balsam of copaiba and extract of cubebs. Solutions of bichlo- ride of mercury, 1 to 20,000 ; carbolic acid, 1 to 20 ; per- manganate of potash, 1 to 25 ; weak solutions of nitrate of silver, and strong solutions of iodine, bromine, and of chlorine destroyed the gonococci promptly. Regarding copaiba and cubebs, it is important to state that, by an ingenious experiment, he seems to prove that these sub- stances undergo a chemical change in the system, the products of which are destructive to the gonococcus. This accounts for their efficiency in internal medication. Conclusions reached by such purely experimental methods must be tested by clinical experience. Nitrate of silver not only acts efficiently in destroying the gono- coccus in culture-fluids, but is found most satisfactory also in stopping the discharge, relieving the congestion, and restoring a healthy tone to the tissues. Such other drugs as serve this double end are the most efficient ad- juvants. 594 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vaginitis. Valerian. In all cases, unless decidedly contraindicated by weak- ness, a calomel purge, gr. viij.-x., with an equal quantity of bicarbonate of soda, should be given, to be followed from time to time by saline cathartics. If the external parts are much inflamed a general hot bath will afford great relief and produce a tranquillizing effect upon the system. This is preferable to the sitz-bath. The vagina should then be douched with tepid carbol- ized water to cleanse away the discharge, and this followed two or three times a day by a hot bichloride douche, 1 to 20,000, at a temperature of 110° F. As soon as the parts will tolerate a speculum (and in mild cases this can be done immediately), the vagina should be thoroughly ex- posed by means of Sims's speculum, all discharge carefully wiped away, and the membrane dried with absorbent cot- ton. Any excoriated points are to be touched with the stick of nitrate of silver and the entire membrane thoroughly swabbed with a solution of nitrate of silver forty grains to the ounce. The cervical canal is also swabbed with the same solution. Should the urethra be involved, an ap- plicator moistened with a weaker solution, twenty grains to the ounce, should be passed into it. Care must be employed in this manoeuvre lest the applicator or an ex- cess of the solution pass into the bladder, although if the bladder be full at the time no harm can result. The labia and external parts are also to be brushed thoroughly with the twenty-grain solution. Nothing brings so much re- lief as this free and thorough use of nitrate of silver. The immediate smarting soon wears away and a cooling sensation follows. If the patient is nervous and com- plains of this application, it can be readily neutralized by a little salt water. The patient and attendants must be cautioned about the contagious nature of the discharge, especially the danger to the eyes. All cloths and napkins used about the patient should be burned or at once soaked in strong bichloride solution. In the meantime the patient must be kept in bed, if possible; the diet should be light, simple, and nourish- ing ; she should drink plenty of milk and avoid all spir- ituous or malted liquors. The hot douches are to be continued thrice daily and the nitrate applied every third day ; the strength of the solution and area of application being determined by the progress toward recovery. When abraded, the walls of the vagina should be separated by adjusting a small tam- pon of cotton previously smeared with carbolized vase- line. It may be necessary also to separate the labia by placing between them a bit of linen smeared with the same. When an anodyne is necessary, a ten-grain Dover powder, or a suppository of opium, morphine, or chloral, is best. The pruritus is at times the most difficult symptom to relieve. The most efficient application is carbolic acid, which can be used in the strength of a five per cent, solu- tion, although it is well to commence with a weaker so- lution and increase the strength if necessary. The parts thus affected may be brushed with a solution of cocaine or of the nitrate of silver. Both are efficient. Treatment should not cease upon recovery from the acute symptoms, nor, indeed, upon recovery from all the subjective symptoms. Especially should the treat- ment in the fornix vaginae (Douglas's pouch) and interior of the cervix be carefully followed up. When the Na- bothian glands of the cervix are deeply involved, the plug of muco-pus hanging in the cervix is most tenacious. It can be thoroughly and easily removed by dilating the cervix with the steel dilators. This squeezes the con- tents out of the ducts and glands and brings the plug away in one mass, thus leaving the surface clean for the application. In some cases this tissue becomes so dis- eased that a cure is effected only by scraping it all away with the sharp curette. Should the vulvo-vaginal glands become involved it will be necessary to poultice them till fluctuation is de- tected, and then open as far within the vaginal outlet as possible. This condition may be mistaken for a prolapsed ovary or an inguinal hernia. The former is excluded by previous history and the latter by its percussion-note and, possibly, by reduction. The opening of the abscess will relieve temporarily ; but when once this gland has been invaded, it becomes a source of frequent annoyance, and a permanent relief is only obtained by its complete eradication. This, however, must be postponed till a subsequent occasion. It is accomplished by carefully dissecting out the sac of the gland or by making a free incision, curet- ting out the gland-structure, stuffing the wound with iodoform gauze or oakum, and making it granulate from the bottom. The former method is preferable, as the wound can be closed at once by deep sutures, but it re- quires careful, patient dissection and sometimes is im- possible. This abscess of the labium is the most frequent com- plication. Irritation of the bladder, and even cystitis, is not uncommon. The urine should be made bland and unirritating by alkaline and diluent drinks. Copaiba, as combined in the Lafayette mixture, acts very efficiently. Buboes are not apt to occur. When present, an effort should be made by purgatives and counter-irritants to dispel them. If suppuration is inevitable, a poultice hastens the process and gives relief. Granular and adhesive vaginitis are described by some authors as distinct forms of inflammation. They also occur as phases of simple or gonorrhoeal vaginitis, and hardly demand special consideration. The former, how- ever, sometimes declares itself as a distinct form of vagi- nitis in connection with pregnancy. Bibliography. J. Lewis Smith : Diseases of Children. Revised edition. 1886. Milton : Gonorrhoea and Spermatorrhoea. William Wood & Co. 1884. Van Bnren and Keyes: Genito-urinary Diseases with Syphilis. Revised edition. 1888. Emil Noeggerath : Latent Gonorrhoea, Transactions of the American Gynaecological Society, 1876. Emil Noeggerath: Die latente Gononhoe iin Weiblichen Geschlecht. Bonn, 1872. Charles W. Allen : Practical Observations on the Gonococcus, Journal of Cutaneous and Genito-urinary Diseases, vol. v., March, 1887. Keyser: Maryland Medical Journal, 1882-83, ix., p. 481. Eschbaum : Deutsche Med. Wochen., March 28, 1883, p. 187. Neisser: Centrl. ftir die Med. Wissen., 1879, p. 497. Oppenheimer: Arch. f. Gyn., vol. xxv., p. 51. Buinm : Arch. f. Gyn., xxiii., 3, 327. Andrew F. Currier: Gonorrhoea in the Female, New York Medical Journal, January and October, 1885 ; especially valuable for bibliog- raphy. Salisbury : American Journal of the Medical Sciences, 1868, p. 2. Thomas : Diseases of Women. Bryson and Burnett, of St. Louis : Clinical Observations of Gonorrhoea, etc. James B. Goffe. VALERIAN {Valeriana, U. S. Ph. ; Valerianae Badi.r, Br. Ph. ; Badix Valerianae, Ph. G. ; Valeriana. Codex Med.). Valerian, Valeriana officinalis Linn., Order Valerian- acece, is a very familiar perennial herb. It has a very short, thick, erect rhizome from which numerous slightly fleshy and soft, long, cylindrical, pale rootlets extend in all directions. It also produces horizontal suckers bj means of which the plant grows in gregarious clumps The stems are upright, simple below, cylindrical, hollow, and fluted ; the leaves odd-pinnate with sheathing bases ; the inflorescence is a large compound, cylindrical cyme. Flowers small, pale pink. The aspect of the plant seen at a little distance is much like that of some umbellifer. Calyx superior, very inconspicuous ; corolla funnel- shaped, slightly oblique and irregular, five-lobed, sta- mens three, pistil one, ovary one-celled, ovule pendu- lous. It is a native of the temperate portions of Europe and Asia. It is cultivated for medical use in England, Holland, parts of the United States, etc., and is common in house gardens, being grown partly as an ornament, and partly as a medicinal plant. The parts used are the rhizome and rootlets, which should be collected and dried in the fall. Wild plants are said to be the best. Valerian is a very characteristic and easily recognized drug. The pharmacopoeial description of it is as follows : " Rhizome from four-fifths of an inch to an inch and a 595 Valerian. Vanilla. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. half (2 to 4 centimetres) long, upright, subglobular or subconical, truncate at both ends, brown or yellowish- brown, internally whitish or pale-brownish, with a nar- Oil of valerian suitable for medical use is described in the Pharmacopoeia as follows : "A greenish, or yellow- ish, thin liquid, becoming darker and thicker by age and exposure to air, having the characteristic odor of vale- rian, an aromatic, somewhat camphoraceous taste, and a slightly acid reaction. Sp. gr. about 0,950. It is readily soluble in alcohol." Valerianic acid is also liquid, but thicker than the oil, colorless, of a strong valerian-like, but also sour and cheesy, odor, and a sour, burning taste. It is an active acid base and forms salts with the metals and alkaloids, several of which are in use. The action of valerian (and of the oil which represents it) is principally upon the nervous system, as a reducer Fig 4502.-Cross Section of Valerian Root. (Baillon.) of rellex and other excitability-that is, as an anti-spas- modic, like musk, asafoetida, chamomile, lavender, etc., as well as ether and the bromides. Like most essential oils, it is also a general and digestive stimulant, in moderate doses. Valerianic acid appears to have no useful medici- nal properties ; it is disagreeable, an irritant poison, and without the calming properties of the oil or fresh root. The intoxicating action of valerian on cats, which seem to have an irresistible craving for it, is well known. In very large doses, several drachms several times a day, it may produce, in man, dizziness, disturbance of vision, hallucinations, or active delirium. Nausea and vomiting are also likely to occur from such doses. It appears to be eliminated by the kidneys, which it stimulates slightly. Valerian is frequently given to patients suffering from emotional unbalance, hysterical and "ner- vous " (in the popular sense) disturbances, head- aches and other pains due to the same causes, as well as wakeful- ness, with con- siderable bene- fit. It is also given in some more serious a n d obstinate diseases, as cho- rea or epilepsy, especially petit mat, with occa- sional benefit. The most use- ful way to use valerian is to give either one of the galenical preparations of the drug, or the oil. Valerianic acid is not to be given. Even in the valerianates (zinc, iron, quinine, etc.) it is probably the other bases only that are useful. Dose of Fig. 4500.-Valeriana Officinalis. Flowering Branch. (Baillon.) row circle of white wood under the thin bark. Rootlets numerous, slender, brittle, brown, with a thick bark, and a slender ligneous cord. Odor peculiar, becoming stronger and unpleasant on keeping ; taste, camphorace- ous and bitter." Plants growing in dry, stony soil pro- duce the most highly flavored " roots." The most important derivative of Valerian is the es- sential oil (Oleum Valerianae, U. S. Ph.), obtainable to the extent of from one-half to one per cent. It is a mixed substance consisting of a terpene (valerin). a camphor, valeri- anic acid, and resins, the pro- portions varying according to the age of the root after collection, as well as to the length of expos- ure of the oil after it has been distilled ; when fresh it is light- colored, limpid, and fragrant; with age, becoming brown, thicker, and acquiring the sharper odor of valerianic acid. Valeri- anic acid (Isovalerianic acid) also exists in the root in in- creasing proportion according to its age. Fig. 4501.-Valerian Rhizome and Rootlets, about two-thirds natural size. 596 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Valerian. Vanilla. the root one or two grains (gr. xv. to xxx.). The offici- nal preparations are : Abstract (Abstractum Valeriana), a dry extract diluted with sugar of milk until its strength is | of the crude drug. Fluid Extract (ExtractumValeriana Fluidum), strength Tincture (Tinctura Valeriana), strength and the more commonly employed ammoniated tincture of the same strength as the tincture, but made with the aromatic spirit of ammonia as a basis. Allied Plants.-A few other species of this rather large genus have the same properties as the officinal valerian, and are used in its place, especially in the East. Allied Drugs.-Asafoetida, Musk, etc. W. P. Bolles. VALS. Tins well-known spa is situated in the Depart- ment of Ardeche, Southern France, lying in a valley at an altitude of about eight hundred feet above sea-level. There are sixteen or more cold, alkaline, strongly car- bonated mineral springs in the place, which vary consid- erably in strength, but are all of the same general type. The following are the constituents of four of the princi- pal springs calculated in grammes per litre : stems about as thick as the finger, and a metre or so long, producing root- lets by which it attaches itself to its " host," and alternate, somewhat two- ranked, thick, oval leaves a decimetre or more in length. The stem and leaves are smooth and shining, and of a dark, bright-green color. Flowers in axillary spikes, eight or ten in one cluster, about five centimetres across, of a yellowish-green color, and the peculiar irregularity and cohesion of stamens and pistil which characterize the order to which Vanilla belongs. Fruit linear, very long (fifteen to thirty centimetres, i.e., from six to twelve inches), about one centimetre in diameter, longitudinally striate, curved, and at maturity splitting into two unequal halves. Seeds innumer- able, minute (one-fourth to one-half millimetre), oval, flattened, hard, black, reticulated, exalbuminous. Vanilla grows wild on trees in moist, shady woods of Eastern Mexi- co. It is also extensively cultivated in Mexico, as well as in Madagascar, Java, the Mauritius, and other tropical places. Like other orchids, it requires the assistance of insects for fertiliza- tion. Under cultivation, fertilization is artificially accomplished. The fruit is over a year in coming to maturity. For use the fruits, usually called pods or " beans," are collected before they are quite ripe, and dried either sim- ply in the shade or by artificial heat, and smeared with a Saint- Jean. Madeleine. Desiree. Precieuse. Calcium bicarbonate 0.310 0.520 0.571 0.670 Magnesium bicarbonate 0.120 0.672 0.900 0.750 Sodium bicarbonate 1.480 7.280 6.040 5.940 Potassium bicarbonate 0.040 0.255 0.263 0.736 Iron-manganese bicarbonate... 0.006 0.029 0.010 Sodium and potassium chlorides 0.006 0.160 1.100 1.080 Sodium and calcium sulphates. 0.124 0.235 0.200 0.185 Total 2.086 9.151 9.084 9.361 Fig. 4504.-Fruit of Vanilla, X natural size. There are also traces of sodium arseniate, and of alumina. There is a large amount of carbonic acid gas. The temperature of the different springs varies from 57° to 60° F. In treating of the therapeutic indications for these waters many balneologists attempt to distinguish be- tween the different springs. But there is probably very little difference between them in regard to their therapeu- tic effects, since their constitution is practically identical, the differences being in degree rather than in kind. Among the affections for the relief of which a course of Vais waters is often recommended are the various forms of dyspepsia, especially those in which there is much acid eructation or vomiting, hepatic conges- tion, gall-stones, nephritic colic, catarrhal a f f e c - tions of the uri- nary passages, gout, obesity, and anaemia. In vari- ous forms of skin diseases baths of these waters are taken with appa- rent advantage. The accommo- dations for guests are good, and the climate is pleas- ant, though it is apt to be pretty warm in the sum- mer months. Vais water is exported in large quantities. T. L. S. VANILLA, U. S. Ph. (Fructus Va- nillcB, Ph. G.; Va- nille, Codex Med.). The fruit of Vanilla, planifolia. Order, Orchidacea. This is a parasitical climber (epiphyte) with perennial Fig. 4503.-Vanilla Plant. (Baillon, copied from Berg and Schmidt.) Fig. 4505.-4, Transverse section of vanilla pod, enlarged ; E, seed nat- ural size ; F, the same, magnified ; G, section of same ; D, the papil- lary gland-hairs lining the cavity of the pod. (Berg.) 597 Vanilla. Varicocele. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. little oil. A certain "sweating" effect, like that ob- tained in the curing of tobacco, is said to be sought, in order to develop the odor to its fullest extent. The pods are tied in compact bundles and are then ready for the market. The best vanilla comes in long, straight, flexible, dark brown, and shining, longitudinally-w'rinkled, very pleas- antly fragrant pods, twenty or twenty-five centimetres in flavoring and perfum- ing articles of food or for the toilet. A tinct- ure is officinal {Tinct- ura Vanilla), strength Th?. Allied Plants.- V. Pompona Schiede, furnishes the inferior Vanilla spoken of above. Very few or- chids have any econo- mic importance, ex- cepting their popu- larity as expensive hot-house ornaments. Orchis mascula Linn., and half a dozen other orchids, furnish Salep, a drug that is almost obsolete. Allied Drugs.- The Tonka Bean sup- plies a fragrant crys- talline substance, cou- marin, something like vanillin. See also Ben- zoin. W. P. Bolles. VARICOCELE. A dilated condition of the veins of the sper- matic cord is very com- mon in adult males, at least one-tenth of whom have such vari- cosity in greater or less degree. Unlike varix of the leg, it is an affection of early life. It has been seen in young children, but in the great majority of cases it appears at or soon after puberty, though oftentimes not attracting any special attention until the individual is twenty or more years old. In a compara- tively small number of cases it has first appeared after the fortieth or even the fiftieth year ; but, as a rule, it is then the vessels of the scrotum rather than those of the cord that are diseased. The frequency of occurrence has been attributed to the laxity and pendulous position of the scrotum, to the length of the spermatic veins, to their compression by an habitually overloaded large intestine, to the few- ness of their valves, to the effect of the contraction of the anterior abdominal muscles, to the constriction of clothing, to prolonged standing, to hard marching or rough riding, to the oft-repeated congestions due to sex- ual excitement, to genital excesses, to epididymitis, to hernia; in a word, to the multitude of causes which in- crease the flow of blood through the veins of the testis and cord, or hinder its ready passage to and through the renal veins. It cannot be questioned that such in- fluences do act in favoring the development and main- tenance of the condition, but there must be something beyond and behind all these exciting causes, or the dis- ease, often as it occurs, would be greatly more frequent, and it would not be so almost universally developed at the time of puberty. The essential cause must lie either in the original structure of the affected veins or in the changes effected in them at the period of sexual maturity. Spencer (" St. Bartholomew's Hospital Reports," 1887) has attributed the disease to a persistence of foetal veins which normally undergo complete involution dur- ing early life. In more than nine-tenths of the cases the varicocele is on the left side ; indeed to most practitioners a right- sided varicocele is one of the rare surgical curiosities. For this many causes have been assumed : greater weight Fig. 4506.-Section of Vanilla, showing Spiral Cells. (Berg.) length, and about seven or eight millimetres in diameter, flattened or somewhat three angled, one celled, with three placentae, and innumerable seeds. It is a striking micro- scopical object, in consequence of its beautiful spirally- marked cells, and the remarkable papillary glands which line the cavity (see Figs. 4507 and 4508). There are several commercial varieties of Vanilla, mostly of geographical origin, although one at least is from another species; this is shorter and thicker and less agreeable than the officinal (Mexican). Vanilla was found in use for flavoring chocolate among the aborigines of Mexico, when that country was first dis- covered by the Spaniards, but it did not become common in Europe for a hundred or more years afterward. It Fig. 4508.-Section of Vanilla through the Commissure where the Fruit splits. (Berg.) Fig. 4507.-Longitudinal Section of Brazilian Vanilla, showing Spiral Markings. (Berg.) was then used for scenting tobacco and other things, and as a domestic flavor, as it has been since. Composition.- The fragrant principle Vanillin, to which all the value of Vanilla is due, crystallizes in square, hard, colorless prisms of intense vanilla-like odor and warm, aromatic taste. It was first exactly studied by Gobley, in 1858. Since this time its chemical constitu- tion has been more completely determined, and its arti- ficial production on a commercial scale, from coniferin as well as from the oil of cloves, has appeared, but the arti- ficial vanillin has not yet attained the unexceptionable flavoring qualities of the natural principle. Vanilla has no value as a medicine, and is only used for 598 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vanilla. Varicocele. of the left testis and greater length of the left cord ; greater intestinal compression on the side of the sigmoid flexure; greater fixity of the left abdominal muscles to permit of more extensive movements of the muscles of the right half of the body ; greater arterial supply on the left side during the formative period ; right-sided location of the ascending vena cava ; the more direct entrance of the right spermatic vein into the cava, the left joining the renal at a right angle ; the presence of a valve at the junction of the right vein and the cava. This latter anatomical condition, for the discovery of which we are indebted to Professor Brinton, of Philadel- phia, without doubt has something to do with the pro- tection of the veins of the right cord, but does not alto- gether explain the greater frequency of varicocele of the other side ; for it has been clearly shown that in a large number of cases there is a valve guarding the entrance of the left spermatic into the renal vein, and when this is wanting, one will almost certainly be found a short distance below, or in the renal vein. It may then be declared that at present we do not know why there is the enormous disproportion which exists in the number of cases affecting the left and right cords. In the less serious cases of varicocele it is, as a rule having but few exceptions, the anterior veins that are en- larged ; the posterior ones being involved late, if at all, and when the varicosity is great. Occasionally it is the latter alone which are diseased. Almost invariably the affection begins in the lower part of the cord, where is to be found the greater portion of the mass, the dilated ves- sels becoming fewer and smaller as the external ring is approached. At times the large tortuous veins can bte felt in the inguinal canal. The veins of the testis may, but generally do not, take on varicose change. As is the case with the veins in general, there may be either (1) simple dilatation, or (2) dilatation with elonga- tion and thickening of the wTalls, or (3) dilatation with irregular thickening and thinning, the first-mentioned alteration being found only in recent or mild cases. The dilatation of the vessels may take place slowly and grad- ually, or quite rapidly, or rapidly after a previous long- continued slow development. A rapidly formed vari- cocele may be symptomatic of renal tumor. In one-half of the cases the disease, after progressing for awhile, is spontaneously arrested, and the condition of the parts later remains unchanged. In but a small proportion of the other half does it go on to form large varices presenting great structural alterations, and, with but few exceptions, it is only in connection with these extremely aggravated varicoceles that marked atrophy of the testis occurs. The diagnosis is usually readily made, as in the pendu- lous scrotum the dilated vessels are easily felt, th6 sensa- tion being generally that of a mass of earth-worms grasped between the fingers. In many cases the disease has been mistaken for hernia, the points of resemblance being the presence of a scrotal fulness, which becomes smaller upon lying down or when pressed up, and per- haps receives a slight impulse upon coughing. The pe- culiar feel of the enlarged veins, the more ready and complete reduction of the intestinal or omental pro- trusion, the return of the fulness in a case of varicocele while firm pressure is maintained over the external ring, the individual being in the erect posture (particularly this latter), should serve to prevent mistakes in the great majority of instances. When acutely inflamed the vari- cocele may present symptoms very like those of stran- gulation. Occasionally the two affections are associated, in which case the dilated veins may be separated and spread out upon the hernial sac. A congenital hydrocele may be confounded with vari- cocele, but the absence of the ordinary symptoms of the latter, and the presence of fluid, a little of which may be withdrawn with the hypodermic syringe, will determine the true nature of the affection. In a few cases of long standing, in which extensive clots have formed and the perivascular tissues become much thickened, the indurated mass has been mistaken for a malignant tumor. Aside from the already-mentioned feel of the enlarged veins the symptoms of varicocele are those of uneasiness and heaviness in the part, and of pain in the testis and cord extending up to and beyond the groin, or located in the perineum, the rectum, or the back. These symp- toms may be, and often are, almost or altogether absent. When present, they are, as a rule, aggravated in warm weather, by much exercise, and after sexual intercourse ; though coitus may afford decided relief. As is the case with varix in general, the amount of discomfort frequently has no direct relation to the extent of the dis- ease in the veins. In a great number of instances there is much mental distress present because of fancied im- pairment of virility. Atrophy of the testis does some- times occur, but not often, and not seldom the only mor- bid condition of any moment is in the head and not in the scrotum. An attack of gonorrhoea may cause rapid changes for the worse in a varicocele, and a resulting epididymitis is most likely to occur on the diseased side, as also wasting of the gland. Treatment.-Like that of any other form of varicose dilatation, the treatment of varicocele is either palliative or radical. In many of the milder cases so little discom- fort is experienced that nothing needs to be or is done, and in the majority of cases it is only necessary that a suspensory bandage be worn. One of the best, if not the most effective suspensory, is that first employed by Mor- gan, of Dublin, and bearing his name. This not only se- cures the desired compression, but also, by holding up the testis, favors the ready outflow of blood through the sper- matic vessels.* Passing the lower part of the scrotum through a ring has by some individuals been found more serviceable and less troublesome than wearing a bandage. Occasion- ally a light truss may be employed with advantage, the pad resting upon the vessels at and near the external abdominal ring, but much care must be taken to prevent undue pressure which will increase the difficulty ; this has often been seen when the truss has been applied for supposed hernia. With many patients the most impor- tant, and at the same time the most difficult, part of the treatment will be that having reference to the existing mental distress. When, because of the size of the varicocele, the extent of the annoyance, or the severity of the pain caused by it, or its interference with intended business plans (for it disqualifies for military and naval service), it becomes necessary to secure obliteration of the affected vessels, recourse may be had to extirpation, ligation, injection, or removal of a part of the relaxed scrotum. The first- mentioned form of radical treatment has been advised and practised from time to time since the days of Celsus, but until very recently the dangers attending it (haemor- rhage, inflammation, and septic infection) have been very great. At the present time, because of the use of aseptic ligatures and improved wound treatment, a much more favorable opinion may be entertained of it than formerly; and many surgeons have lately found extirpation through an open wound an excellent method of treating large and troublesome varicoceles. In by far the greater number of cases in which an operation is indicated, ligation is performed, and ordi- narily the relief afforded is complete and permanent. The simplest and best of the many ligature-operations that have been devised is the carrying of an aseptic cat- gut or silk ligature between the vas deferens and the *In the Dublin Quarterly Medical Journal, 1869, p. 490, Morgan thus describes the "Suspender," which consists of "a piece of web about 3% inches wide at one end, 4% inches long, 4 inches wide at the other, and gradually tapering to the narrower end. A piece of thick lead wire is stitched in the rim of the smaller end, and the sides are furnished with neat hooks, a lace, and a good tongue of chamois leather, two tapes being sewn along the entire length of the web, which are afterward attached to the suspending belt. The application is easily made by the patient in the morning before rising, and when the parts are relaxed, laying the affected organ, while in the dependent position, in the ' Suspender,' and lacing up the hooks with a moderate degree of tightness, then raising it up and attaching the tapes to the suspending belt previous to rising from bed. The size of the ' Suspender ' must, of course, vary more or less, but the measurements named will suit an ordinary case." 599 Varicocele. Variety Springs. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. varicose mass, and then between such mass and the skin, bringing the thread out at the point of entrance. When tied down firmly the knot buries itself, and later undergoes absorption or encapsulation. If necessary, the veins may be ligated at two or more levels. The spermatic artery is supposed to be pushed aside with the vas deferens, but probably is somewhat often included in the grasp of the ligature, without, however, any spe- cial damage resulting, because of free anastomoses with the other arteries. Recurrence of dilatation sometimes takes place, but seldom to the original extent. The use of a long straight needle, with an eye near the point, much facilitates the performance of the operation. Keyes' needle is an excellent one. The treatment by injection, into either the veins or the neighboring connective tissue, is rarely resorted to, being attended with some risk, and very likely to result in failure. Removal of a part of the scrotum, first suggested by Sir Astley Cooper, has proved to be one of the most sat- isfactory operations, the resulting contracted scrotum acting as a natural suspensory to support and compress the dilated vessels. In the modified operation of Henry the part removed lies on both sides of the median line, the narrow cicatrix occupying the position of the orig- inal raphe. To prevent haemorrhage the redundant tis- sue should be clamped, and after excision the edges of the cut carefully and thoroughly sutured before the clamp is removed. Primary union may be expected to take place. In many cases, after a considerable time, secondary relaxation and elongation of the scrotum occurs, but rarely to such an extent as to allow of the veins becoming as dilated as before the operation. Gener- ally such failure can be attributed to too limited removal of the scrotal tissues. As the ordinary result of radical treatment, when suc- cessful, the scrotum becomes smaller, the annoying weight and dragging are no longer experienced, pain ceases, and the mental distress is removed. The testis, if it has become softer and smaller, usually regains its normal condition, or nearly such. Occasionally, fortu- nately not often, the atrophy of the gland continues and the wasting becomes extreme ; attributed, but erroneous- ly, in the great majority of cases certainly, to the opera- tion if ligation has been done; being really due to the disturbances of the nutrition and innervation of the tes- tis from the disease of the veins, aided perhaps by in- flammatory changes in the connective tissue of the organ. P. S. Conner. VARICOSE VEINS. Permanent dilatation of veins is one of the most frequently observed surgical diseases. As usually seen, it affects the external veins, particularly those of the lower extremity, the spermatic cord (vari- cocele), or the lower end of the rectum (haemorrhoids) ; more rarely those of the vulva, the vagina, the prostatic plexus, the anterior surface of the abdomen or chest, and very seldom those of the upper extremity : in the latter case, the disease is almost always, if not always, congenital. The veins of the neck and face may be, but are not likely to be, varicose. Frequently the dila- tation affects numerous veins in various parts of the body, indicating a general weakness of the venous sys- tem. Varicosity of the internal veins is not often noticed, though doubtless it is of more frequent occurrence than is generally supposed. The deep veins of the lower ex- tremity may be affected, either alone or in connection with the superficial, and it would appear from the inves- tigations of Verneuil and others that, in the majority of cases at least, the disease begins in the deep or com- municating veins, and from them extends to the superfi- cial ; the perineal and posterior tibial being generally, the femoral, popliteal, and anterior tibial rarely, affected. The internal saphena and its branches are much more often diseased than the external saphena, and dilatation of the latter alone is seldom found. Women are less frequently the subjects of the disease than men. Though occasionally appearing in child- hood or in advanced life, the first manifestations are or- dinarily seen in the years between twenty-five and thirty- five ; when affecting the spermatic cord, at or about the period of puberty. An hereditary tendency exists ; and leaving out of consideration the cases in which there has been pro- longed pressure upon the larger trunks, the disease may be regarded as always consequent upon a predisposing original development. Etiology.-The exciting causes are many, but all act either by favoring the inflow, or, as is more often the case, hindering the outflow of blood from the affected area. Occupation, position, gravity, climate, season, tumors, pregnancy, compression, narrowing or plugging of the main vessel, anatomical obstacles (as fibrous rings surrounding the veins, or the emptying of smaller into larger vessels at an angle more or less closely approxi- mating a right angle), are the well-known causes to which the disease is attributed, and they all act mechani- cally. As the result, there is produced either (1) simple dila- tation, without structural alterations, or (2) uniform dilatation, with increase in the length and diameter of the vessel and in the thickness of its walls, or (3) un- equal dilatation, with irregular thinning of the walls and formation of pouches, in which only the internal and ex- ternal coats are present; such pouches are most frequent upon the internal saphena, and a tortuous, dilated, and pouched mass is often to be found just below or just above the knee. The valves may remain unchanged, but usually are more or less altered, and not seldom de- stroyed. Pathology.-The first variety, which is the least seri- ous, is due to a more or less distant obstruction to the outflow of blood through the vein ; with the removal of which the vessel resumes its original size. In the second and third varieties there has been developed a chronic inflammation of the vein, affecting chiefly its middle coat. If the vasa vasorum are involved, such dilatation of them may take place as that the vein-wall on section will present a cavernous appearance. Sooner or later, associated inflammatory changes take place in the peri- vascular tissues, the connective tissue thickening and be- coming adherent to the vein, and the overlying skin un- dergoing hypertrophy or atrophy, with discoloration, dryness, or more or less eczema. Small fugitive patches of redness, in apparently healthy skin, over the course of the vessel are not seldom noticed. As the result of stasis and of the inflammation of the perivascular tissues and of the skin, ulcers are very likely to be formed, espe- cially upon the legs, though many of the ulcers met with upon varicosed limbs are not true varicose ulcers. The nerves of the part often, but not always, are chronically inflamed. The bones of the extremities are very rarely affected, though the tibia frequently seems to be channelled, ow- ing to the thickening of the soft parts on the side of the readily yielding vein. Varicose veins of the meninges will cause absorption of the overlying skull, extending even to complete perforation, as I have seen in one case observed during life and examined post mortem. As the results of the phlebitis, clots are often formed here and there, at times plugging the vein for a consider- able distance or filling up the lateral pouches. Calca- reous deposits may occur in the vein-wall or in the contained coagula, forming vein-stones (phleboliths). Suppuration may take place in the clots or in the in- flamed perivascular tissues, and abscesses form. Spon- taneous rupture of the thinned wall at times occurs, permitting of the escape of blood subcutaneously or externally, the opening in the vein being usually quite small, even though the haemorrhage be a large one. Pregnant women are especially liable to this accident, which not seldom is followed by abortion. Frequently the rupture takes place without any preceding distress or apparent inflammation. Though occasionally the loss of blood is so great as to, directly or indirectly, cause death, the bleeding can generally be easily and quickly controlled by compression. 600 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Varicocele. Variety Springs. Diagnosis.-The diagnosis of external varix is usually readily made, as the large and tortuous vessels can be both seen and felt, and marked change in size and ap- pearance is rapidly produced by elevation and depression of the limb or by the application of heat. When the dilatation is located at or near the saphenous opening the case may be mistaken for one of hernia, but the differen- tial diagnosis can ordinarily be quickly established. When it is the deep veins of the extremity that are varicose it may be impossible to diagnosticate the affec- tion, though its probable nature can, as a rule, be estab- lished by consideration of the symptoms present (heavi- ness, pain, quick tiring, oedema of the parts below), and by noticing the effects of position and of pressure. A distinctly indurated condition of the calf (the veins of which are the ones most frequently affected) may occa- sionally be detected. Symptoms.-At times varix even of large size may cause little or no distress, but usually it is attended by a sense of weight, of fulness, of uneasiness, or of fatigue ; and often there is much pain in the limb, or the patient complains of heat or burning. No constant relation ex- ists between the size of the dilatations and the intensity of the nervous symptoms, though, as a general statement, the larger and more numerous the affected vessels the greater is the suffering. The accidental complications-haemorrhage, eczema, ulcerations, erysipelas, detachment of emboli and their lodgement in distant parts, even in the pulmonary artery, as at times occurs-are attended by the ordinary symp- toms of such conditions. When there is a rupture of a deep varix the symptoms are much like those following a blow upon the part; and if due to violence the resulting extravasation, swelling, and impairment or complete loss of motion may lead to an incorrect diagnosis of muscle- or tendon-rupture. Sudden plugging will be followed by the same general symptoms as rupture. Treatment.-The treatment adopted will differ accord- ing as it has for its object the relief of symptoms or a cure of the affection ; in other words, whether it is palli- ative or radical. The former, regard of course being had to the avoidance of undue standing and walking, consists in giving external support to the weakened veins by the application of a bandage or compressing stocking. The ordinary roller bandage should not be employed, as in the great majority of cases, if not always, no matter how carefully and how skilfully it is put on, it makes unequal pressure. The rubber bandage (Martin's) is much to be preferred, although many patients cannot or will not wear it because of the skin irritation pro- duced. This latter can generally be prevented by wear- ing underneath the bandage a thin stocking. A properly fitting elastic stocking, as a rule, gives better support and affords more relief than any bandage ; but the use of it at times causes irritation of the skin ; it may crease be- hind the knee and thus make painful pressure, and it is somewhat costly and soon wears out. If they are to be worn day and night, two stockings should be used, change being made on retiring and on rising. For patients of quite limited means the rubber bandage is better than the stocking, or a laced stocking of cloth may be worn with advantage. Occasionally, in persons having very irri- table skin, the elastic stocking will have to be worn over a thread one (as indeed it had better be always), or even to be split down and laced. In all cases attention should be paid to the removal of undue pressure upon the veins. In women disuse of the garter, or its application above and not below the knee, will often be followed by decided improvement. Constipation should always, if possible, be removed and prevented. When the varix is conse- quent upon tumor pressure, the removal of the growth is of course indicated. The radical treatment seeks to obtain the obliteration or removal of the dilated vein ; and this may be accom- plished by caustics, by injections, by ligature, or by ex- tirpation. Caustics (of which the Vienna paste, caustic potassa, and Canquoin's paste, especially the first, have been chiefly employed in modern times) act by destroy- ing a limited portion and inducing closure of adjacent parts of the vessel. Small quantities of the caustic, e.g., the Vienna paste, are laid upon the dilated vein at dis- tances of three or four inches, allowed to remain for a few minutes (ten to twenty), and then removed, the parts being then bathed with a weak acid solution (vinegar) and later poulticed. Direct injections of coagulating fluids, such as the solutions of the persulphate or perchloride of iron, have often been employed, and alcohol and ergotin have also been introduced in the same manner with the hypodermic syringe. Instead of throwing the fluids into the veins they have been injected into the adjacent connective tis- sue, ergotin being found to be the best agent for use in this way. The probabilities of cure following this method of treatment are not great, and occasionally vio- lent inflammation of the connective tissue is lighted up. Ligature has been resorted to from the earliest times, and the thread has been introduced through an open wound or subcutaneously, has been carried over the ends of a pin or pins thrust under the vessel, has been tied down upon a roll of cloth or plaster placed over the vein, and, finally, with the ends cut short, has been buried under the skin. At the present time aseptic gut or silk ligatures, subcutaneously placed, are the ones or dinarily employed, and if ligation is made it should be done preferably in this way. Extirpation of the enlarged vessels has been, from time to time, since the days of the Romans, a favorite pro- cedure ; to be again and again abandoned because of the associated dangers of haemorrhage and septic infection. The employment of the Esmarch bandage, of the anti- septic method of operation and after-treatment, and of the aseptic ligature now renders excision of varicose masses both safe and often advisable, and the long, tor- tuous, dilated veins may be removed en masse (I once removed twenty-six inches through a sixteen-inch inci- sion), or may be taken away in sections, as originally suggested by Davies-Colley. Of the various kinds of radical treatment subcutane- ous ligation and extirpation are the best, the latter being reserved for cases in which the dilatation is very great. Properly performed there is but little danger of serious complications arising, primary union may be expected, and the desired effect is produced quickly and without much distress. Very generally, however, the relief afforded is but temporary, neighboring veins enlarging and the incon- convenience from weight, swelling, and pain becoming as great as, or greater than, before. For this reason, as a general rule, the palliative is to be preferred to the radical treatment. P. S. Conner. VARIETY SPRINGS. Location: Augusta County, Va. Access.-During the season these springs are a station on the Chesapeake & Ohio Railway. Analysis, by Professor William Gilliam. One pint contains: Grains. Chloride of potassium 0.037 ' Sulphate of potassa 0.036 Sulphate of magnesia 1.455 Sulphate of alumina 4.301 Sulphate of protoxide of iron 0.639 Sulphate of lime 1.666 Free sulphuric acid 0.171 Silica 0.142 Total 8.447 Therapeutic Properties.-This is an excellent alum water, acting as an astringent and diuretic. These springs are situated in the mountains on the western border of Virginia, not far from the Rockbridge Alum Springs, which the water of the spring analyzed above, known as the Alum Spring, closely resembles. In addition to the above spring there are several others, known as the "All Healing," "Sulphur," and " Chaly- beate ; " hence the name of Variety Springs. G. B. F. 601 Vehicles. Vehicles. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. VEHICLES. By a liberal interpretation of the term vehicles, I shall include the animals that draw them, trusting that no apology will be needed for treating either branch of a subject as to which most physicians are supposed to be informed. There are three kinds of carriages that doctors use-the chaise, the buggy, and the brougham. Nothing more comfortable or more conven- ient than the old-fashioned chaise or gig is likely to be invented, and so far as "top" vehicles are concerned, none perhaps is more picturesque. The principal objec- tion to the chaise lies in the fact that a four-wheeled wagon of equal, or even of somewhat greater, bulk is easier for the horse to draw, and in a mountainous coun- try, where in descending a hill the weight would come chiefly upon his back, the gig is altogether out of place. For use in the city, however, or for comparatively short trips in the country, it is an admirable doctor's carriage. The top affords protection from storm or cold in winter, from the sun in summer, and with the back curtain up there is a draught which makes the gig far cooler than a brougham. It is, of course, very easy to turn, hard to upset, and it has an eminently professional and work- manlike air. There used to be, and in some remote country neigh- borhoods might doubtless still be found, a queer, con- tracted gig, just large enough to hold one person, which was used chiefly, if not exclusively, by doctors. Some- times, but not often, it had a top, and it was extremely light. This carriage was probably the forerunner of the modern sulky, and it would be interesting to see a col- lection of vehicles representing the gradual development from the physician's chaise to the present gossamer-like structure. A track sulky now weighs about forty pounds, and is, nevertheless, strong enough to carry a heavy man at the rate of a mile in two minutes and ten seconds, or less. Whether the first step in this direction was taken by some horsey young physician, or by a jockey who ob- served that in a brush on the road the doctor competed with him on more than even terms, must be left to con- jecture. During the past few years very light carts, weighing about one hundred and fifty pounds at the most, and va- riously known as road-carts, gigs, or jumpers, have come into use, chiefly for breaking colts and for exercising horses. Some of them are, under favorable circumstances, easier to ride in than almost any other vehicle yet made, and they are so well balanced that little or no weight comes on the horse's back, except in going down hill. They do not, it is true, pass lightly over a stone, but they dip into a hole and out again very pleasantly, and on smooth or even on paved roads, they are excellent. Of course they are not suited to horses that trot with much movement, for the motion is communicated to the cart; but with a short-stepping, smooth-going horse-and such a gait is the proper one for a roadster-these light carts are very comfortable; the best of them are strongly made, and their cost is very low, being twenty-five or thirty dollars. For a young practitioner in the country a cart of this description would make a very convenient second or " change" vehicle, to be used especially when the roads are muddy and bad. The two-wheeled dog-cart, or the stanhope, which is a dog-cart with a top and with no back-to-back seat, is well adapted for a city doctor's use. It should not, however, be too high, which is a little finical and foppish in a vehicular sense, nor so low as to suggest that it is even remotely intended to collect orders for a grocer. More- over, there should be no back seat, the groom's place being beside his master. This is in accordance with the general principle that in a doctor's carriage not an ounce of superfluous weight, or an inch of unnecessary space, shall be permitted. The physician's vehicle most in use is, of course, the buggy, no other carriage being capable of assuming so many forms, or of adapting itself to so many exigencies of road and weather. It varies from the single-seated, side-bar, top-wagon, so called, weighing sometimes not more than one hundred and twenty-five pounds, to the family buggy, which tips the scale at four hundred and fifty. The present fashion is to make these carriages low, but this is a disadvantage for a doctor, at least for a country practitioner. In a high carriage one can see the road, and is better able to avoid the stones, holes, and gullies which have to be encountered ; and on a dark night it is much easier for the driver to discern what is ahead if he can look over the horse's back and between his ears. A low carriage may be permitted to the in- firmities of age, but even in this case a high one, fitted with proper steps, might be made to serve. One never sees on a high buggy a folding step, such as is sometimes used on large carriages, but an arrangement of this sort might easily be contrived. Another device that ought frequently to be employed is the brake. This, if of small size and nicely made, need not look amiss on any buggy of moderate dimensions. It would be of great assistance to the horse, and a safeguard in case of his running away. It is singular that in England, where there is much less need of them, brakes are used far more com- monly than on this side of the water. Many young doc- tors in the country, especially those who are so fortunate as to own a fast stepper, have very light side-bar buggies. This is an excellent carriage for good roads, but it is a very poor all-round vehicle, and when the side bars lose their elasticity, the motion which they produce is ex- tremely unpleasant. Much better for general country use is the strong, arched, side-spring known as the Con- cord wagon spring. A carriage thus equipped runs very comfortably on smooth roads, and it will bound over stones and glide through gullies with extraordinary agil- ity. These springs, it must be confessed, give a some- what awkward appearance to a top-buggy, but with an open one they look very well, and a wagon thus made is an excellent doctor's carriage. The physician should see to it that he has room enough in front for his legs. There is a tendency in builders to make the box of an open wagon too short. There are three types of buggies. The lightest kind is, properly speaking, a top-wagon, and it is usually con- structed with the side-bar springs which have been mentioned. Next comes the piano-box buggy, so-called, which differs from the top-wagon in that it has a stuffed back ; and, thirdly, we have the heavier kind, known commonly as the Goddard buggy, the name being derived from that of a famous builder who flourished in Boston about forty years ago. The most suitable doctor's buggy is perhaps a sort of cross between the piano-box and the Goddard, built on straighter lines than the God- dard, and avoiding the laisser-aller, lounging appearance of the latter. The Goddard buggy is also too low, and, as a rule, too heavy. A carriage constructed with "piano-box" sides is hard to get into, and many people condemn it on that ground ; but the box-sides protect the feet and legs from cold, and although this might seem a frivolous point, it will not be regarded as such by those who have taken long drives in winter in both forms of buggy. Very little need be said as to the kind of brougham that is proper for a physician's use, but let it have a straight and not a circular front. In other respects, also, it ought to be made just as light as is consistent with durability, and no larger than is absolutely necessary. The present tendency among carriage-makers is exactly in the opposite direction. Our American builders are cap- able of turning out strong, graceful, and comparatively light carriages of this description, but the prevailing Anglo-mania directs that they shall be ponderous and cumbersome. As to the harness for the physician's horse, it ought to be a trifle heavier than the common, and either brass- or nickel-mounted. In short, the doctor's equipage in gen- eral-horse, carriage, and harness-should be distinctive, and its proper key-note is solidity. Being calculated for hard drives in all sorts of weather, on all kinds of roads, its outward appearance should typify an in- ward state of preparation. A nicely-groomed horse sug- gests a well-fed one, and if the wagon is clean, it looks stronger and more ready for use than if it be dirty and mud-bespattered. There are various little touches that 602 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Veliiclem. V chicle*. give the true professional air, such as side lamps on a buggy, a "boot" held by straps on the dasher, a top witli an extra projection in front, a heavily-mounted harness, and the like. These are all matters not only of style, but of substance, and rightly distinguish the pro- fessional from the lay equipage. Much more interesting than any construction of wood and iron, however cunningly put together, is the living creature that draws it. The doctor and his horse, espe- cially if they are country practitioners, should be not only on easy and familiar, but upon confidential and af- fectionate, terms. The first requisite of the equine part- ner is intelligence. The doctor's nag must travel by day and night, and wait at the roadside till he is wanted. He has to encounter all kinds of objects, sometimes to endure a breakdown, and if he be stupid, his master's life may be the penalty of his folly. The horse to buy is one whose eyes have a full, clear, steady look, and whose ears are in continual movement. If he pricks them, and simultaneously puts one forward and one back, when anything attracts his attention, he is pretty sure to be an intelligent animal. The horse to avoid is one whose eyes are small and have a wild, timid, quick- moving appearance, whose ears are planted near together and are apt to be held slightly backward, and inclined toward each other. Many amiable horses have a trick of laying back their ears flat on the head when anyone ap- proaches them. This is not necessarily a bad sign. The amount of space between the eyes affords some indica- tion as to the size of the brain, but the depth of the head between the poll and eyes is a surer criterion, and the eyes themselves are the main point. With some practice, any observant person can become a connoisseur in equine intellect; and if he wishes models to start with, let him study the houyhnhnms in a fire department, where in- telligence is a sine qua non. It is possible, of course, for a horse to be both intelligent and vicious, but such cases are not frequent, and usually the explanation is that the animal has been abused. One of the best horses ever driven in New England was owned by a doctor, who bought him for a song, shortly after he had killed his former master. He was a high-strung, mettlesome beast, and wdien treated kindly and gently, became docile, good- tempered, and affectionate. The same physician once had an experience which illustrates the value of intelligence in the doctor's horse. On a dark night he was driving fast in a lonely neighbor- hood, the reins hanging loose, for he could see nothing, when suddenly, and before he could interfere, his mare plunged to the left side of the road, dragging the buggy after her. The next moment a wagon containing two drunken men dashed by in the track from which the doctor's horse had just escaped. The explanation is ob- vious : the mare, knowing that she was on the right side of the road, waited till the last possible minute, and then, perceiving that a collision was otherwise inevitable, jumped out of the way. Well-bred horses are, of course, more apt to be intelligent than " dung-hills," as they are called ; but among American horses of all grades it is not difficult to pick out good intellects. The trained horses that were exhibited in this country a few years ago were, with one or two exceptions, ordinary "fam- ily " nags of no particular descent. It may be a superfluous, or even an impertinent, task to inform physicians what kind of a horse is suited to their needs, but a few words on this subject might possibly be of use to some young doctors whose experience in this matter is just beginning. About the worst type for their purpose is the Hambletonian, the most fashionable horse in recent years. He is apt to be long-backed, sluggish, not over-intelligent, ungainly, and very coarse about the head, ears, and neck, speed being his good quality, though he is not deficient in endurance. The proper horse for a doctor is short-backed, round-bodied, intelli- gent, courageous, and tough. Such an animal is the Morgan horse of New England. This family fell into neglect when the craze for fast trotters arose, and the Hambletonian horse came into the ascendant; but of late its high value has been recognized, and Morgan stallions and still more Morgan mares are now much sought for as crosses even in the breeding of trotters. The Morgan horse bears a striking resemblance to the Arabian. Both are somewhat under-sized, though the Morgan is larger than the other, the Arab rarely exceeding 14J hands; and both are round, compact, enduring, intelligent, gentle, and courageous, with perfect feet, noble heads, and small, aristocratic ears. Of course the Arab is much more finely turned and smoothly coated than the Morgan. The Percheron horse also is founded upon the Arab, and for his size is a very nimble beast. He is in fact a kind of magnified Arabian, retaining the fine head and ears as well as the gentle disposition of his ancestors. A span of Percherons are said to have drawn an omnibus one mile in four minutes. They are of course too heavy for a gig or brougham, but crossed with a smaller horse, of similar blood and build-such, for instance, as the Arab himself-they might produce a strain of noble road- sters and coachers. For long, hard driving, Arabian blood, derived through the English thoroughbred (as was the Morgan horse), or otherwise, is indispensable. In no other way can the requisite bone, muscle, nerve, and en- durance be obtained. For bad going, especially in the city, a short-stepping horse is almost essential; he gets over mud, ice, and snow more cleverly, and is much less likely to strain himself, than a long-striding beast. High-steppers are of course to be avoided; they are only fit for purposes of display, and would soon pound themselves to pieces in front of a doctor's brougham. For such work rather small horses, even so light as nine hundred pounds, will prove more serviceable and more enduring than larger horses ; a stout body on short legs, producing what is known in horse language as " a big little 'un," is the kind to be sought. In addition to these suggestions, and with such an apology as writers used to make for translating a Greek or Latin sentence, a few hints may be offered about the care of the doctor's horse. In the city this will be left to the groom, a faithful one, it is to be hoped, though the reverse is probably the case. But in the country it usually happens that the physician either looks after his own nag, or has a hired man whose time is dis- tributed between the stable, the garden, and the wood- shed. The doctor comes home, we will say, after a long drive, and, supposing him to be careless or ignorant in equine matters, does not slacken speed until the stable door is reached, when he puts his horse in the stall, takes off the harness, and, after allowing an hour for cooling, gives him water and oats. This insufficient treatment will leave the animal a great deal less comfortable and render him much less " fit," than he might be made at the expense of a little time and pains. The instructed and merciful driver will, in the first place, "slow down " when near home, allowing the horse to become cool, or comparatively so, before he enters the stable. When the harness is off, he will take a pail of water, and sponge out the horse's eyes and nostrils, letting him drink not more than one or two swallows, or better yet, rinsing his mouth with a clean sponge. With another sponge kept for the purpose, he will then wash his feet, taking out any dirt or gravel with a pick, and finally, with a damp, but not wet sponge, he will wipe the dust or dirt from his legs. He will then straighten his hair with a brush, dry his head and ears with a cloth, wipe the inner side of his legs, and blanket him, according to the weather. These little services can be rendered in five or ten min- utes, and they are of great benefit. When the horse has become perfectly dry, he ought to receive a thorough grooming, and if the exigencies or resources of the es- tablishment are such that he can be cleaned but once a day, it is much better to forego the dressing that will be due the next morning than to leave him as he is over- night. When the horse comes in thoroughly tired, much more can be done to restore him. His ears should first be handled gently, and dried; then he should, if possible, be allowed to roll in a paddock or box-stall; and finally he should receive a good rubbing, especially in the legs. Nothing else restores a tired horse so well as rubbing his 603 Vehicles. Veins. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. legs. A drink of oat or other meal and water may be given when the animal is perfectly cool. After a very hard day the doctor should accommodate his horse with a particularly soft bed ; and it is well to do so, if possi- ble, the night before a long drive, according to the prin- ciple upon which Wellington made his soldiers stretch at full length on the ground whenever he halted in the course of a protracted march. For the same reason a box-stall is always better than a straight one. The most approved way to treat a horse who comes to the stable in a sweat is to rub him dry, but this is impracticable, except in large establishments ; it cannot be done prop- erly by one man, for the animal is likely to take cold before the long process is completed, and therefore it is better to blanket him, unless the weather is very hot, and to walk him about, if convenient, though this is not ab- solutely necessary. If the horse be exhausted, a dose of wine or spirits, or a bottle of beer, will revive him ; and let him have a bran mash at night instead of his oats. The mash, in ordinary cases, should be given regularly once a week, and it is usually best to stuff a driving horse's feet about as often. Moss is good for this pur- pose, or oil meal and bran, and, perhaps best of all, a mixture of cow-dung and garden loam. Inasmuch as the doctor's horse has to stand out in all weathers, his street blanket should be a heavy one, and, what is less obvious, it ought to fasten under the belly with a strap and buckle. Without this simple device-which, by the way, is almost always omitted-the blanket will be of little benefit in windy weather. Of late years thin woollen blankets have come into the market. These are excellent for summer, and very good in winter, when they take the place of a " sheet" under the heavy blanket. A. word ought to be said concerning the vexed subject of clipping. On the whole, it is best not to clip the legs, though the fetlocks should be trimmed ; and the horses of the city doctor, which seldom travel far without stop- ping, should not be clipped at all. But in the country the case is different. The country doctor's horse has to go long distances, often at high speed, and conse- quently, if unclipped, he will be wet a large part of the time, not only on the road, but in the stable. For him, clipping is undoubtedly the best plan. If his coat be long, he will, at the end of his drive, when the pa- tient's house has been reached, stand still outdoors, wear- ing first a heavy blanket composed of his own hair, wet through, and secondly a dry one on the top of that. If, on the other hand, he has been clipped, he will be provided at the end of his drive with a single dry cover- ing, and that is much better than two blankets, of which the one next to his skin is wet. Of course the street blanket of a clipped horse should be made double the usual thickness, and should cover his neck. In very se- vere weather, the doctor might throw his bear-skin over the blanket. Thus protected as to his body, and with his legs unclipped, the horse will not suffer from cold. In the city, physicians often use quarter-blankets while their horses are in harness. They are better than noth- ing, and if, as is frequently, perhaps commonly, the case, the coachman is too lazy to get off his box and put on full-sized blankets while waiting for his master, the quarter-blanket serves more or less efficiently as a sub- stitute ; but even under such circumstances a full blanket under the harness is preferable. What with the failure of coachmen and grooms to cover the animals properly in the street, and still more with their neglect in the stable, the horses of a city practitioner are apt to fare hardly in winter. It is no uncommon thing for the physician who owns four horses, to find two and even three of them disabled at one time, occasionally from cold, and more often from scratches or " mud fever." In nine cases out of ten the trouble might have been avoided. If, on com- ing into the stable, the horse's legs and feet be washed and thoroughly dried, and a little vaseline, or something of that nature, applied, scratches are very nearly impos- sible. It is a good plan also to use glycerine once a week or so ; and the hair about the fetlock-joint should be trimmed so that the legs can be dried perfectly and with comparative ease. The legs should never be washed without drying ; it is better to let the mud stay on until it can be brushed off. In fact the whole duty of man to- ward his horse in this respect is summed up pretty well in the stable aphorism : " If his legs are dry, leave them dry ; if they are wet, dry them." Other kindred topics might be treated, but too much perhaps has already been said ; and yet so great and so common is the suffering inflicted upon horses by the ignorance or carelessness of those having them in charge (to say nothing of positive brutality), that the writer will doubtless be pardoned by the instructed reader for having discussed the subject somewhat in detail. Henry Childs Merwin. VEINS, ANOMALIES OF. The anomalies of veins, though of great morphological interest, are, with a few exceptions, of no great surgical importance. The most important variations of the venous system are found in the great veins entering the heart, and their large tribut- ary branches in the thorax and abdomen. Although variations of veins are more frequent than those of arteries, they have been much less studied, one reason being that veins are rarely injected with paint for purposes of dissection. Their variations also are of much less surgical importance than those of arteries. When arteries are anomalous, so are their accompanying veins ; an exception to this rule is seen in the obturator vein which empties into the internal iliac vein, even when the artery is abnormal. Abnormal communications by aberrant vessels are much more common in the venous than the arterial sys- tem. Many veins which are normal in the lowrer animals occur as anomalies in man. Many varieties which occur in man are really persistent foetal conditions, and these are permanent conditions in animals low'er in the scale. An example of this is seen in the occurrence of a double vena cava, the supernumerary vessel (the left cava) being merely a persistent left duct of Cuvier. The following account of the anomalies of veins is necessarily incomplete; the reader who is interested in the subject is referred for further information to W. Krause's Varietaten der Korpervenen, in vol. iii. of Henle's " Anatomie des Menschen," the various articles in the Journal of Anatomy and Physiology, and R. Quain's " Commentaries on the Arteries," 1844 ; and for an ex- cellent account of the development of the veins to vol. ii. of Quain's "Anatomy." Cardiac Veins. Coronary Sinus.-The coronary sinus and the small oblique vein connected with it must be re- garded as the persistence of a fcetal condition w hich will be described in connection with the superior cava ; it is really the termination of the left duct of Cuvier, or left superior cava. The vena azygos minor has been seen emptying into the coronary sinus, in this case the left superior cava was persistent as a small branch. It is not uncommon for one or more of the cardiac veins to be absent. When the left superior cava per- sists, it may receive veins which normally enter the co- ronary sinus. The great coronary vein may end in the auricle itself, as also the middle cardiac vein ; this is the normal condition in the horse, camel, etc. Pulmonary Veins.-The pulmonary veins occasion- ally communicate with other veins, as the innominate (Hyrtl); the right upper pulmonary has been seen to empty into the superior cava, and the left upper into the innominate. The two pulmonary veins of one side may unite into a single trunk (more commonly on the left side) before emptying into the left auricle. There may be three pulmonary veins on the right side, the third coming from the middle lobe of the right lung. Hepburn1 records a case of double vena cava in which there were three right pulmonary veins, the upper open- ing into the superior cava of the right side, and the two low'er into the right auricle ; there was also a separate foramen (quite distinct from the foramen ovale) between the right and left auricles. Peacock5 records a similar case in a child six years of age. Development of the Great Veins.-In order to understand more thoroughly the variations of the great veins which return the blood from the heart, the follow- 604 Vehicles. Veins. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ing description, abridged from Quain's "Anatomy," 9th edition, vol. ii., will be of service : "At the time of the commencement of the placental As development proceeds, the direction of the ducts of Cuvier is altered by the descent of the heart to the thoracic region, and then becomes continuous with that of the primitive jugular veins. A communicating branch makes its appearance between the two jugulars, directed obliquely downward from left to right; further down in the dorsal region, between the posterior vertebral veins, another communicating branch is developed. The communicating branch between the jugulars is con- verted into the left innominate vein (see Fig. 4510). The portion of the prim- itive jugular below the communicating vein, together with the right duct of Cuvier, form the superior vena cava, while the cardinal vein opening into it (az, Fig. 4509), is the extremity of the great azygos vein. On the left side, the portion of the prim- itive jugular placed below the commu- nicating branch, and the cardinal and posterior vertebral veins, together with the cross branch between the two posterior vertebral veins, are converted into the left superior intercostal, and left superior and infe- rior azygos veins. The left duct of Cuvier is obliterated, except at its lower end, which always remains pervious as the coronary sinus. Traces of this vein are recognized in the adult as a fibrous band or a small vein (see Fig. 4511 A). The variability in the adult arrangement of these vessels depends on the various extent to which the originally continuous vessels are developed or atrophied at one point or another. Varieties of the Superior Cava and Innomin- ate Veins. Double Vena Cava.-This anomaly is rather a rare one, and is due to the persistence of the left duct of Cuvier. When the left duct of Cuvier persists, the transverse innominate vein is absent or of a very small size, and the vein formed by the junction of the left in- ternal jugular and subclavian is continued down in front of the arch of the aorta and root of the left lung to the heart (see Fig. 4510), where it receives the great cardiac vein, and then passes outward to become continuous Fig. 4510.-Double Vena Cava seen from the Front, with Small Transverse Innominate Veins. (R. Quain.) Fig. 4509.-Diagram Illustrating the Development of the Great Veins. (After Kolliker.) A, Plan of the principal veins of the foetus of about four weeks or over, after the first formation of the vessels of the liver and the vena cava inferior; B, veins of the liver at a somewhat earlier period ; C, principal veins of the foetus at the time of the first estab- lishment of the placental circulation ; D, veins of the liver at the same period ; de, the right and left ducts of Cuvier ; ca, the right and left cardinal veins.; jj, jugular veins ; s, subclavian ; az, azygos; u, um- bilical ; o, omphalo-mesenteric vein ; p, portal vein ; p 'v'. venae ad- vehentes ; /, ductus venosus ; h, hypogastric or internal iliac veins in the line of continuation of the primitive cardinal veins; li, transverse innominate. circulation two short transverse venous trunks, the ducts of Cuvier, one on each side, open into the auricle of the heart; each is formed by the union of a superior and inferior vein named the primitive jugular and cardinal vein. The primitive jugular receives the blood from the cranial cavity by channels in front of the ear, which are subsequently obliterated ; in the greater part of its extent it becomes the ex- ternal jugular vein, and near its lower end it re- ceives small branches which grow to be the inter- nal jugular, and subclavian veins." The cardinal veins are primitive vessels which return the blood from the Wolffian bodies, the ver- tebral column, and the parietes of the trunk. The inferior cava is a vessel of later development, which opens into the trunk of the umbilical and omphalo-mesenteric veins above the vena hepatica revehentes (Fig. 4509). The iliac veins, which unite to form the inferior cava, communicate with the cardinal veins. The inferior ex- tremities of the cardinal veins are persistent as the inter- nal iliac veins; above the iliac veins the cardinal veins are obliterated in a considerable part of their course ; their upper portions then become continuous with two new vessels, the posterior vertebral veins of Rathke, which receive the lumbar and intercostal twigs. Fig. 4511.-A, Diagram showing vestige of the left superior cava with brachio cephalic, superior intercostal, azygos, and cardiac veins. B. Diagram showing persistence of left superior cava and its communica- tion with the coronary sinus. (After Marshall.) with the coronary sinus, and thus opens into the right auricle (see Fig. 4511, B). 605 Veins. Veins. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The explanation of this anomaly is simple, if the de- scription of the development of the great veins, given above, be referred to. It is merely a persistence of the foetal condition. The left duct of Cuvier is not obliter- ated, and in consequence the transverse branch between the two primitive jugulars has been developed but slightly or not at all. The persistent left cava has been seen in a few cases to open into the left auricle (Hyrtl, Gruber, and others). In birds and some mammals, as the rabbit, etc., the left duct of Cuvier persists normally as well as the right. R. Howden8 reports a case of double vena cava in which the left vein was joined by a large left azygos vein ; the right azygos was broken up into several veins ; the most inferior one joined the left azygos, and the superior the vena cava. This is a reversal of the usual condition, and the left azygos in this case must be looked upon as a persistence of the left cardinal vein. The writer has met with no less than three cases of persistence of the left duct of Cuvier. They all oc- curred in adults (two males and one female), and were of the usual form : in two the transverse innominate was of considerable size. In the third case it was very small, and formed chiefly by the inferior thyroid veins. Cases have been recorded where the right superior cava was absent and the left persisted ; in such cases there was a right transverse innominate vein. This variation oc- curred without transposition of the arch of the aorta or any of the viscera. In cases of transposition of the vis- cera this is the normal arrangement. In some cases the transverse innominate vein is of normal size, and yet there is a persistence of the left duct of Cuvier in its whole length, either as a good-sized canal or as a very small, but patent, vein. In some cases where two superior cavse are present, the left has been seen to enter the left auricle instead of the coronary sinus. Connection between the Vena Cava and Pulmonary Veins.-Cases are on record of the upper right pulmon- ary vein emptying into the superior cava (Meckel, Ge- genbauer); also of the left pulmonary vein joining the innominate (Bachhammer). Hyrtl reports a case where there was a communication between a rudimentary left cava and the left inferior pulmonary vein. Transverse Innominate.-This vein may be placed higher up than usual-so high, in fact, that in children with short necks it might be accidentally wounded in the low operation for tracheotomy. Cooper4 reports it as passing through the thymus. Gruber examined many embryos of children, and found that in certain cases the vein passed behind the left and in front of the right lobe of the gland, and in others in front of the left and behind the right lobe (quoted by Krause). Vertebral.-This vein not infrequently passes behind the subclavian to reach the innominate, or it may em- brace the subclavian by dividing above and reuniting be- low. It occasionally passes through the transverse pro- cess of the seventh cervical vertebra, or sends a branch through the foramen to join the deep cervical vein. Internal Mammary.-May be double. May anastomose with the upper intercostal. The writer has seen it empty into the superior cava. It may empty into the azygos major on the right side (Portal). Superficial Veins of the Head and Neck.- The arrangement of the superficial veins of the neck often varies greatly from that described in text-books of anatomy. The two divisions of the temporo-maxillary vein are frequently very unequal in size ; the branch joining the facial may be of large size, and that going to the external jugular very much diminished, or vice versa. In some cases the branch joining the facial returns all the blood into the internal jugular, and in other cases the internal jugular receives no branch from the temporo-maxillary. When the latter arrangement exists all the blood empties into the external jugular. The facial vein sometimes passes back over the sterno- mastoid muscle to join the external jugular. It may pass across the sterno-mastoid to its posterior border, and then join the internal jugular beneath that muscle. It sometimes joins the internal jugular behind the posterior belly of the digastric and stylohyoid muscle, or it may be continued downward to the anterior jugular (see Fig. 4513). External Jugular.-This vein may be double. In those cases where the posterior division of the temporo- maxillary trunk is wanting, and all the blood goes to the internal jugular, the external jugular is very small, being formed altogether by the posterior auricular. When the posterior auricular joins the temporo maxil- lary trunk, the external jugular is wanting altogether in the upper part of the neck. Gruber describes a case where a loop was formed in this vein through which passed the transverse cervical nerve. The lower end of the external jugular may divide into two branches, one of which joins the subclavian vein or transversus colli, and the other the anterior jugular, subclavian, or inter- nal jugular. Occasionally the vein may pass over the clavicle and join the cephalic vein, or the cephalic may join the exter- nal jugular beneath the clavicle, and communicate with it at the same time by a loop line above the clavicle (Nuhn). (See Fig. 4514.) The writer has seen several cases where the external jugular passed over the clavicle and then turned up be- Fig. 4512.-External Jugular Passing over the Clavicle and Going up be- tween that Bone and the Subclavius Muscle to join the Subclavian. (Richard Quain.) tween that bone and the subclavius muscle to join the subclavian (see Fig. 4512). A knowledge of these ano- malies is important in operations on the clavicle and subclavian artery. According to Hallett, the external jugular is absent once in ninety-three subjects. Anterior Jugular Veins.-These veins are not constant. One may be much larger than the other. Occasionally the two join to form a single median trunk. The two veins may be united by a large trunk over the trachea, which may give rise to troublesome haemorrhage if wounded in the operation of tracheotomy. Pilcher says that when one of the veins is absent it is compensated for by a large obliquely transverse branch which comes from the external jugular and crosses the neck at its lower third to join the anterior jugular which persists.* 606 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Veins. Veins. Pilcher also describes a deep anterior jugular of large size which is occasionally seen. It has its origin in the subhyoid region, passes down directly in the median line, deeply seated beneath the muscles; it passes over the crico-thyroid space, and, going down the middle of the neck over the trachea, receives the superior and inferior thyroid veins, and finally empties into the transverse in- nominate vein. The anterior jugular may in rare cases pass outward over the sterno-mastoid muscle. Transverse cervical and suprascapular veins not infre- quently empty into the subclavian vein independently. Occasionally they join the internal jugular (R. Quain). Internal Jugular.-This vein frequently covers the common carotid artery to such an extent that the artery cannot be seen until the vein is drawn aside (see Fig. 4513). According to R. Quain e this occurs most fre- quently in the left side. The left vein is occasionally of superior intercostal has been seen to empty into it (Lauth) ; or a large bronchial vein (Weber). The exter- nal jugular has been seen to empty into the internal about the middle of the neck (Fuhrer). Varieties of Cerebral Sinuses.*-The sinuses about the torcular Herophili are subject to considerable variation. A true confluence of the sinuses is not always found at this point. The torcular may be placed to one side or other of the median line. The connecting branch between the torcular and straight sinus may be of large size and convey the blood from the superior longitudinal sinus. Superior Longitudinal Sinus.-This sinus maybe com- pletely absent (Portal). Knott8 describes it as being oc- casionally so small as hardly to represent a normal sinus. It may join the straight sinus ; it may bifurcate posteriorly a little behind the coronal suture, and re- unite about an inch posteriorly (Knott and Vicq d'Azyr). Malacarne reports a case of bifurcation of the sinus near the apex of the occipital bone, each branch following the lambdoidal suture of its own side and joining the lateral sinus. Lateral Sinus.-The right is often very diminutive. Lieutaud has recorded a case of complete absence of the left lateral sinus. Both lateral sinuses may be of small size ; in such cases the occipital sinuses are much en- larged, and empty their blood into the internal jugular. Sometimes one or both sinuses are divided into two by a septum (Hallett). Verga describes an aberrant vein from the cavernous sinus or ophthalmic vein to the left lateral sinus. • One sinus may be of large size and the other small. The left is usually the larger. A case is reported9 where both lateral sinuses were small, espe- cially the right, which became quite minute after the exit of a large vein through the mastoid foramen. In this case three large emissary veins were present at the ante- rior extremity of the superior longitudinal sinus, also three others opening into the torcular, one into the commence- ment of the right lateral sinus, and one into the posterior extremity of the superior longitudinal. Inferior Longitudinal.-Knott10 reports a case where this sinus, instead of joining the straight, turned up be- tween the layers of the falx and ended in the superior longitudinal sinus, one quarter of an inch above the in- ternal occipital protuberance. Straight Sinus.-Sometimes absent. In a case re- ported by Knott the vein of Galen and the inferior lon- gitudinal sinus met at the anterior edge of the tentorium, formed a trunk three-quarters of an inch long, and then divided into three veins, one of which passed up between the layers of the falx to join the superior longitudinal, and the other two passed between the layers of the ten- torium to the left side to join the lateral sinus. Cavernous Sinus.-Complete absence of this sinus is reported by Santorini. There is sometimes a vein from it going through the foramen rotundum with the supe- rior maxillary division of the fifth cranial nerve (Nuhn). Superior Petrosal.-Sometimes absent; may communi- cate with the ophthalmic vein (Verga). Inferior Petrosal.-Sometimes terminates within the skull above the margin of the jugular foramen. Circular Sinus.-May receive the ophthalmic vein. Occipital Sinuses.-Sometimes wanting, occasionally of large size ; in such cases the lateral sinuses are small ; they may be very small. The sinus is often much larger than its fellowr, and may groove the occipital bone as it passes forward to join the lateral sinus. Petro squamous Sinus (Luschka ; W. Krause).-This additional sinus is sometimes present, lying in a small groove along the junction of the petrous and squamous portions of the temporal bone, and opening behind into the lateral sinus. In rare cases it is found passing through an aperture (foramen jugulum spinosum) in the squamous portion of the temporal bone, between the orifice of the external auditory meatus and the glenoid cavity, and joins the temporal vein. In the dog and many other an- Fig. 4513.-Facial Vein, continuous with the Anterior Jugular, which is Joined to the Internal Jugular by a large Communicating Branch over the Carotid. The internal jugular is seen covering the upper part of the carotid artery. (R. Quain.) very small size, its place being taken by the external jugular (W. Krause). This is a persistence of an early foetal condition, for in early foetal life the primitive or external jugular returns all the blood from the heart. This is the normal adult condition in many mammals, as rabbits, squirrels, etc. The internal jugular is altogether absent in fishes, many amphibia, birds, and some mam- mals, as the horse and ruminants. A case is reported by J. W. Williams 1 in which the right omohyoid muscle, instead of passing over the vein, " played by means of its intermediary tendon through a slit in the vessel." In some cases the temporo-facial trunk fails to empty into the internal jugular, the external receiving all its blood. R. Quain reports a case where a very large anterior jugular vein communicated with the internal jugular over the carotid artery (see Fig. 4513). The internal jugular may receive the vertebral, the transverse cervical, and the suprascapular veins. A * J. F. Knott has given an excellent account of the variations of the sinuses in the Journal of Anatomy and Physiology, vol. xvi. 607 Veins. Veins. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. imals a similar vessel forms the principal outlet for the intracranial blood. In the human subject also, at an early period of foetal life, the lateral sinus is continued forward in this course, and opens into the primitive (afterward the external) jugular vein ; the occurrence of the petro-squamous sinus is due to the persistence of this channel, which usually becomes obliterated after the development of the internal jugular." Veins of the Upper Limb.-The superficial veins of the forearm are subject to considerable variation, both as to arrangement and size. At the bend of the elbow the arrangement varies greatly. The radial vein may be very small or absent, and in such cases the cephalic vein is wanting, the outer branches from the radial side being collected into the median vein, which goes directly to form the median-ba- silic. This latter is occasionally double. The cephalic vein may be absent (Hallett found it ab- sent in 2 out of 93 cases). It may be double. It some- the usual single subclavian vein. On the right side the two veins were of equal size, about five inches long, and reached to a point where the internal jugular ends. On the left side one of the veins was of very small size. The anterior jugular, suprascapular, or transverse cer- vical may empty into the subclavian separately. Weber reports the subclavian receiving a large bronchial vein. The cephalic vein may empty into the subclavian above or below the clavicle. An aberrant vein may unite the upper end of the cephalic vein with the subclavian by passing behind the clavicular portion of the pectoralis major (W. Krause). Azygos Veins.-The variations of the azygos veins are considerable, the veins on the left side being especially liable to variation. Two or three of the middle inter- costal veins of the left side not uncommonly unite into a single trunk which passes directly into the azygos major. The left superior (hemi-) azygos vein may be absent, the intercostal veins emptying separately into the main trunk. The hemiazygos may empty into the subclavian (Wris- berg) or into the left innominate, joining with the supe- rior intercostal. A case has been reported (Cerutti) where the hemiazygos joined the internal jugular vein. All the intercostal veins on the left side may be collected into a single trunk which empties into the left innomi- nate, a distribution somewhat similar to that on the right side. The writer has reported an example of this arrange- ment.12 By referring to the short account given above of the development of the great veins it will be seen that this anomaly is due to a persistence of the left cardinal vein. A case is recorded by Gruber where the left azy- gos opened into the coronary sinus, and was met by a small vein descending from the union of the subclavian and jugular. In this case the jugular vein had been de- veloped in the usual way,while the left vena azygos con- tinued to pour its blood into the left duct of Cuvier (Quain). The azygos veins may be transposed, the larger vessel being placed on the left side and being joined by the right azy- gos ; the trunk formed by these veins then arches over the root of the right lung and opens into the left coronary sinus (Gruber). This is the normal ar- rangement in the sheep and some other animals. R. Howden 13 reports a case of double vena cava where a single large left azy- gos, after being joined by some of the right intercostal veins, emptied into the left cava near the coronary sinus. The upper right intercostals formed a trunk which emptied into the right cava. There may be a single azygos vein ascending in front of the spinal column and receiving the intercostal veins of both sides (Wagner). The azygos ma- jor may empty into the right innominate (Meckel) or higher up than usual into the superior cava. Wrisberg has de- scribed a case where the azygos major passed through a canal by grooving the upper lobe of the right lung. Most of the varieties mentioned above may be easily explained by studying the devel- opment of the veins, for they are all persistent foetal conditions. The vena cava inferior has been seen continuous with the azygos major (see Fig. 4515. This will be more fully described with the vena cava inferior.) The right spermatic has been noted as emptying into the azygos vein ; also the left renal and suprarenal veins (Quain). An aberrant branch has been seen going from the angle of junction of the left renal and inferior vena cava to the right azygos (W. Krause). Inferior Vena Cava.-R. Quain 14 divides the pecu- liarities of this vein into two classes : (a) Where the Fig. 4514.-Cephalic Vein passing up under the Clavical to Join the Subclavian. The cephalic is connected with the external jugular by a loop-line which passes over the clavicle. (Nuhn.) times empties near the insertion of the deltoid into the brachial vein. Sometimes it anastomoses with the bra- chial vein by an aberrant branch. It may pass up over the clavicle to join the external jugular, or it may be con- nected with it by a branch called the jugulo-cephalic (see Fig. 4514). In two cases this branch has been seen to perforate the clavicle (Allen Thompson). This vein may pass up between the clavicle and subclavius muscle to join the subclavian vein ; the writer has seen several examples of this anomaly (see Fig. 4514). The median cephalic vein is not infrequently absent. Basilic Vein.-May be double in its whole course. May anastomose with the ulnar vein. May be separated from the brachial artery by only a very thin fascia ; this fact should be kept in mind in bleeding from this vessel. The basilic may anastomose by a large branch with the cephalic vein (Theile). Axillary Vein.-This vein may be double, from a fail- ure of the venae coinites to unite with the basilic. R. Quain has repeatedly seen the axillary vein perforated by a branch of the internal cutaneous nerve. Subclavian Vein.-This vein may be placed at a higher level than usual, overlapping the artery at the outer edge of the scalenus anticus. In rare cases the vein passes behind the scalenus anticus muscle with the ar- tery, or, in cases where the artery passes in front of the muscle, the vein may pass behind. Luschka has several times seen the subclavian vein passing between the clav- icle and the subclavius muscle. The same anatomist also reports having seen the vein divide and embrace the scalenus anticus muscle, and reunite and follow its usual course. Double Subclavian.-Morgagni (quoted by R. Quain, p. 182) in one instance found on both sides of the same body two venous trunks placed side by side, instead of Fig. 4515.-The In- ferior Cava con- tinued into the Thorax as the Vena Azygos, and the Blood from it entering the Heart through the Supe- rior Cava. In this case the hepatic veins opened into the right auricle in the usual situa- tion of the inferior cava. (R. Quain.) 608 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Veins. Veins. vein has the usual mode of termination in the heart; (b) where it terminates in the superior vena cava. The common iliac veins may not join at the usual place ; the left common iliac, after sending a branch across to join the right, may pass up on the left side of the aorta cases are examples of the persistence of the lower part of the cardinal veins. Another somewhat similar anomaly is that where the two common iliac veins join to form a common vein which passes up on the left side of the aorta, but, after receiving the left renal, crosses over (rarely under) the aorta and from there on takes its usual position. The explanation of this anomaly is that the right car- dinal vein has been obliterated while the left persists. In cases of transposition of the viscera the vena cava in- ferior passes up the whole distance on the left side of the aorta, grooves the transposed liver, and joins the right auricle of the heart in its transposed position on the left side. A case of transposition of the viscera is recorded (Ilernholdt) in which the inferior cava passed up on the right of the aorta, pierced the diaphragm, and then crossed over to join the transposed superior cava. In some rare cases the inferior cava passes up normally to the diaphragm without receiving the hepatic veins, it then pierces the dia- phragm, and goes over the root of the right lung to join the infe- rior cava, thus taking the place of the vena azygos major ; the he- patic veins in these cases form a trunk, which opens into the right auricle at the usual place of termina- tion of the inferior cava (Fig. 4515). Again, the inferior cava may pass up on the left side of the aorta and, after piercing the diaphragm on that side, go behind the aorta and thoracic duct to join the supe- rior vena cava, thus following the course of the left azygos vein. The hepatic veins, as in the former case, open into the right auricle (see Fig. 4518). These cases are ex- plained on the suppo- sition that the normal inferior cava has never been developed, and that the blood is re- turned from the lower part of the body by a persistent cardinal vein. W. Gruber 16 reports a case of the inferior cava being formed by the junction of three trunks-right and left external iliacs and a common iliac formed by the junc- tion of the two internal iliacs ; this arrangement is seen in some of the lower animals, as the bear, etc. The vena cava inferior is occasionally formed by a common iliac vein and the veins of the other side, not opening by a com- mon trunk, but separately. Renal Veins.-The left renal vein, in order to reach the inferior cava, may pass behind instead of in front of the aorta. Supernumerary renal veins are not so common as supernumerary renal arteries, but they not infre- quently occur. One of these supernumerary vessels of the left side may open into the azygos of that side. Walsham 11 reports a case of double left renal vein em- bracing the aorta, one passing in front and the other be- hind. The posterior branch received the spermatic and also the third lumbar vein. The writer has seen a some- what similar case, referred to below. When the kidney is placed lower than normal, a vein from it usually emp- ties into the common iliac. In the museum of McGill University is a beautiful Fig. 4516.-Case of Double Inferior Vena Cava, the two Common Iliacs being joined a Transverse Branch. A, Occluded vena cava; e, right renal; f, right spermatic ; d, large branch, probably joining the splenic, thro igh which circulation was carried on. View taken from behind. (W. Osler.) and join the left renal. This is not a very uncommon anomaly, and has been seen several times by the writer. It is sometimes called an example of double vena cava inferior. A case is reported by William Osler15 of oc- clusion of the vena cava as it entered the liver. There was in this case a double cava arranged as above de- scribed (see Fig. 4516); the circulation was carried on by Fig. 4518.-Vena Cava to Left Side of Aor- ta ; below, but crossing behind that ves- sel above, and, passing up the thorax on the right side ; it empties its blood into the superior cava. (R. Quain.) Fig. 4517.-Example of Double Inferior Vena Cava. The left cava is joined by the left renal and then crosses the aorta to join its fellow, and below, the inferior cava proper. Each cava is really a continuation upward of the common iliac vein of that side. (R. Quain.) a large branch from the left renal,which probably joined the splenic. In some cases there is no transverse branch below be- tween the two common iliacs (see Fig. 4517). These 609 Veins. Veins. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. specimen of abnormal renal veins obtained by the writer. Both kidneys were placed lower down than normal, reaching to the intervertebral substance between the fourth and fifth lumbar vertebrae, and each received a supernumerary artery from the common iliac artery. On the right there were two renal veins, on the left one large vein proceeded from the hilus of the kidney in front of the aorta, and a smaller one passed behind the aorta to join the inferior cava lower down. This com- municated below, by a large branch which passed beneath the left common iliac artery, with the left common iliac vein, and above, by another large branch, with the splenic mg it near the second perforating artery and then joined the profunda vein. Another case is mentioned in the same paper where the venae comites of the posterior tibial, instead of uniting to form the popliteal, con- tinued up as two veins, being joined by the external sa- phenous, and going up on the adductor magnus to open into the. profunda vein near the first perforating artery. The writer has seen the external saphenous empty about the middle of the thigh into an abnormal popliteal vein which passed up the back of the thigh to join the pro- funda. The external saphenous may empty into mus- cular branches in the adductor magnus. Branches of communication have been seen between the perforating and ischiatic veins and the external saphenous. Internal Saphenous Vein.-This vein may pierce the fascia lata higher or lower than usual. It may be doubled, orform an island. It may receive the superficial epigastric, c i r - cumflex iliac, an accessory saphe- nous, or the ex- t e r n a 1 saphe- nous. It is in some cases very large, and in others of no great size. There is frequently an ac- cessory internal saphenous. Deep Veins of the Lower Limb. Popliteal Vein. - The veins which form the popli- teal occasionally unite farther up than usual, so that the lower part of the artery i s accompanied by two veins. In some rare cases the vein is double in its en- tire length. It may be double as high up as the profunda vein. Sometimes the popliteal vein passes up the thigh and joins the profunda ; in such cases the external saphe- nous empties into this vein high up on the thigh. When the popliteal vein does not accompany the artery to become the femoral, a small vein is occasionally seen with the artery (see Fig. 4521). The popliteal vein may lie deeper and more internal than the artery and next the bone.20 Femoral Vein.-Occasionally double in part and, more rarely, in the whole of its course. When double, the fem- oral artery lies between the two veins (see Fig. 4522). In some cases one of the veins may cross the artery. Small veins are occasionally observed passing over the artery in various directions, sometimes in transverse loops (see Fig. 4523), or obliquely; these transverse branches usually con- nect various parts of the double vein. The femoral vein may be much diminished in size when the popliteal vein empties into the deep femoral and pierces the adductor magnus at a higher point than usual. In these cases the femoral vein proper first comes in contact with the artery Fig. 4519.-Anomalous Renal Vessels. A, Aorta; V, vena cava: ft, com- munication between left renal and left common iliac; 8, vein from left renal going to join the splenic: c, supernumerary renal veins. (Shep- herd.) vein (see Fig. 4519). This case is probably one of persist- ence of the left cardinal vein in its lower part. Spermatic and Suprarenal Veins.-These may empty by a common trunk into the azygos. The right spermatic may empty into the right renal and the left spermatic into the inferior cava. The spermatic vein may empty into the suprarenal. It may be double in the upper parts of its course or may be altogether absent. Common Iliac Veins.-A perforation is occasionally seen through which passes a small artery. Sometimes the vein divides and reunites farther on, thus making it double in part of its course (R. Quain). The left com- mon iliac vein has been seen passing in front of the right common iliac artery (Zaaijer). Absence of the common iliac vein of one or both sides has been met with by Gruber ; the left external and internal iliac veins in one instance being continued upward to enter the com- mencement of the inferior cava, and in another the two internal iliac veins were joined into a common trunk which united with the right and left external iliac veins to form the vena cava.18 Obturator Vein.-Often double, one accompanying the artery and the other coursing around the inner side of the femoral ring. It may open by two mouths into the external iliac. Internal iliac vein of the right side has been seen to empty into the left common iliac vein. The internal iliac may be double (Quain). Veins of the Lower Limb ; Superficial Veins. External Saphenous.-This vein may empty into the long saphenous or femoral instead of the popliteal. It may communicate with the gluteal veins beneath the gluteus maximus muscle. A case is reported19 where the external saphenous, after piercing the deep fascia in the popliteal space, ran up on the posterior surface of the adductor magnus, perforat- Fig. 4520.-Example of Popliteal passing up the Thigh to Join the Profunda; in this case the lower end of the femoral artery is accompanied by a very small vein. (R. Quain.) 610 Veins. Veins. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. in the groin. R. Quain mentions a case where he could find no femoral vein accompanying the lower end of the artery ; the writer has seen one such case. Portal System of Veins. Hepatic Veins.-Rothe, a German surgeon, reported many years ago (1787) a case in which one of the large hepatic trunks from the right lobe of the liver terminated, not in the inferior cavaTor right auricle, but in the base of the right ventricle. Its entrance was guarded by three valves (quoted by W. Krause). In cases where the inferior cava, as already described, joins the superior cava, the hepatic veins may open separately (Horner) or by a single trunk (Abernethy) into the right auricle. This arrangement is normal in some animals. The writer has described21 a case in which the vena cava inferior, after piercing the liver and being joined there by a few small hepatic veins (prin- cipally from the left side), passed as usual to the dia- phragm, and as it pierced that muscle it was joined by a large vein, the size of one's finger, and with walls as Fig. 4521.-Case of Double Popliteal Vein. (R. Quain.) Fig. 4523.-Small Looped Veins passing over the Femoral Artery, form- ing a Double Femoral Vein. (R. Quain.) thick as those of an artery. This vein, when traced back, proved to be a common trunk formed by two large hepatic veins which came from the right lobe ; the common trunk measured one inch in length (see Fig. 4524). Morgagni reports a case of the hepatic veins joining the vena cava inferior after it had pierced the diaphragm (quoted by W. Krause). Hyrtl has seen the hepatic veins empty by a common trunk into the right auricle to the inner side and separately from the inferior cava ; this, as mentioned above, is the normal course when the vena cava is absent or its place is taken by a persistent cardinal vein. Umbilical 'Vein.-This vein has occasionally been found patent for a variable distance below the liver. It may communicate with the epigastric, and thus establish a collateral circulation ; this is much more evident when a diseased condition of the liver obstructs the venous circulation. J. A. Russel22 reports two cases of persistent commu- nication between the umbilical and portal veins in the human subject. F. Champneys23 describes a communica- FlG. 4522.-Case of Double Femoral Vein. (R. Quain.) 611 Veins. Ventilation. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tion between the external iliac and portal vein through the epigastric and umbilical veins. This was due, probably, to fusion of Luschka's parum- bilicalis (which, according to him, always exists nor- mally as a communication between the portal and epigastric veins), and the channel was afterward in- creased in size by obstruction, due to enlarged liver. A communication of large size between the umbilical and epigastric veins is the normal arrangement in many of the lower animals, as the rorqual, seal, sheep, pig, etc., and in man is an early foetal condition. Numerous examples have been recorded of communication between the veins of the abdominal parietes, as the phrenic (azy- gos, etc.) and the portal vein. The writer has already described, in connection with the renal vein, a case where a large branch of communication existed between the left renal vein and the splenic. Meniere has described a case where a large vein, as thick as a finger, went from the portal vein to the right iliac. And recently Brigidi24 has reported a case of free 20 St. Thomas's Hospital Reports, vol. vi.. 1875; and R. Quain. 21 Annals of Anatomy and Surgery. 1882. 22 Journal of Anatomy and Physiology, vol. viii., p. 149. 23 Ibid., vol. vi. 24 Lo Sperimentale, April, 1888. 26 Henle's Anatomie des Menschen, vol. iii. VENTILATION AND WARMING. Under the article Air, consideration has been given to the composition and impurities of air, the effects of the latter, and various modes of analysis. The matter left to be treated of in this article may be discussed under the following heads : I. The Amounts of Impurities given off into the Air. II. The Standard of Purity which must be Maintained, with a due Regard to Health. III. The Total Amount of Fresh Air required to Di- lute Impurities to this Standard. IV. The Frequency of Changes of Air which can in Practice be Carried out. V. The Air-space consequently Required. VI. The Modes of Changing and Distributing Air of a Suitable Temperature, and containing a Suitable Amount of Moisture. Warming and cooling of the air will necessarily be included under this heading. VII. Modes of Determining the Sufficiency of the Means of Ventilation (other than those already consid- ered under Air). I. The Amounts of Impurities Given Off.- The impurities with which we have most commonly to deal are those contained in the exhalations from the lungs and skin, and those caused by the com- bustion of fuel and lights. 1. Pulmonary and Cutaneous Exhalations. -The most injurious of these impurities are the organic matters eliminated from the sys- tem. But as the amounts of these are diffi- cult to estimate, and as they are generally found to maintain a pretty constant proportion to the amount of carbon dioxide exhaled, the latter has been fixed upon as the measure of impurity. The amounts of carbon dioxide given off vary with the varying conditions of exertion and repose, size, sex, and age. According to Pettenkoffer,1 a man weighing 132 pounds (a small-sized man) gives off per hour : At night during repose 0.56 of a cubic foot. During moderate exertion 0.78 " " During hard work 1.52 cubic foot. From these figures as a basis the following calcula- tions are made of the amounts evolved per hour in re- pose: Adult males 0.636 to 0.678 cubic foot. Adult females 0.424 to 0.509 " Children 0.254 to 0.339 " But, as is properly added by the late Dr. Parkes, " the estimate for children is probably too little, as tissue- change is more active in their case." And this remark should always be borne in mind in making practical ap- plication of this factor in providing, as we shall do later on, for the air-space and total amount of air required for children in schools and elsewhere. It must also be re- membered that any provisions based upon the above figures should be for persons in a state of comparative re- pose. Fortunately, persons actively exerting themselves can bear a more rapid and frequent change of air; but the oft-occurring sequelae of the dance warn us how care- fully the compensating substitution of frequent changes of air-draughts-for sufficient air-space and gradual change is to be watched. As a result of all the calculations considered by him, Dr. Parkes2 fixes upon 0.6 of a cubic foot of carbon di- oxide as the amount given off per head of a mixed com- munity. 2. the amounts of carbon, dioxide given off by the lower animals may, for practical purposes, be estimated in the same proportion of carbon dioxide to body-weight, the proportion being relatively greater in the smaller ani- mals, their more rapidly attained maturity necessitating more rapid tissue-change. Fig. 4524.-Hepatic Veins from Right Lobe of the Liver opening by a Common Trunk near the Entrance of the Inferior Vena Cava through the Diaphragm. R, right auricle ; D, line of diaphragm ; L, liver; V, vena cava ; If, abnormal hepatic veins. (Shepherd.) communication between the umbilical vein, which was patent, and the right iliac by means of a branch of large size in a case of cirrhosis of the liver. W. Krause25 mentions a number of cases of communi- cation between the portal vein and the iliac veins by means of a patent umbilical, connected directly by a branch or through an epigastric vein.* These commu- nications are all due to persistent foetal conditions, and are much more apparent when there is any obstruction to the portal circulation. Francis J. Shepherd. 1 Journal of Anatomy and Physiology, vol. xxi., p. 438. 2 Malformations of the Heart, 2d edition, 1866. 3 Journal of Anatomy and Physiology, vol. xxi. 4 Anatomy of Thymus, 1832. 5 Annals of Anatomy and Surgery, vol. iii., 1881. 6 On Arteries, p. 103. 1844. 7 Journal of Anatomy and Physiology, vol. xxi. 8 Ibid., vol. xvi. 9 Guy's Hospital Reports, vol. xiii.. 1883-84. 10 Journal of Anatomy and Physiology, vol. xvi. 11 Quain's Anatomy, 9th ed., vol. i., p. 505. 12 Annals of Anatomy and Surgery. 1881. 13 Journal of Anatomy and Physiology, vol. xxi. 14 Arteries, p. 427. 15 Journal of Anatomy and Physiology, vol. xiii. 16 Virchow's Archiv, 54, 1870. 17 St. Bartholomew's Hospital Reports, 1880. 18 Virchow's Archiv, liv., 190, 1870. 19 Guy's Hospital Reports, vol. xliv., 1887. * Sappe.v is of opinion that all recorded cases of free communication between the umbilical and epigastric veins rest on eryors of observa- tion ; he holds that the dilated vein is not the umbilical vein, but one of the accessory portal veins. Professor Giacominl is also of the same opinion, saying that the umbilical vein, in its course from the umbilicus to the portal vein, neither gives nor receives any branch normally. Pro- fessors Bordoni and Romiti. however, have investigated the subject afresh, and find that the umbilical vein anastomoses with the epigastric, not only in infants a few days old, but in those five and sixteen months of age. In bodies of infants several days or months old they never failed to demonstrate the anastomoses between the branches of the epi- gastric and umbilical veins by means of Richardson's injecting medium (see London Medical Recorder, July, 1888, p. 274). 612 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Veins. Ventilation. 3. In various forms of disease the amount of impurity evolved differs much, according to the nature of the disease. It will be evident that, with increased temper- ature, pulse, and respiration, there will be increased ex- halations ; and especially in cases of exanthematous and pyogenic affections will this be the case. In certain diseases of the nervous system, such as insanity and nervous prostration, a very peculiar organic odor is to be noticed; this will be readily perceived in the wards of asylums, unless the ventilation is exceptionally good. 4. The Amounts of Impurities from Lights.-A foot of good coal-gas, when burned, produces about two feet of carbon dioxide,3 and a small burner will allow about three feet of gas to be burned per hour ; in other words, one of our ordinary gas-burners produces about six feet of carbon dioxide. In addition, sulphur dioxide and some other impurities are generated. Few persons have a proper conception of the amount of impurity caused by burning gas ; were it otherwise, simple contrivances, such as will be explained hereafter, would be more com- monly introduced for converting gas-jets into a means of ventilation instead of allowing them to make the air so injurious. This remark is especially applicable to the lighting of churches, public halls, and printing offices. This seems to be the proper place to refer to a matter of great importance to the public health-the action of illuminating gas when allowed to escape unburned. Of late years rapidly fatal effects have become so common that in many different quarters the subject has been investi- gated and dealt with. In the opinion of the writer, the increase in the number of fatalities is principally due to the invention and introduction of water-gas, which con- tains a much larger percentage of carbon monoxide than is contained in coal-gas. A minor cause of cases of gas- poisoning may be that, with the increased facilities for travel and the more general introduction of modern im- provements in cities, larger numbers of our rural popula- tion are brought into occasional contact with illuminat- ing gas and gas-fixtures, with the use of which they are not familiar at home. Moreover, as cases of poisoning by coal-gas were not usually attended with fatal results, so much attention may not have been given to their oc- currence. In the years of his student-life and the earlier years of practice, the writer could only report the case of one family in which fatal poisoning by illuminating gas occurred, and this was owing to the gas from a street- main finding its way into a house at night. In later years, however, since the introduction of water-gas, cases have come under his observation every few months, and sometimes every few weeks. The results of the obser- vations and inquiries of others accord with the above. A very thorough investigation of the subject was made about three years ago by the State Board of Health, Lu- nacy, and Charity of the State of Massachusetts. From 108 cities,* having a population of 10,000 and upward, reports of 189 deaths were received. Of these 40 were recorded as due to coal-gas during twenty-one and a half years ; and 45 as due to water-gas in seven and a half years ; 1 to a mixture of coal- and water-gas ; and in 103 the kind of gas was not specified. In Boston,5 where coal-gas was used, there were 4 deaths in twenty years ; in Baltimore, with the same population (about 400,000), there were 19 deaths during the same period, 17 of them occurring during the years 1883, 1884, and 1885 ; in Bal- timore water-gas is used. In England and Wales, where illuminating gas (coal-gas) is largely used, the returns of the Registrar-General (which are acknowledged to be very accurate) give only 12 deaths from "gas and coal- gas " in the last three years referred to in the report (1881-83), and it is not certain that all of these were from coal-gas used for illuminating purposes, or, indeed, from coal-gas at all. In the reports there are deaths recorded as from charcoal gas, nitrous oxide, carbonic-acid gas, sulphuretted hydrogen, and mephitic gas; others from coal-gas, and others from " gas." But, taking those from "gas" and from " coal-gas" together, there were only 12, and this out of a population of about 26,000,000 ; so that, giving to the English illuminating gas all the cases about which there may be doubt, the proportion of deaths in Baltimore from illuminating gas is more than ninety times as great as in England and Wales ; and Bal- timore is no exception to the cities in which water-gas is used. A number of experiments wrere conducted by Professors Sedgwick and Nichols, of the Massachusetts Institute of Technology, to test the relative lethal effects of coal-and water-gas. At Athol and Newton,6 respectively, two rooms w'ere constructed, each of seven hundred cubic feet capacity, and as much alike as possible in all re- spects. In the room at Athol three dogs, two cats, and two rabbits were placed, and the water-gas used there was turned on from an ordinary burner at the rate of six feet per hour. In the room at Newton, where coal- gas is used, two dogs, two cats, two rabbits, and two pigeons were placed, and the gas turned on as in the other case. At Athol " symptoms of poisoning were well developed in an hour and a half. Deaths began to occur in a little more than three hours, and all were dead within eight hours." In Newton, " for three and one- half hours no symptoms of consequence wrere observed. After eight hours . . . recovery w'ould have been still possible and even easy. After twenty-four hours . . . one cat and one rabbit were dead, but the others, though stupefied, were not unconscious, being still re- sponsive to knocks and calls." One important difference in practical results is that the amount of coal-gas escaping into a room from an ordi- nary burner during sleeping hours, and hence before dis- covery, is not sufficient to cause death ; whereas, with water-gas the reverse is the case-fatal effects being often produced before discovery takes place. Another point observed by the writer is the difference in prog- nosis, even after partial consciousness returns, in regard to persons found asphyxiated by water-gas and those asphyxiated by other causes. Even after a partial re- turn to semi-consciousness and improved breathing, per- sons poisoned by water-gas may live for a day or so, and then die, as if unable to recover from the destruction of the blood-corpuscles by the carbon monoxide. The relative average proportion of this compound in the coal- and water-gas is as 1 to 5, or thereabout.1 Regarding the amount of impurities from illuminating oils and candles, Dr. Zoch8 states that petroleum gives off more carbon dioxide than coal-gas and that oil gives off less for the same amount of illuminating power ; and Dr. Odling9 says that candles give off a greater propor- tionate impurity than gas. But with candles and oils people are generally contented with more feeble illumina- tion, and hence with good samples the impurities given off into the air of dwellings are less in amount. 5. The impurities from, fires usually pass into the out- side atmosphere, and, while the smoke from factories sometimes forms a serious nuisance, the ventilation of dwellings is generally improved by the action of fires. There are, however, some cases in which that villanous carbon monoxide and other impurities, such as the vari- ous carbon and sulphur compounds, exert their baneful influence, Many forms of base-burner stove are very injurious in this way, especially when, after two or three years' use, the joints become somewhat open. This in- jurious action is often increased by the ignorance of per- sons who might be supposed to understand more about pneumatic principles, but who damp off their stoves by closing the draughts leading from the stove to the chim- ney, instead of first closing those which admit air to the fire ; in this way the products of combustion are, under pressure, forced into the dwelling-rooms. The writer has had frequent opportunities of noting the effects of chronic poisoning thus produced, the symptoms being headache, dizziness, languor, loss of appetite, nausea, anaemia, etc. In one case he was called to see a family in which acute symptoms with intense weakness, vomit- ing, and stupor were present. The escape of carbon monoxide through the pores of heated cast iron has been referred to in the article on Air. Sheet-iron stoves with tight joints seem to be preferable. The health of workmen in buildings is sometimes im- paired by the pernicious practice of plasterers and build- 613 Ventilation. Ventilation. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ers, who introduce, for the purpose of hastening the dry- ing of plaster, what are called " salamanders ; " these are large iron stoves not connected with the chimney, but pouring out their poisonous fumes into the houses which workmen are engaged in finishing off. II. The standard of purity adopted by most sani- tarians at the present day is that air must not contain a greater amount of impurities than will be indicated by 6 parts of carbon dioxide in 10,000 of the air ; i.e., 2 parts in 10,000 more than that normally present in atmos- pheric air. In framing on this basis our demands for fresh air and cubic air-space we are frequently met with the objection that this standard is too high. It is there- fore worthy of note that, with the opportunities of re- newed observation and reconsideration furnished as time rolls on, sanitarians are more generally and firmly con- vinced that this should be the limit of impurity. In the earlier edition of Parkes's " Hygiene," although the limit of impurity was fixed at 6 of carbon dioxide in 10,000, yet the late Dr. Parkes spoke of a cubic space of 600 cubic feet with two changes per hour as being a proper allow- ance for the soldier, and this, we will find, will yield about 9 parts of carbon dioxide in 10,000 ; and, by mak- ing a calculation of the quality of the air resulting from the air-space and change recommended by General Mo- rin in his report of the Commission on the Heating and Ventilation of the Buildings of the Palais de Justice in Paris in 1860, we shall find that it contains 9.56 parts of carbon dioxide in 10,000. But it has been found that the allowances then laid down were not sufficient for the maintenance of health, and now 6 in 10,000 is the gener- ally received limit of impurity. III. The amount of fresh air required to dilute any given impurity up to the standard fixed upon may be calculated from a formula obtained by the simple rules of proportion ; in adopting a standard, we necessarily name (as we have done just now) a certain amount of impurity (carbon dioxide) in a certain imaginary space. Let us call The imaginary air-space named in the ratio of our standard, a; The amount of impurity which it may be allowed to contain in excess of that normally existing in the atmos- phere, 6; The amount of impurity in any case under considera- tion (and which must be diluted to the proportion of b in a), c ; The volume of air which must be added for the pur- pose of so diluting c, d. Then our formula will be derived from the propor- tional statement that as b is to a so will c be to d, and will be expressed thus : cxa and, applying this to the case under consideration (0.6 of a cubic foot of carbon dioxide being the average amount per head per hour given off), X 10,000 = 3,000 ; and this gives us 3,000 cubic feet as the amount of fresh air per hour required to dilute the impurity per head of a mixed population. From this same formula, by trans- position, we may find c or b. Thus, if we wished to find how much carbon dioxide from any source might be tol- erated in conformity with our standard in a room where there were supplied 24,000 cubic feet per hour, our sum would be 2 X 24,000 c= 10,000 = 4-8 cutac feet. Or, again, if we wish to find the ratio of impurity under certain given circumstances ; e.ff., when ten persons are in a room to which 15,000 cubic feet per hour are sup- plied, our sum would be cxa . (0.6 x 10) x 10,000 , ... 6 = W' wW = 4 cubic feut of carbon dioxide, which, with the 4 contained in the atmospheric air, would be 8 in 10,000. We must bear in mind not to confound the a of this formula, the imaginary or assumed air-space of our ra- tio, with the actual air-space in any given case under con- sideration ; important as the latter is when we come to the actual changing of the air in it, it is of little conse- quence in connection with the above formula, for the amount of air in any actual air-space has to be subtracted once only-at the commencement of the operation-in any calculation of the total amount of fresh air to be sup- plied. Of the practical importance of a large air space we shall speak shortly. IV. The frequency with which air may be changed depends to some extent upon the temperature and degree of moisture of it, whether it is warmed be- fore being introduced, upon the appliances for introduc- ing and breaking it up, and upon the absolute size of the air-space (as distinguished from its relative size, or size per individual). Let us briefly consider these points in succession. It will be evident that the air may be allowed to flow around and past us more freely and rapidly if it be at such a temperature as is suitable to our requirements than if it be so cold that it abstracts and carries off from us more than wye can spare of our own animal heat. According to Parkes and De Chaumont,10 at a temperature of 55° or 60° F. a rate of H foot per second is not perceived, a rate of 2 to 24 feet is perceived by some, 3 feet by most persons, and 3| feet by all; any greater speed will give a sensation of draught. If the air be about 70° a greater velocity will be required to produce the above effects, and at 80° to 90° the movement becomes again more per- ceptible. A cold current of air is more unpleasant if its de- gree of moisture be excessive, and a warm current if the moisture be excessive or deficient. If the inlets are distributed throughout the room and if the entering air is broken up into small and feeble cur- rents, it is less perceptible and may be introduced more rapidly ; the same is the case when, with a due regard to its proper distribution, it can be introduced overhead or at other positions at a distance from us, instead of impinging more directly upon us. It will be readily seen that air can be more rapidly introduced without draught into a room 20 x 40 x 12 feet with ten people in it than into a room 9 x 10 x 12 feet with one person in it ; although in the latter the rela- tive air-space is larger. As the result of observation and experiment it has been found that, with the ordinary means of ventilation, three times per hour is the greatest frequency with which the air of living rooms can be changed with a due regard to health and comfort; if air already warmed and mois- tened be introduced by some of the systems of what is termed artificial ventilation, then it may be possible to change the air five or six times without discomfort or injury. The remarks which have been made regarding tem- perature and frequency of change of air show the fallacy of the popular supposition that a larger number of people may huddle into small rooms and dwellings in winter than in summer. So far as heat is concerned this may be the case, but not as regards the maintenance of a pure and wholesome supply of air. V. (1) The amount of air space per head has, by the preceding remarks, been reduced to a very simple calculation. We have found that, in order to dilute the impurities of respiration to a wholesome standard, 3,000 cubic feet of air per hour are required, and we have further ascertained that about three times per hour is as often as the air of a dwelling-room can be safely and comfortably changed with the ordinary appliances for ventilation ; hence we come to the conclusion that the room should hold one-third of the total amount required per hour per individual ; that is, 1,000 feet. We further conclude that if the air be warmed and moistened to a suitable degree before being introduced, then with the best systems of artificial ventilation an air-space of 600 cubic feet might suffice. But these systems of ventila- tion become costly as they approach perfection, and it is difficult, too, to secure a "thorough distribution of the air 614 Ventilation. Ventilation. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. throughout the air-space ; hence it is desirable that, as a general and safe rule, 1,000 cubic feet of air-space be pro- vided. (2) For sick people we have seen that a larger amount of air per hour is required to dilute impurities ; and there is one other fact that we must not overlook, namely, that, as a rule, sick persons are less able to bear draughts and rapid changes in temperature than healthy persons. The air-space required will, of course, vary with the nature of the illness ; this variation may range from 1,500 to 3,000 cubic feet. Most of the readers of this article are no doubt familiar with the admirable results in surgical and other cases from the removal of patients to tent hospi- tals ; and this is a strong argument in favor of an in- crease in the amount of fresh air and sunlight, and of increase in the air-space, which becomes practically un- limited by the rolling up of the curtain-walls when the temperature is such that this may be done. (3) The relative dimensions of the air-space must also receive consideration ; they must be such as to facilitate rapid and even distribution of the impurities evolved and of the fresh air admitted. If very high ceilings exist, it must not be at the expense of the floor-space. This is a matter of great importance in schools and hos- pitals. It has been laid down "as a rule" that the minimum floor-space in square feet should be not less than one-twelfth of the number of cubic feet of air-space. In other words, if ceilings are over twelve feet high, the floor-space must not be diminished on that account. (4) The air-space in schools demands our serious con- sideration ; the observations of many sanitarians, in this and other countries, go to show that as a rule it is not half what it should be, even in schools which are called " model schools "-schools held up as models for the other schools of the province or State. The " sanitary cranks " are told by trustees that the children are hardy and elastic, knocking about, and that the ideal standard is too high and impracticable. A more rational plea is that they are small and do not require as large air-space as adults ; but, in reply, we must remember that their tissues are in the stage of rapid growth and development, that the vital processes are more rapid and, consequently, the chemical changes and the chemical impurities gen- erated are greater in proportion. And, moreover, if by hardy it is meant that their recuperative power is great, well and good ; but, on the other hand, they are more susceptible to surrounding influences. Teachers and scholars spend a great part of their lives in the school- room ; and it is a fact worthy of note that the death-rate from consumption of female teachers, as gathered from the returns of the Registrar-General of Ontario, is ex- cessive. In some places, where the air-space is only half what it should be, the plan has been adopted of using two such rooms, having the windows of one open while the other is being used, and changing the children from one to the other every half-hour. If the rooms were ventilated by air previously warmed, this would do well; but where cold air is introduced and warmed in the rooms, this plan subjects the children to too great changes of temperature in winter-time. (5) In rooms or halls where gas is used, it may be con- cluded, from the calculations and figures already given, that about 1,800 cubic feet of air-space should be allowed for each ordinary burner, unless means are provided for carrying off the products of the combustion. The remark is made in De Chaumont's " Parkes's Hy- giene " that " a notion . . . that, if a larger cubic space be given, a certain amount of change of air may be dis- pensed with ... is quite erroneous." This, taken strictly in the terms stated, is true, but we should not forget that a larger cubic air-space generally means a larger extent of outside walls and windows, through the pores and cracks of which a certain amount of inter- change is constantly going on. (6) The cubic space for the lower animals has been roughly calculated and laid down. It is relatively smaller than for human beings, the supposition being that the lower animals can bear more frequent change of air and temperature. "We might put the estimate roughly at two cubic feet of space for every pound avoir- dupois the animal weighs, the floor-space being not less than one-twelfth of the cubic capacity." " At present the Army Regulations 13 allow, in new stables, each horse 1,605 cubic feet, and 100 square feet of floor-space, and the means of ventilation are ample. In the Army Horse Infirmaries the superficial area is to be 137 square feet, and the cubic space 1,900 feet per horse." VI. For ventilation, the changing of air, re- placing that which has become impure by pure, the forces which are found in existence in nature are : (1) Diffusion and (2) the action of unequal weights of air, whether (a) in the formation of winds prevailing throughout a district or (6) in the more limited inter- changing currents of air in the portion of space, room, hall, etc., the ventilation of which may be under consid- eration. Many writers divide the systems of ventilation in vogue into the two classes of natural and artificial, and the above-named forces they call the natural forces of ventilation, or " the forces continually acting in nature," in contradistinction to " the forces set in action by man which produce the so-called artificial ventilation." We shall find the distinction a somewhat arbitrary one : for if " man " heats a room by means of a steam-coil and al-, lows the air to flow' into the room through a window or even through an opening artistically constructed for the purpose, he may be ventilating by a "natural " system ; but if he lights a lire in a chimney-place he has (inno- cently it may be) started a mode of " artificial " ventila- tion ; and yet it is the " natural " force of the action of unequal weights of air which he has called into play. There are, however, other means and appliances of which the artificial character is more apparent, as will be seen presently. 1. Diffusion of gases, it is well known, takes place even through partitions or dividing substances, the rate of dif- fusion of gases being inversely as the square of their densities ; the familiar experiment of placing a bladder containing carbon dioxide in a jar of oxygen is a good example of this. This is an admirable provision of nat- ure for diluting noxious gases and vapors ; but its action in the removal of the impurities of respiration and com- bustion would be slow, and, besides, little general use can be made of it designedly by us. It might in certain ex- ceptional cases be taken advantage of, as by carrying oxygen into a cave, well, or other confined space contain- ing air dangerously impure ; or as a therapeutic agent in cases of gas-poisoning, asthma, etc. It is not of any service in removing suspended impurities. 2. The Action of Un- equal Weights of Air.-Air is a ponderable com- pound, 100 cubic inches of dry air weighing about 31.07 grains at a tempera- ture of 60° F. and with the barometer at 30 inches. It expands or increases in volume with the addition of heat, the rate of expan- sion varying under differ- ent circumstances, but be- ing, in general terms, about 1 in 491 for every Fahrenheit degree of heat. Hence of two equal vol- umes of air at different temperatures the colder will be the heavier, and it will fall and displace the warmer and lighter ; and as air, like other fluids, presses equally in all directions, this cool heavy air will be forced laterally to take the place of the w'armer lighter air which it displaces upward. This may be readily understood by reference to the accompanying diagram (Fig. 4525). Let us suppose that Fig. 4525.-Diagram illustrating the Action of Bodies of Air of the Same Height but of Different Tempera- tures and hence of Unequal Weights. 615 Ventilation. Ventilation. REFERENCE HANDBOOK OF THE MEDICiYL SCIENCES. d e jis a chimney, 40 feet high, in which, in the first place, there is no heat; a b c and d e f are columns of air of which b and e are, respectively, the middle points, and they are of the same height and of the same temperature; they are consequently of the same weight, and will balance each other-the air is at rest. If a fire be lighted at the bottom of the chim- ney and the air be heated to such a degree that that contained in d e will ex- pand and fill the whole space def, then the col- umn a b c becomes twice as heavy as d ef ; the state of equilibrium isdisturbed, the cold heavy air column a b c, presses downward and sideward and displaces rapidly upward the lighter column d ef. Air being a fluid, pressure upon it acts equally in all directions, and hence it will make no difference, except in dis- tribution of the air in the room represented in the diagram, if the opening is made at the top, as in Fig. 4526. To determine the rate of movement, calculations and laws have been stated by Montgolfier and others. These are based upon the law which determines the ve- locity acquired by bodies falling in vacuo; namely, that the velocity in feet per second is equal to about eight times the square root in feet of the height through which they have fallen. The air not rushing into a vacuum, but into a space filled with lighter air, difference in pressure becomes one of the factors. The formula given is : v, being the velocity in feet per second ; h, being the height in feet of the warmer column ; d, being the difference in Fahrenheit degrees between its temperature and that of the outside air. is the amount of expansion of air for every de- gree. Allowance has to be made for friction, counter-cur- rents, etc., and this has been estimated to require a re- duction of from one-fourth to one-half in the rate of speed according to varying circumstances. These cal- culations cannot be said to be exact or reliable and are only of value as an approximation to the truth. As such an approximation the following table is given in Parkes's " Manual of Practical Hygiene 14 Fig. 4526.-Modification of Preceding Diagram. " Table to Show the Velocity of Air in Linear Feet per Minute. Calculated from Montgolfier's formula ; the expansion of air being taken as 0.002 for each degree Fahrenheit, and one-fourth being deducted for friction. (Hound numbers have been taken.)" Height of column. Difference between Internal and External Temperature. 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 30 10 88 102 114 125 135 144 153 161 169 176 183 190 197 204 210 216 222 228 233 239 244 249 254 279 11 92 107 119 131 141 151 160 169 177 185 192 200 207 213 220 226 233 239 245 250 256 261 292 12 96 111 125 136 147 158 167 176 185 193 201 209 216 223 230 237 243 249 255 261 267 273 279 305 13 100 116 130 140 153 164 174 183 192 201 209 217 225 232 239 246 253 259 266 272 278 284 290 318 14 104 120 135 147 159 170 181 190 200 209 217 225 233 241 248 255 262 269 276 282 289 295 301 330 15 108 125 139 153 165 176 187 197 207 216 225 233 241 249 257 264 -2 4 2 279 286 292 299 305 312 341 16 111 129 144 158 170 182 193 204 213 223 232 241 249 257 265 273 281 288 295 302 309 315 322 853 17 115 133 148 162 176 188 199 210 220 230 239 248 257 265 274 282 289 297 304 311 318 325 332 £63 18 118 136 153 167 181 193 205 216 226 237 246 255 264 273 282 290 298 305 313 320 327 335 342 374 19 121 140 157 172 186 198 210 222 233 243 253 262 272 281 289 298 306 314 321 329 336 344 351 384 20 125 144 161 176 190 204 216 228 239 249 259 269 279 288 297 305 314 322 330 338 345 353 360 394 21 128 147 181 195 209 221 233 245 255 266 276 286 295 304 313 321 330 338 346 354 361 369 404 22 131 151 169 185 200 214 226 239 250 261 272 282 292 302 311 320 329 338 346 354 362 370 378 414 23 134 154 173 189 204 218 232 244 256 267 278 289 299 309 318 327 336 345 354 | 362 370 378 386 423 24 136 158 176 193 209 223 237 249 261 273 284 295 305 315 325 335 344 353 361 370 378 386 394 432 25 139 161 180 197 213 227 241 254 267 279 290 301 312 322 332 342 351 360 369 1 378 394 402 441 26 142 164 183 201 217 232 246 259 272 284 296 307 318 328 338 348 358 367 394 402 410 450 27 145 167 187 205 221 237 251 264 277 21H) 302 313 324 335 345 355 365 374 383 392 401 410 418 458 28 147 170 190 207 225 241 255 269 282 295 307 319 330 341 351 361 371 381 390 1 399 408 417 426 467 29 150 173 194 212 229 245 260 274 287 300 312 324 347 357 368 378 388 397,407 416 425 433 475 30 153 176 197 216 233 249 264 279 292 305 318 330 341 353 363 374 384 394 404 414 423 432 441 483 31 155 179 200 219 237 253 269 283 297 310 323 335 347 358 369 380 391 401 411 420 430 439 448 491 32 .. . 158 182 204 223 241 257 273 288 302 315 328 341 353 364 375 386 397 407 417 427 437 446 455 499 33 160 185 207 226 215 261 277 292 307 320 333 346 358 370 381 392 403 414 424|434 443 453 462 506 34 162 188 210 230 248 265 282 297 311 325 338 351 363 375 387 398 409 420 430 । 440 450 460 469 514 35 165 190 213 233 252 269 2S6 301 316 330 343 369 381 393 404 415 426 436 447 457 467 522 36 167 193 216 236 255 273 2D0 305 320 334 348 361 374 386 398 410 421 432 4421 453 463 473 483 529 37 170 196 219 240 259 277 294 310 325 339 353 366 379 392 404 415 427 438 448 459 470 480 490 38 172 198 222 243 262 281 298 314 329 344 358 371 384 397 409 421 432 444 454 465 476 486 4945 543 39 174 201 246 266 284 302 318 333 348 362 376 389 402 414 426 438 450 461 471 482 492 503 40 176 204 228 249 269 288 305 322 338 367 381 394 407 420 432 444 455 467; 477 488 499 509 558 45 187 216 941 286 305 324 341 358 374 389 404 418 432 445 458 471 483 495 I 506 518 529 540 591 50 197 228 254 , 279 301 322 341 360 377 394 401 426 441 455 469 483 496 509 5221 534 546 558 569 623 3 4 5 6 7 8 9 10 11 12 13 14 15 | 16 17 18 19 20 21 22 23 24 25 30 The measurement in the above table is linear, and to ascertain approximately the number of cubic feet per minute which have passed through an outlet we must multiply the linear measurement by the sectional size of the discharge-tube in square feet or decimals of a foot. 3. The action of winds is too uncertain to be relied upon for the ventilation of stationary dwellings, but a similar action may be called into play in the case of steam-vessels, railroad cars, and other habitations which produce external currents of air by their own locomotion. A current of air blowing against a dwelling may be made use of in one or both of two methods, by causing it to force its way into the dwelling, a method to which the term perflation is applied, or by drawing air out of the dwelling by aspiration. The process of aspiration is similar to that which takes place in an atomizer, where a blast of air rushing over the open mouth of a tube draws up in its wake the contents of-the latter. It will be seen, hereafter, that the perflation and aspira- tion of the natural system of ventilation are analogous to the propulsion and extraction of the " artificial" systems. Perflation.-The wind may be allowed to blow in through windows, through louvered or latticed openings in the sides of a dwelling, or by means of downcast tubes. One of these tubes, with a movable cowl which revolves to catch the wind, is shown in Fig. 4527. Movable cowls are most efficient so long as they continue to act as in- tended, but they are apt to become fixed, and their action 616 Ventilation. Ventilation. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. may be reversed by winds from opposite directions. Fig. 4528 shows a downcast shaft with a fixed cowl ; the wall of the upper end of the tube slopes upward and outward, like a short truncated funnel, and is surmounted by an inverted cone. The wind, blowing into the opening left be- tween cone and funnel, will be deflected downward from whatever direction it may come. In steam-vessels large cowls of the kind shown in Figs. 4527 and 4529, with their mouths directed respectively for- ward and backward, are used with great advantage to force air into and withdraw it from the furnace-rooms and other confined spaces. These cowls and tubes on board ships are sometimes made of canvas. In aspiration, if the movable cowl be used, the vane must be so placed as to cause the cowl to turn with its mouth in the opposite direc- tion to that from which the wind is blow- ing, as seen in Fig. 4529. The upcast shaft will work well in the form of a simple straight tube without any con- trivance, but it may be improved by the addition of a fixed cowl, such as is shown in Fig. 4530.. To the top of the tube is affixed a flange, sloping downward and outward from the rim of the tube ; this is surmounted by a cowl (the walls of which will, of course, slope in the same direction). Upcast shafts and chimneys may be made more efficient by blackening them, so that they may absorb heat from the rays of the sun, and also by putting behind them, on their northern sides, screens to reflect the rays upon them. It must be borne in mind that without any special contrivance, and even in well-built houses, wind will force its way through the porous walls and through chinks and cracks. It is of importance that we bear in mind and provide for the possible inter- ference of the wind with our plans oi ventilation. Having now considered the material forces at our command for the purposes of ventilation, wre must next proceed to the application of them. We shall find many modifying circumstances of season, mode of warming, etc., which will necessitate differences in the mode of ventilation ; but we shall be assisted very materially in determining and arranging these modes if we remember- 4. Certain cardinal principles: a. That the air supplied should be pure. b. That it should be of a suitable tem- perature and degree of humidity when it comes in contact with our bodies. c. That it should be distributed through- out the whole air-space. d. That warm air is lighter than cold. These principles may appear to be so self-apparent that the enunciation of them may seem puerile and unnecessary; it may, therefore, be well to point out how they are frequently forgotten or over- looked. a. The air supplied, should be pure, and yet how often do we find the so-called fresh-air box of a furnace drawing air from the surface of a back yard, and this not always a clean one ; often its mouth will be found under a veranda floor with quantities of decaying wood in its vicinity ; in one case the ventilating man-hole of a sewer was being placed in dangerous proximity to the mouth of a flue drawing the furnace-supply from the street. Then, again, the cold-air box and the various flues are often so constructed that it is impossible to clean them out. In one public building which the writer was called upon to examine, he found the cold-air boxes commenc- ing in area-windows close to the sidewalks, and into them had been drifting for years straw', street-debris, bones, and other waste from a neighboring market- square. It is not an uncommon thing to find hot-air furnaces supplied wholly or in part from the cellar ; and sometimes false economy is practised, especially at night, by partially closing the communication of the fresh-air duct with the outside air, and drawing back into it the air from the inside of the dwelling. In dwelling-rooms we often find that air is admitted through the doors leading into the halls, this air having been already used, in many instances, in other rooms. Of course a house may be so spacious and have so few inmates that the air from the halls may be pure enough, especially if there are open windows or other fresh-air inlets in other parts of the house. But we often find houses in which the air in the halls has been used over and over again, and where fresh outside air is not ad- mitted, the occupants of the several rooms supposing that they are obtaining fresh air from the hall. Those who are intrusted with the sanitary oversight of buildings should be on the alert to see that no acci- dental malposition of an inlet exists by which impure air may be brought into use for breathing purposes. One or two instances which have come under the obser- vation of the writer may serve as instructive examples. The offices of a bank building were supplied by means of Tobin's tubes, and in some of them the air was very bad ; on investigation it was found that the supply-pipe of one of these passed through a cellar in which were some water-closets and urinals, and a workman repairing the cellar-window had cut off the connection of the tube with the outside air ; the inlet of another tube was found concealed behind the wooden box protecting a tin rain- pipe ; this boxed-in rain-pipe was at a convenient dis- tance from the corner of a thoroughfare, and its projec- tion had made it very useful to pedestrians at night for the purpose of a urinal. In another building, steam- heating had been substituted for hot-air furnaces, but the hot-air flues were still left open in the ceiling of the cel- lar and were carrying up through the building the foul air from the closets and urinals. In this case all the flues were closed up except one, and it was carried up to the roof, and its draught (as a foul-air shaft) assisted by a cowl and suitable contrivances for warming the shaft. In modern buildings two plans are being adopted to prevent the air from closets and urinals from being drawn through the building. One is to place them in an annex with ventilated passages and double doors leading to the other portions of the house. The other plan is to place them in the highest flat. The means of preventing offensiveness are pointed out in the articles on Sewage Disposal and Sewerage ; but the plans here proposed are extra precautions in case sufficient care has not been used. For similar reasons, kitchens are sometimes placed in the upper flats of hotels and other buildings where elevators are in use. In some systems of ventilation the incoming air is made to pass through a water-spray which washes it free from impurities. b. The Air should be of a Suitable Temperature and De- gree of Humidity.-This introduces the subject of warm- ing and of so disposing our inlets and outlets as not to defeat our object in warming the air supplied. The degree of warmth which seems most conducive to health and best suited to us in living rooms is from 65° to 70° F. of artificial warmth ; a somewhat higher de- gree of natural climatic warmth proves very agreeable and not unhealthy for most persons. The amount of humidity most suitable in general is about seventy-five per cent, of saturation (for the amount of saturation, see the article on Air). For con- sumptives a smaller amount of moisture seems to be more beneficial (see Climatic Relations of Consumption). A low temperature is very much more disagreeable and unhealthful if accompanied by much moisture. Fig. 4527.-Revolv- ing Cowl for Per- flation. Fig. 4528.-Down- cast Shaft with Fixed Cowl for Perflation. Fig. 4529.-Revolv- ing Cowl for As- piration. Fig. 4530.-Tube with Fixed Cowl for Aspiration. 617 Ventilation. Ventilation. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES Systems of warming may, in relation to ventilation, be divided into the indirect, or those in which air is warmed before being introduced into dwelling-rooms ; and the direct, in which warmth is generated in the rooms themselves ; for the questions con- nected with the size and position of inlets and outlets, the amount of air-space and the fre- quency of change, will be much modified ac- cording as one or other of these two methods is in use. Warmed air will seldom be of such a temperature but that it may be allowed to come in contact with the body at a distance of a few feet from its point of entrance into a room without causing discom- fort. Hence if we have secured a supply of pure warm air the questions left us are, to arrange for a thorough distribu- tion before leaving the room, and for sufficient egress and ingress. If, on the other hand, cold air enters a room, then we have not only to see to a proper distri- bution of it after it is warmed, but to see that the currents are broken up and well distributed before they come in con- tact with our bodies. The question of distri- bution is doubly com- plicated. Indirect Heating. - Air is warmed before being introduced by passing over some heat- ing surface, whence it is conveyed in flues to the apart- ments to be warmed. A hot-air furnace consists of a sort of large iron stove surrounded by a casing of brick or metal. The fresh air is led through the cold Hue to the space between the furnace and the cas- ing, where it is warmed, and it then passes off by hot-air flues, which commence in the walls of the casing, and con- duct the air to the vari- ous apartments, its exit into the latter being regu- lated by registers pro- vided with valves which may be opened or shut. The hot smoke and flame from the fire-pot are made to pass through Hues in the "radiator" of the furnace so as to increase the area of heat- ing surface and obtain all the heat possible be- fore the smoke is allowed to pass off into the smoke- pipe. In the space between the casing and furnace pans of water are placed to supply moisture to the heated air. When the casing is of brick, a perforated water-pipe is sometimes carried around the inner surface of the brick wall, and water from it trickles down the heated wall, thus presenting a larger evaporating surface. The fresh air should, of course, be brought from out doors, and enter at the bottom of the air- space, between furnace and casing. It should be sifted or screened by passing through a tine screen of wire or other suitable material, so as to rid it as far as possi- ble of suspended impu- rities. The fresh-air due should also be left ac- cessible by means of re- movable openings, so as to admit of periodic cleansing. Fig. 4532 shows a hot-air furnace to which is superadded a steam- generator from which steam is caused to cir- culate through coils or radiators placed in some of the rooms to be warmed. By means of this contrivancewe have indirect heating by the air conveyed from the f urnace, and direct heat- ing by the coils in the respective apartments. The principal advan- tage of this addition of steam appears to be that it enables one to carry heat in cases where there are rooms at a long distance hori- zontally from the fur nace, as it is difficult to get hot air to travel far horizontally. Fig. 4533 shows the construction of a tubular hot-air furnace; one side of the fire-box, and portions of the chambers connecting fire-box, fines, and smoke-pipe are cut away so as to show the manner in which the flues are heated. The mode of heating the air is similar to that Fig. 4531.-Cut of "Perfect" Hot-air Furnace. The outside casing is cut away, as also portions of the side of the furnace. Fl«. 4532.-Combination Heater-hot- air and steam-with a portion of outer casing, dome, and fire-pot broken away, to show internal construction and working of the respective parts. It may also be set in brick. Fig. 4533.-Tubular Air-warmer. of other hot-air furnaces. The features of the Smead- Dowd system of ventilation will be referred to hereafter. Air may also be warmed through chambers or flues containing coils of steam or hot-water pipes. This plan is adopted in many of our public.buildings. 618 Ventilation. Ventilation. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Direct heating is accomplished by means of tires in grates, fires in stoves, steam-coils or radiators, and hot- water coils or radiators. From the ordinary open grate or fireplace, built at the bottom of a chimney, warmth is produced by radiation This plan of introducing fresh air is certainly to be commended as a step in the right direction, although the current of hot air obtained from grates of this kind in this northern climate has not, in the experience of the writer, been very large. A much more equable and rapid warmth results from the application of a similar principle in the jacketed stove (Fig. 4535). Any stove can be surrounded by a jacket of sheet metal, the space between the two being supplied with fresh air by a tine of tin, galvanized iron, or other simi- lar material, passing under the floor, as seen in Fig. 4536. Steam-coils may be treated in a similar manner, as is the case in some hospitals. The plan cannot be safely pursued with hot-water coils; if the temperature of the water falls and the air is very cold, the ■water may freeze in the pipes. In heating a house it is de- sirable to have the proportion of heating apparatus larger on the lower stories, as the ten- dency of the hot air is to as- cend. It is not desirable that the upper stories should be devoid of heating apparatus, however, as they wTould thus be liable to rob the lower sto- ries of their heat. Warming by means of gas- stoves has become popular on account of its convenience. It is very unwholesome, unless the heating apparatus is provided with some kind of flue for carrying off impurities. Its power for direct radiation of heat is small. Hence the only economical healthy manner in which it can be used is by making it heat some radiating body, or by circulation of water or air in coils passing through its flame. In places where there are large supplies of natural gas, devices of these kinds can be readily and economically made use of. Large burners with numerous jets may be introduced into the ordinary stoves and furnaces before used with coal or wood fires, these burners taking the places of the grates and fire-pots formerly used. Fig. 4537 shows one of the burners in use for this purpose. With manufact- ured illuminating gas the warming of rooms will be ex- pensive if carried out with a due regard to the require- ments of health ; or, putting the case conversely, we find that the practicable devices for warming by manufact- ured gas are not conducive to health. In steam-heating steam is generated in a central boiler, and forced through (iron) pipes to the various apartments to be heated, where it is made to pass through coils of pipe or "radiators." The condensed steam is brought back by return pipes to the boiler. Fig. 4538 shows one of the many kinds of steam-boiler. It is a " magazine " boiler, having a supply of coal from which the fire is automatically fed, as in the self-feeder stoves. The smoke and flame pass down flues surrounded by the water, a large heating surface being thus obtained. Fig. 4539 shows one of the various devices of radiator; the sections are so made that they can be coupled one to the other, thus making the radiator of any desired size. When coupled there is a tubular passage from end to end, both above and below, with which all the vertical passages or "loops" connect, so that the steam or hot water (for the same radiator answers for both) may cir- culate rapidly and return. In some cities a method is in operation of heating houses by steam generated at a central depot, and con- veyed through street-mains to the various houses, in a manner similar to that by which illuminating gas is dis- tributed. The system originated in Lockport, N. Y., and has been introduced into many cities on this conti- nent. The results are said to be satisfactory. In hot-water heating the water, becoming lighter when Fig. 4534.-Grate with Air-chamber by which Fresh Air is brought from Out-doors, warmed, and discharged into the room. Fig. 4536.-An Ordinary Stove surrounded by a Jacket, the air-space thus formed being supplied with fresh air by a flue passing from the outside of the building and under the floor. only ; heat is radiated from the fire to the persons sitting within reach of its rays, and also to the floor, walls, ceil- ing, and furniture, whence it is again radiated. In the Galton grate, the Griffin grate, and others of similar design, a plan said to have been proposed long since by Desaguliers has been put in practice, whereby Fig. 4535.-A Jacketed Stove: a space exists between the fire-box aud outer casing into which fresh air enters and is heated. fresh air is brought in to the back and sides of the grate and around the smoke-flues, and, after thus becoming heated, passes into the room (Fig. 4534). 619 Ventilation. Ventilation. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. heated, rises to the different coils or radiators, where it gives off its heat, and, be- coming again cooler and heavier, descends to the boiler, entering the latter at its lower portion (see Fig. 4540), rising to the top and passing out as it is again heated. The coils or radia- tors are similar to those used with steam, but they require to be larger, owing to the fact that water is lower in temperature than steam. It will be evident that the pipes should have a continuous rise from the boiler to the top of the coil or radiator, in order that the water may circulate properly. The same precaution should be observed with steam, other- wise water will collect in the dips in the pipe, and the steam will be forced through with a series of small ex- plosions, causing cracking sounds in the pipes. In hot- water heating the supply-tank must be higher than the highest radiator ; a small tank will suffice, as the amount of water lost by evaporation is very little. Steam-coils, like stoves, may be surrounded by a jacket between which and the coil cold air may be introduced. Great care would have to be exercised in adopting a similar plan with hot-water coils, as a very low tem- perature might freeze the water in the coil. In one of the Boston hospitals the wards are supplied with a num- ber of small steam- coils to which fresh air is supplied di- rectly. In all systems of direct heating it is desirable to bring the heating body as near as practicable to the wundows or other in- lets, so that the enter- ing air may come in contact with the heater before traversing the apartment. In cli- mates where the tem- perature is very high, various means of cool- ing the air are resorted to, such as hanging wet mats on the sides of the house, pumping water up to the high- est point of the roof and allowing it to trickle dowm. The extractive powTer of chimneys is also in- creased by blackening the portions of them which project above the roof; as before stated, a large fan or punkah may also aid in producing currents of air. In India a plan is in use by which a punkah is worked and water elevated to moisten it ; a wheel turned by a bullock is the motor power. Sometimes air is made to pass through inlet passages containing ice, or a stream or sheet of cold water. The heating of railroad cars has recently been the sub- ject of much thought, on account of the numerous acci- dents from fire which have occurred. It would be well Fig. 4537.-A Gas-burner adapted to a Stove for Heating by Natural Gas. Fig. 4538.-Base-burning Magazine Boiler. Fig. 4540.-Hot-water Heater. The cold water enters below into a water-chamber around the grate ; it then rises through a number of small tubes, around which the fire freely plays, to the top chamber and off through the " flow " mains to the various coils or radiators. Fig. 4539.-Radiator for Circulation of Steaui or Hot Water. 620 Ventilation. Ventilation. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. that, at the same time, and in connection with their heat- ing, their ventilation should also secure increased atten- tion. Many cases of illness can be traced to " colds" contract- ed especially in sleep- ing-cars. Small air- space, direct systems of heating and ven- tilation, and the ag- gravation of the con- sequent evils by ignorant and careless porters are the causes of this condition of things. c and d. The other two principles will be illustrated in their application to various modes of ventilation. 5. Devices for break- ing up and distribut- ing currents of cold air are especially necessary in cold cli- mates for rooms heated by the direct methods. One of the most simple of these con- sists in the raising of the lower sash a few inches and filling the space between it and the sill with a piece of board (Figs. 4542 and 4543), or temporarily with a quilt or other material ; the draught is thus thrown upward. In Fig. 4544 a modification of this plan is shown. A board slants downward and outward from the top of the window-frame and a second opening is provided ; if there is some other opening in the room acting well as an outlet, the upper opening here shown will act as an additional in- let, and the current of entering air will impinge against the ceiling and will be then broken up. If there is no other good outlet, it may happen that the upper opening may act as an outlet and the lower one as an inlet. A further modification of this last-de- scribed method is to have a board attached to the upper part of the window-sash and sloping upward and inward from it; the air is thus deflected toward the ceiling. A similar method is to have a double pane in the window, the outer pane having a slit of a few square inches at its lower edge, and the inner one a similar slit at its upper edge. Louvered openings, with the slats sloping upward and inward, may be used. The opening in the window may be covered by a wire screen, by means of which the air is broken into small minute currents. Perforated bricks are sometimes placed in the outer walls. In some of these the openings are funnel-shaped, the apex communicating with the outer air, and the current of air expanding along the sides of the funnel as it enters. In the Sheringham valve (Fig. 4545) the air, after en- tering through a perforated brick, is directed upward by a sloping valve, which may be closed wholly or partially if too much cold air is entering. In the Jennings air-brick (Fig. 4546), at the upper part of the apartment, is a hollow wall with a narrow air-space between its inner and outer portions ; the air-space com- municates with the outer air by means of a horizontal opening, and with the inside of the room by means of a louvered brick -the slopes of the lou- vers being upward and inward. Another plan is to run a box or large tube from side to side of the room across the ceiling, allow- ing the ends to commu- nicate with the outside, and perforating the tube with openings which ad- mit the air into the room at various points along the ceiling. Sometimes a partition is placed in the tube or box, one portion of which becomes an outlet while the other is an inlet. A perforated metal cornice, similarly constructed, may be run around the room. Stallard's double ceil- ing is a similar device ; the whole surface of the (lower) ceiling being provided with perfora- tions. Tobin's tubes lead from the outer air under and upthrough the floor, and, rising, discharge fresh air at a point some eight feet or more above the floor. McKinnell's plan is shown in Fig. 4547. It consists of two concen- tric tubes with a space between them through which cold air enters. The inner tube, being protected by this air- space, becomes an outlet. A flange attached to the lower edges of this inner tube, and spreading outward below the inlet-space, directs the cold entering air toward the ceiling and walls, and pre- vents it striking down upon the heads of the inmates. The so-called Watson's tube is the simple device which so commonly projects from the roofs of root-houses and other similar structures. It is a tube with a partition dividing it in its own axis. One-halt' of the tube acts as an inlet, the other as an out- let ; the question of inlet and outlet being determined by some such circumstance as the sun shining on one side or the wind blowing on the other. 6. Inlets.-In spacious houses, with proportionately few Fig. 4545.-Slieringhain Valve. Fig. 4541.-Hot-water Heater. Fig. 4546.-Jennings's Air-brick. Fig. 4542.-Window with its lower sash raised a few inches, and the space be- neath filled by a board ; an upward inlet is thus made between the sashes. Fig. 4547.-McKinnell's Circular Tubes. Fig. 4543.-Sec- tional View of Fig. 4542. Fig. 4544.-A board slant- ing downward and out- ward is affixed to the top of the window-frame, and the upper sash lowered ; a second opening is thus secured. Fig. 4548.-Watson's Tube. 621 Ventilation. Ventilation. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. inmates, and in poorly constructed houses with loosely fitting windows and doors, a sufficient amount of fresh air may enter without providing special inlets, or, with intelligent persons, sufficient window-ventilation may be effected to meet the requirement of 3,000 cubic feet per hour per individual. There are many cases, however (and among them we may include schools and other public as- semblages and institutions'), where special inlets should be provided. They should be of a sufficient size to admit the requisite amount of air at a practicable rate of move- ment, and not so large as to interfere with the proper degree of warmth. We have seen that a current of 3 feet per second is about what can be borne safely and comfortably. In order to supply 3,000 cubic feet per hour at that ve- locity, the section of the current, or, in other words, the in- let-space per head per individual would have to be 40 square inches. In the barrack regulations of the British Army the inlet-space is set down at 24 square inches. This would necessitate a current of 5 feet per second. This would be too rapid for any except hardy persons, un- less the air were warm. It is, of course, desirable that the inlet-space of a room should be broken up and dis- tributed. When warm air is introduced, these points are of less consequence. Inlets should be so constructed as to be readily kept clean. 7. Outlets, their size, construction, and maintenance. It is of great importance to have outlets of such a size that they will, at an attainable velocity, carry off three thou- sand cubic feet of air per individual; also, that they should be outlets not in name only, but in reality. It must have occurred to most of the readers of this work to meet with so-called ventilating outlets through which there was no movement of air, or a movement inward. A very common reason for this has already been ex- plained. This reversed action of outlets is a reason why they should be so constructed that they may be kept clean. It may, in certain cases, be feasible to turn win- ter outlets into summer inlets, by the action of valves. It is well, also, that outlet-flues should have valved regis- ters near the ceiling line, so that summer outlets may be available. 8. The position of outlets and in lets must be such that the fresh air will not pass at once from the one to the other without traversing the space occupied by the inmates. In the case of direct heating there is the further requi- site that the incoming air must be modified in temper- ature before it traverses this space. Hence it will be- come apparent that the positions of outlets and inlets must vary with the differences of season, of modes of warming, of size and shape of rooms, of the forces for distributing air, and of other modifying circumstances. It may be stated, as a general rule, to which an excep- tion will be noticed presently, that when artificial warmth has to be employed the outlets should be from the floor- line ; and, as another general rule, also with exceptions, that where artificial warmth has not to be employed the outlets should be at the ceiling-the exception being that when powerful artificial extraction is employed we may use the same outlets as in winter. If we could have a large number of minute inlets dis- tributed throughout the floor, and a broad sheet of warm air rising in minute currents throughout the apartment, we could have a thorough distribution of the incoming air with outlets at the highest part qf the room. No ad- ditional extractive force (such as the heating of flues) would be necessary, and all the impurities of respiration and lights would be carried off together. But it is seldom that such a thorough distribution and breaking up of incoming currents at the floor-line can be obtained. To ascertain how warmed air is distributed when introduced from the ordinary register, a series of experiments was conducted by Mr. W. R. Briggs. He introduced smoke through the registers, and the results are thus recorded in a paper published in one of the An- nual Reports of the State Board of Health of Connecti- cut : " The air entering upon the outer wall at the floor, and being removed on the inner wall at the ceiling level, does not benefit the occupants of the room as it should. The action of the air as it enters is rapidly upward to the ceiling, where it stratifies, then along its surface to the outlet. The entering air is warm and light, and naturally rises and flows across the top of the room to Fig. 4549. the nearest outlet. The foul air of the room, being heavy with impurities, remains at the bottom, becom- ing constantly more contaminated. There is no doubt a certain amount of radiation, Or mixing is going on, but the great bulk of the pure warmed air entering the room takes the short cut across it and up the chimney, as shown in Fig. 4549. This action of the warm air occa- sions, as may readily be seen, an enormous loss of heat, Fig. 4550. without accomplishing the very points aimed at-the utilization of every particle of heat before it is allowed to escape, and the thorough mixing of the pure incom- ing air with the air already in the room. If anyone doubts the correctness of the action of air as herein described, let him fill the incoming flues with smoke, that can be readily seen, and watch its course as it en- ters, flows upward and outward, and see where the great mass of it goes. The dotted lines on this sketch indicate the breathing point of a person sitting. "It may be well to explain that in these experiments the outlets have been at least twice as large as the inlets, and that there has always been heat in the outgoing flues to produce a strong up-current, as I believe this to be the only sure way to produce a constant outflow of air. Fig. 4551. 622 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Ventilation. Ventilation. "In Fig. 4550 the outgoing flue is in the same posi- tion, but the incoming flue has been raised about two- thirds of the way toward the ceiling. " In Fig. 4551 the flues have been placed on about the same level, but with no better results. rapidly upward and outward, stratifying as it goes to- ward the cooler outer walls, thence flowing down their surfaces to the floor and back across the floor to the out- going register. By this method all the air entering is made to traverse with a circular motion (see Fig. 4554) the entire room before it reaches the exhaust-shaft, and there is a constant movement and mixing of the air in all parts of the room. All the heat entering is utilized, and I believe that if the supply and exhaust-flues are properly balanced as to size, there can be a very small loss of heat. "The inlets are all intended to be large, and the flow of air through them moderate and steady. The air is not intended to be heated to a very high temperature ; the large quantity introduced is expected to keep the thermometer at about 68° at the breathing level." In looking at the last of these figures one naturally asks how far the hot air will travel before it descends to its distribution, and whether in a very long room the distri- bution will be perfect. It is evident that there w'ill be great diversity, according to the temperature of the warmed air, the sizes of flues, the distance and direction from the furnace, and that each case will require special study by the architect, and much experience, in order to attain a perfect distribution, and that this will be espe- cially the case in schools, churches, and lecture-rooms, where space is all utilized, and where each part should receive its own share of fresh air, and where persons cannot move about to find a spot where the temperature is congenial. One of our leading architects communicated to the writer the details of a very instructive series of experi- ments made to test the ventilation of a church. The building was heated by three large registers in the floor, admitting hot air from three separate furnaces ; the out- lets were numerous, and were situated along the ridges of the roof. Pieces of paper and tin-foil were scattered in the ascending columns of hot air : those in the column were carried directly up to the roof ; those which were more than three or four feet from the central axis of a column fell to the floor. The inference drawn by the committee was that with hot-air inlets at the floor, and outlets at the roof, even though the latter were well dis- tributed, the mixing of the air was extremely incomplete, the air, with the exception of those three columns of six to eight feet in diameter, being comparatively stagnant. If, instead of outlets at the roof, there had been outlet- flues leading from the junction of the wall with the floor- line, in good working order, drawing the air from the floor-line, the air at the roof, becoming somewhat cooler than the incoming columns of hot air, would have stead- ily floated down through the body of the church, and, the more numerous the flues and the more evenly dis- tributed along the bottoms of the walls, the more thorough would the mixing be. It will be noticed that " flues in good working order''have just been mentioned as one of the requisites for the efficient working of this plan. If these flues are at the same temperature as the outer air, and there is no artificial force to cause an exit of the air in them, stagnation will result, and the want of at- tention to this point has been a fruitful cause of failure in the working of the Ruttan system of ventilation, and it is also one reason for disappointment which sometimes occurs in the working of hot-air furnaces. Fig. 4555 represents a section of a building warmed and ventilated by the Smead-Dowd system, an artificial system of ventilation. The outlets may be seen at the bottom of the sheeting along the floor-line. These out- lets are distributed at the sides of the rooms, and open into spaces beneath the floors. These spaces are con- nected with flues down which the air is drawn by the powerful action of the furnace-chimney, which is marked " Vent Shaft " in the diagram before us. The foul air, on its way to the chimney-shaft, is drawn through the vault of the latrines, desiccating the faeces, as explained in the article on Sewage, Disposal of. In winter-time the blast from the hot-air furnace forms a powerful extractive force. On heavy days in summer- time a fire is lighted in the small heater seen at the bot- Fig. 4552. " In Fig. 4552 the outgoing flue has been placed at the floor, with the results shown in the sketch. "In Fig. 4553 both flues are at the floor-level, with better results than have yet been obtained, but still far from satisfactory. I have thus tried to show the general action of incoming and outgoing currents of air by the placing of the introduction-flues on the outer walls. " In the Bridgeport School the coil-boxes for the heat- ing of the various rooms have all been placed in the Fig. 4553. main ventilating shafts in the centre of the building, and the air conveyed from them through these shafts to the rooms by means of metal tubes. The air enters the in- ner corner of the room about eight feet from the floor, the corner being clipped so as to form a flat surface for the register opening ; underneath the register the space is utilized for a closet for the use of the teacher. The outgoing flue has been placed directly under the plat- form, which is located in the same corner as the intro- Fig. 4554. duction-flue. This platform measures 6' x 12', and is supplied with casters, so that it can be moved at any time it is necessary to clean under it. Its entire lower edge is kept about 4" from the floor, to give a full circulation under it at all points. The action of the incoming air is 623 Ventilation. Ventilation. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tom of the shaft in our diagram. The writer has visited, shortly before the time neys may be increased by blackening their outside surface, so that they will absorb heat from the rays of the sun. Other means are referred to under the head of Artificial Ventilation. In warm weather-when we do not require artificial warmth-our outlets are better at the upper part of the room, and, unless we have powerful artificial means, they must be so placed. In temperate climates the tem- perature of the air is rarely as great as that of our bodies (981° F.), and consequently the air in contact with our bodies obtains addi- tional heat, and will rise ; it should be allowed to pass directly up from us, and out into the outer air. In rooms with lights the ascen- sional action will be increased, as it will be, also, by the rays of the sun striking the roof and sides of the house. (9.) In artificial ventilation various contriv- ances are employed for causing air to pass through outlets and inlets. When air is drawn out of a room or building by artificial means, the method of extraction is said to be employed ; when fresh air is forced in, dis- placing the air already in the building, the term propulsion is used. These terms are analogous to the terms aspiration and perfla- tion, already referred to in connection with the action of winds. Extraction is accomplished by means of heat, steam-jets, fans, wheels, pumps, or the Archimedean screw. The action of heat has been explained when speaking of the positions of outlets and the distribution of air. In the cases referred to, fire is placed at the bottom of a chimney ; flues with steam-coils or jets of gas are used for the same purpose. Sometimes the heat- ing power is placed near the top of the flue or chimney ; this is a bad plan, as the hot air escapes after acting upon a short section of the chimney instead of the whole length. In churches, public halls, and other buildings where numerous gas-jets are employed for lighting purposes, they might more frequently be taken advantage of for ventilating, instead of being allowed to vitiate the atmosphere. Those who have had occasion to Fig. 4555.-Section of a Building warmed and ventilated by the Smead-Dowd System. for dismissal, school-rooms warmed and ventilated in this way, and has compared them with schools heated by steam-coils on the direct system. In rooms with sim- ilar amounts of cubic space per head, the result has been decidedly in favor of the system of venti- lation just described ; in going into the rooms from the fresh outer air no closeness nor unpleasant odor could be perceived, and the temperature (by the thermometer) was very even throughout the rooms. In each room there is a windlass and small chain by which the hot-air flue can be opened or closed to any desired extent, thus regulating the amount of hot air admitted. This appliance can be oper- ated by the teacher, who has a thermometer hung in close proximity. In a room with an open fire the fireplace and chimney form an excellent outlet-shaft. In a room with a stove the draught to the fire acts to a small extent in the same way. These outlets may be aided by means of flues constructed for the purpose in the chimney-stack. In the case of a room in which no such provision has been made, an outlet may be provided by running a metal pipe, such as is used for a rain-pipe, upward from the floor-line, and connecting its upper end with a chimney-flue or with a stove-pipe (Fig. 4556). It is well to ex- pand the lower end of the pipe into a funnel, so as to admit the air more readily. This pipe may be so decorated as not to be an eyesore and its lower end may stand behind a sofa or other similar article of furniture. In the case of the jacketed stove, the draught to the lire must not be included within the jacket; otherwise it will draw off the fresh in- coming air instead of the foul air, as just described. The extractive power of outlet-shafts and chim- Fig. 4556.-Ventilation of Room by Sheet-metal Flue connecting with the Stove- pipe. 624 Ventilation. Ventilation. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. visit a printing-office at night can testify to the unwhole- some condition of the atmosphere, especially if the visi- tor has come into the office directly from the fresh outer air when the office is in full blast. There is a gas-jet to every compositor, or, at least, to every two compositors ; each of these jets vitiates the atmosphere about as much as two men. The workmen usually have a choice be- tween chilling draughts and a terribly vitiated atmos- phere. If a small funnel (which would also reflect the light downward) were placed mouth downward over each jet, with a piece of inch-tube running upward from the apex, these several tubes connecting with a larger central tube, and this with the outer air, a vast change would be effected. Steam jets in chimneys act in a similar manner to heat. The exhaust in factories may be usefully disposed of in this manner. Fans and wheels are of various designs. The oldest and most common is somewhat similar in construction to the paddle-wheel of a steamer. This is usually con- tained in a box with which the extraction-shaft com- municates. The Blackman wheel (Fig. 4557), a comparatively re- cent American invention, has been brought into use both or pumps, the air being forced into the building to be ventilated. Sometimes the two methods of extraction and propulsion are combined. In order to convey a more specific impression of a system of artificial ventilation, it may be well to describe somewhat in detail one such system, and to select, from among those which the writer has had the opportunity of observing, one in which both propulsion and extrac- tion are employed. In the Canadian House of Com- mons at Ottawa the fresh air is propelled by a fan similar in shape and size to the paddle-wheel of a steam- boat, the vanes or paddles being somewhat wider in pro- portion ; a portion of the air is thus forced through a flue 30 x 36 inches in section into the heating chamber. This is a closed room in which are large quantities of steam-pipe. Another portion is forced onward toward the legislative hall without entering this chamber. In this way air of any desired temperature can be forced into the hall. The floor of the hall is terraced, and inlet- flues open in the risers behind the chairs of the members. Other inlets are placed in the upper surface of a project- ing ledge a few feet above the floor, the air being thus thrown upward along the face of the walls. The special outlets (in addition to doors and windows) are three in number and are situated at the roof of the hall. They communicate with flues along and down which the foul air is extracted by the action of another fan similar to the one used for propelling the fresh air. These fans are in the basement of the building. Sometimes we have a similar combination of propul- sion and extraction, with the difference that for the latter advantage is taken of the smoke-stack of furnaces used for driving the fan, for pumping water, or for other pur- poses requiring steam-power. One such instance comes to mind where on one side of the building the foul air was thus extracted, while on the other side the outlet- flues from the floors of the different stories converged in a cold stack. On this side of the building there was a curious confusion of currents; the air would pass up some flues and blow down through others. The loss occasioned by friction in flues must not be forgotten. Very careful adjustment of sizes for different distances is required. In extraction and propulsion the movement is likely to be greatest in the flues nearest to the extracting and propelling forces respectively. Hence the advantage of a combination of the two. From the foregoing consideration of principles and methods we may deduce the following : (10.) Summary comparison of modes of 'ventilation and heating best suited to special circumstances ; and we trust that the reasons for the following conclusions will be ap- parent from the remarks already made. With artificial ventilation we have greater control and a greater certainty of changing the air frequently and regularly. Hence some system of artificial ventilation is to be preferred when it is proposed to ventilate buildings in which there are a large number of inmates and in which the air-space per individual is not very greatly in excess of the standard laid down. And of the mode's of artificial ventilation, those in which a mechanical con- trivance, such as a fan, is employed are more likely to give even and satisfactory results ; it is more easy to gauge and regulate the revolutions of a fan or wheel than the heat of a chimney-shaft. It is also more difficult to increase the action so as to draw the foul air from a long distance horizontally by means of a heated shaft than it is with one of these mechanical appliances. The best results are likely to be obtained from a com- bination of extraction and propulsion. It should be remembered that when anything causes a temporary suspension of the artificial forces the case is worse, for the time being, than if natural ventilation had been provided for. As regards cost, it will be apparent that the best modes unfortunately require the greatest expenditure of money. In factories the furnace-chimneys and steam-exhaust make it much more economical to use extraction by heat. The same is true (to a less extent) of other buildings in winter-time. Fig. 4557.-The Blackman Wheel. on this continent and in Europe. It works on the me- chanical principles of the screw and inclined plane, its action being the converse of that of a turbine water- wheel ; also the converse of that senseless contrivance which is sometimes inserted in a window-pane, and which whirls around when there is a free circulation of air and stands still when there is not. The wheels and fans described above are driven by some mechanical power, and by their action induce powerful currents of air ; the other so-called ventilators are set in motion by currents of air which they somewhat impede. The Lockman wheel, used in England, is somewhat similar. These wheels do not necessarily require a flue, but may be placed in the side, floor, or ceiling of a room. As an example of artificial ventilation by extraction, the writer would refer to the wood-working shops of the Pullman Car Company, at Pullman, Ill., because there the effect is not limited to the evidence afforded by the sense of smell, but is apparent to the eye ; each machine at which saw-dust, or wood dust of any description, is produced is surmounted by a funnel ; the dust is drawn rapidly up the funnel and along flues to the furnace- rooms. Ventilation by propulsion is effected by means of fans 625 Ventilation. Verruca. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. As regards warming, it has been shown that where abso- lute air-space per individual is small, as in well-filled halls and apartments, indirect heating-a supply of air already warmed-affords the greatest facility for a frequent change of air. The most pleasant and wholesome air will be that of a suitable temperature the character of which has not been changed by superheating or drying ; an abundant supply of air passing over a sufficient quan- tity of hot-water coils enclosed in a flue or chamber will be most likely to give this result; next to that, air passed over steam coils ; and next, again, air passed through a hot-air furnace of sufficient size to do its work without overheating the air. Here, again, the most pleasant is the most costly. In large dwellings with few inmates, and in which a free interchange from room to room exists, direct heating will answer very well. In order to obviate the trouble, dust, and dirt caused by a number of stoves or open fires, modern dwelling-houses, unless of small size, are heated either by the hot-air fur- nace or by steam or hot water. The advantage which hot air, in common with other in- direct methods of warming, possesses in frequent chang- ing of the air, has just been referred to. The advantages of steam and hot-water heating in the direct method are, that the heat can be carried a long distance horizontally and that it can be evenly distributed ; rooms near to the distributing centre or in a vertical line above it do not rob more distant rooms of their share of heat. Nor is there any danger of the air becoming superheated or " burned," as it is popularly termed. Another advantage is that there is no liability of gases from the furnace-fire, nor of cellar-air and ground-air being carried to the dwelling-rooms. As compared with each other, steam and hot water have each their advantages and disadvantages, on account of which we may prefer the one or the other under dif- ferent circumstances. After weighing these, the writer is led to make the following general statement: That for public buildings and offices steam-heating appears most suitable, while hot water is the more agreeable and salu- brious method of the two for residences in the Northern States and the Provinces bordering on the great lakes and ocean ; whether it would answer in the climate of the Northwest is another question. The reasons for these conclusions are based upon the following consider- ations : Steam is a more powerful heat ; it requires a smaller amount of piping or radiators ; it can be shut off from unused rooms without danger of frost obstructing or injuring the pipes ; when steam is up an unused room can be more rapidly got ready for use ; the temperature can be reduced more rapidly in any individual room by shutting off the steam. On the other hand, a greater variety and more easy though slower regulating of temperature may be obtained with hot water in two different ways. In the first place, the whole water-system can be kept at any point between a little above the natural temperature at the time and a point approaching the boiling point ; secondly, by a par- tial closure of the valve admitting the hot water to the radiator a very feeble circulation may be produced, whereas with steam we must have steam-the boiling point of water-or nothing ; * and a rapid cooling may be obtained when required by opening a window. Rapid cooling of a section of a house may be obtained by run- ning off the water of the main supplying that section- but this can rarely be necessary ; the objection to hot water because it is slow in cooling is a trivial one. The air can never be raised to that unpleasant degree that it may with superheated steam, or, to a greater degree still, by a hot-air furnace. The air can never, by neglect, be dried to the extent that it may with the other two sys- tems. Of course, by careful attention, moisture can be supplied in either of the three systems, but careful at- tention is difficult to be obtained, and neglect is less likely to produce a bad result in the hot-water heating. It is a curious fact that many persons with whom we meet forget that the moisture from the inside of pipes doesnot, continually and intentionally at least, communicate itself to the outside ; for leaks are not intentional, and the es- cape-valve of a radiator is not commonly opened for this purpose. Hence we have frequently to remind people that the air around steam-coils is improved by an evap- orating pan. The hissing of a steam-leak and the crack- ing from bad grades are unpleasant features, but with improvements, low pressure, and better workmanship, perhaps it is not necessary to saddle steam-heating with these disadvantageous incidents. Hot-water heating is estimated to require about one- fourth more radiating surface than steam, hence it is somewhat more costly ; while the first cost of both is far greater than that of the hot-air furnace, but less than that of indirect heating by steam or hot-water coils and flues. Open fires will always be a valuable aid to the venti- lation as well as to the warming of a house. In northern climates, where constant and general heat has to be maintained, they must be supplemented by some other form of heating ; their action is rather one-sided, and the warmth is not well distributed. Nevertheless, open fire- places ought to be constructed in every dwelling-room. If there be a little fire in it the aid to ventilation will be greatest; but if the house be heated otherwise the inner walls of the chimney will partake of the heating and an up-current will be the result. A register should be placed communicating with the chimney near the ceil- ing ; a summer outlet, and an outlet for gradual cool- ing, will thus be at our command. VII. Examination of the sufficiency of the means of ventilation requires to be briefly noticed. (1) The cubic air-space should be measured, and allow- ance made for all bulky articles of furniture, such as Fig. 4558.-Anemometer, or Air-meter. desks, wardrobes, etc. The proportion of floor-space should be noted, as also the window-space-light having an important connection with the condition of the air. (2) To determine the direction of the circulation of air, and what openings act as outlets and what as inlets, some slowly combustible material, such as touch-paper, velvet, or sawdust may be placed on a shovel, set on fire, and carried around the room ; the strength or rapidity of the current may be roughly tested in the same way. Tests such as that with a match or with a handkerchief or other light material are familiarly known. (3) The relative positions of inlets and outlets as affect- ing distribution of incoming air and its temperature should be carefully noted. (4) Their sizes, also, should be measured, and notice taken of the condition and position of windows and doors. (5) The ability of the outlets and inlets to respectively re- move and admit air may require to be measured. The * It is asserted that in the pipes, when the pressure is low, as condensa- tion takes place at the periphera, vapor will rise at a temperature less than that of the boiling point of water in the open air. 626 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Ventilation.. Verruca. most reliable means for this purpose is the anemometer or air-meter (Fig. 4558). This consists of a small fan or windmill, which revolves when a current of air impinges upon its blades ; the revolution of the shaft of this fan sets in motion works similar to those of a watch, hands upon the dial indicating the numbers of linear feet- hundreds, thousands, tens of thousands, and millions- up to ten millions of feet. A multiplication of the linear measurement by the sectional area will give the number of cubic feet that have passed through the opening. The current of air in the centre of the opening will be greater than that near the sides, owing to friction on the latter ; for an average rate, then, the instrument must be held between the two. The ordinary size of a portable air- meter is such that it can be placed in a cubic box of 3i inches. It should be supported on some object which will not materially lessen the sectional area nor impede the current of air. If the area be covered by a grating so that the air-meter cannot be placed in it, then a tube or box may be made, and its edges coapted to those of the opening so as to form a continuation of it, and the air-meter may be placed in this tube or box. The manometer is another instrument by which the velocity of a current of air is measured by its being made to impinge on the surface of a body of water or other fluid ; one end of a tube dips beneath the surface of the fluid, and the force of the current of air is indicated by the distance the fluid is driven up the tube. This instru- ment is not so accurate as the air-meter, but may be used in some instances where the latter cannot. Calculations based on Montgolfier's formulae may be made, but cannot be relied upon as being at all accurate. Wm. Oldright. 1 De Chaumont's Parkes' Manual of Practical Hygiene. Wood's Li- brary, vol. i., p. 158, 1883. 2 Op. cit., p. 158. 3 Op. cit. p. 162. 4 Sixth Annual Report of the State Board of Health. Lunacy, and Charity of Massachusetts, 1885, p. 267. 6 Op. cit.. p. 235. 6 Op. cit., p. 284. 7 Op. cit., p. 276. 8 Zeitschrift fur Biol., 1866, vol. ii„ p. 117. 9 Med. Times and Gazette, January 9, 1869. 10 De Chaumont's Parkes' (as above), p. 165. 11 Report of a Committee appointed to Inquire into the Cubic Space of Metropolitan Workhouses (English), p. 12. 1867. 12 Op. cit., p. 167. 13 Report of the Barrack and Hospitals Improvement Commission on the Ventilation of Cavalry Stables, p. 10. 1866. 14 De Chaumont's Parkes (as above), p. 194. VERATRINE (Veratrina. U. S. Ph. ; Veratria, Br. Ph.; Veratrinum, Ph. G.). An alkaloid obtained from the seeds of Asagroea officinalis Lindley (Schoenocaulon offi- cinale A. Gray, Veratrum officinale Schlecht, etc.); Order Melanthacea. This plant is a bulbous herb, with long, grass-like leaves, and a single, upright, slender, cylindrical scape nearly two feet long, the upper half of which is a spike-like raceme of greenish-yellow flowers. Perianth about a quarter of an inch across, spreading regular of six (3 and 3) leaves. Stamens, six ; carpels, three, each several-ovuled. The seeds are the source of the above alkaloid. They are official in England and elsewhere {Sabadilla, Cevadilla, Br. Ph.; Cevadille, Codex Med.), and were formerly so in the United States. They are narrowly fusiform, with a flattened membranous top about a centimetre or less (J inch) in length ; dark, shin- ing, brown, wrinkled. When powdered, the dust excites violent sneezing. Taste bitter and acrid. Sabadilla is an inhabitant of open, grassy places in Mexico and Central America. It is also said to be cultivated there (Pharma- cographia). It was introduced into European medicine, mostly as a parasiticide, during the early part of the last century. Veratrine, its principal alkaloid, was discov- ered in 1819 by Meissner, and called sabadilline, and in the same year by Pelletier and Caventon, and named veratrine. When perfectly pure, it can be obtained in rhombic prisms, but that of commerce is always an amorphous, dull, white powder, " permanent in the air, odorless, of a distinctive acrid taste, leaving a sensation of tingling and numbness on the tongue, producing constriction of the fauces, and highly irritant to the nostrils." Soluble in alcohol and ether, but scarcely so in water ; a feebly alkaline base. It is probable that this alkaloid, as usually seen, is a mixture of veratrine, ceva- dine, and cevadilline, and perhaps others. The alka- loids of this family are very difficult to isolate. It is a most poisonous substance, producing violent vomiting and catharsis, followed by intense cardiac depression and acute gastro-enteritis. In ointments, unless very much diluted, it is also irritating, and not free from dan- ger of absorption. In minute doses it is occasionally given (0.0015 to 0.003 = gr .ad gr. -/p) for chronic rheumatism, neuralgia, etc., but is becoming obsolete. Externally, as liniment, ointment, or oleate, it is more frequently, yet still rarely, in this country, used for the same purposes. Most of all, however, it is employed in the above forms for pediculosis, both in man and ani- mals, for which purpose it is very efficient; yet not so safe, and no more certain, than w'ashing the affected sur- face with kerosene, or a weak (^oVo) solution of corro- sive sublimate. Administration.-The Pharmacopoeia authorizes two convenient preparations : the oleate {Oleatum Veratrince), which is a two per cent, solution in oleic acid, and an ointment {Unguentum Veratrines'), consisting of four parts of veratrine and ninety-six of benzoinated lard. Allied Plants, etc.-The veratrums, several species of which are in use, have a pretty similar composition (See Hellebore, American.) For the Order, see Squill. W. P. Bolles. VERRUCA. Synonyms: Wart; Fr., Verrue; Ger., Warze. Warts are divided into two varieties, viz., V. congenita seu Naevus verrucosus, and V. acquisita. For,the first variety, see article on Naevus in Vol. V. The second variety is the one here described. It is so common among people of all classes that it is recognized by everyone. The wart is a papillary tumor of the skin, varying in size from the point of a pin to that of a ten-cent piece or larger. It is flat or rounded, projecting, sessile or pedunculate, and either has the color of the surrounding skin or is pigmented. If it increases slowly in size, it is prone to split up into branches, which in protected posi- tions, such as the scalp, sometimes resemble minute pieces of pale-pink coral. This appearance is produced by the enlarged papillae projecting above the skin, split- ting, and carrying the epidermis along with them. Warts appear more often on the hands and face. There is, however, no part of the body where they may not be found. Sometimes many of them show themselves sud- denly, especially upon the face or back of the hands. They are then small and flat, and often hardly to be seen except by oblique light. An eruption of this kind is called subacute, and differs from the so-called chronic form in that the warts disappear spontaneously after a few months. Childhood is the usual time of life for such an outbreak, but it is not uncommon in adults or even in the aged. During the summer months in warm climates the backs of the hands of stout adults who per- spire freely will frequently show numbers of these mi- nute warts, glistening, when viewed by oblique light, like small silver pin-heads. When chronic they may last for years, without change of form or size. They usually, however, become darker in color, and in old people may spread out into a flat sur- face, resulting finally in a growth unmistakably malig- nant or cancerous in character. Many chronic ulcers of the hands and face of old people begin with warts, which gradually change, by some manner of metamorphosis, from benign to malignant growths, necessitating a seri- ous operation in the end, which might easily have been prevented by the early removal of the neoplasms. Histologically the warty tumor is produced by hyper- trophy, by the prolongation and thickening of the nor- mal papillae of the integument, which stretch upward and downward through the adjacent layers of skin, in- terfering with the normal formation of the epidermis and corium with which they come into contact. The etiology of warts is not very well understood. There is certainly a predisposition to them in some peo- ple, and they occur in the young and old more frequently than in those of middle age. Occupations in which the hands and face are exposed to irritation seem to cause 627 Verruca. Version. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. them, as do also irritating substances when brought into contact with the skin. The old idea that warts were con- tagious is again revived, although no special virus has yet been discovered for them. They rarely come singly, and, after the appearance of one, others almost invariably follow, sprinkling themselves about in the neighborhood. It is this arrangement which has led authorities to sup- pose them to be either of nervous or of contagious ori- gin- Treatment is mainly local, and consists in applying some strong escharotic which will destroy the growth of the papillae. Unless the wart be large it drops or is burnt off without leaving a trace of its previous exist- ence behind. The preparations used to effect this pur- pose are legion. It may be said that every physician and nearly every layman has his own pet idea as to how a wart should be removed. As they not infrequently dis- appear spontaneously, a cure, when some remedies are used, is post hoc rather than propter hoc. Recently many smaller warts have been successfully removed by electrolysis, an operation explained in Vol. II., under the heading, Electricity in Surgery. When the growths are situated upon the face, this operation is highly to be commended, as there is no danger of an hypertrophic eschar following it. Large warts may be removed as follows : Wash the surface with an antiseptic solution, and then cover it with pure salicylic-acid powder in a fairly thick layer. Over this place moist borated lint in four layers, a piece of gutta-percha fabric or cloth, and a bandage. This may be left on five days, when the wart can be easily re- moved. Another method is to dissolve fifteen grains of corro- sive sublimate in an ounce of collodion, and brush the warts carefully once a day with the solution. The ac- tion of the remedy is hastened if the collodion be pro- tected so that it will remain intact, and if to the first solution a drachm of pure salicylic-acid powder be added. Applications of glacial, or trichlor-acetic acid, morning and evening, for a few days have been highly recom- mended. Nitric, muriatic, chromic, carbolic, concen- trated lactic, sulphuric, arsenious, and citric acids, caustic potash, nitrate of silver, and the hot iron have all been tried successfully. If none of these applications suc- ceeds, there is one more sure method of treatment left, and that is surgical. Warts may be removed with the knife, scissors, or sharp spoon (curette), the latter being preferable in the author's experience. A sharp spoon (see Fig. 2188, Vol. IV.) should be chosen a little larger than the wart, and should be forcibly driven underneath it so as to scoop out a concave wound. The wound should then be energetically cauterized with a hard stick of nitrate of silver sharpened to a point. It heals slowly, leaving at first a smooth whitish spot behind, but which gradually assumes the color of the surrounding skin. The success of this treatment depends upon the thor- oughness with which it is done. Scraping the top or upper half of a wart rarely removes it. It more fre- quently irritates it into extra growth, which may event- ually culminate in malignancy. Crops of warts in children disappear spontaneously, but this disappearance is sometimes hastened by the ad- ministration of teaspoonful doses of sodium chloride- common salt-every morning for a week or more. Small doses of belladonna, tonics, and saline purgatives have also been recommended. Warts in pure-blooded negroes are larger and more numerous than in the members of the white race. Care should be used in removing them, for fear that a keloidal growth may take their place, since negroes are especially prone to the latter form of growth after an operation by knife or other instrument. Robert B. Morison. VERSAILLES SPRINGS. Location and Post-office, Ver- sailles, Brown County, Ill. Access.-By the Quiucy Branch of the Wabash Rail- way. Analysis.-One pint of the water contains Magnesia Spring. (G. A. Marriner.) Curry Spring. (I.V.L. Blaney,M.D.) Monitor Spring. (I.V.L. Blaney,M.D.) Carbonate of potassa and soda Carbonate of soda Carbonate of magnesia Carbonate of iron Carbonate of lime Chloride of sodium Sulphate of lime Potassa . Alumina and trace of iron* Silica Organic matter grains. 0.166 i.ii9 0.008 1.825 trace trace 0.175 grains, trace 0.953 0.933 1.514 trace 0.261 0.091 0.102 trace grains, trace 0.953 0.873 0.267 2.017 trace 0.213 trace Total Carbonic-acid gas 3.292 Cub. in. 3 3.854 .... 4.323 Therapeutic Properties.-Mild alkaline waters. Versailles is situated near the western border of Illi- nois, about fifty miles east of Quincy. The springs are located about two miles from the station in a valley ap- parently a part of the ancient bed of the Illinois River. George B. Fowler. VERSION. The term version is applied to all opera- tions by which the long axis of the child is changed in its relation to the long axis of the uterus. The opera- tion is divided into three varieties-pelvic, cephalic, and podalic version-each named after the part which is to be brought to the inlet ; and is performed by three methods, the external, the internal, and the combined or bipolar. Pelvic version is rarely performed, and then only by the external method. It is indicated in cases in which it is known at the beginning of labor that a breech- presentation is desirable and that some other presentation has occurred, as in a transverse presentation in a flat pelvis; but, after external version becomes impossible, internal or bipolar podalic version should generally be preferred. External Method.-Version by the external method should expose the mother to no added risk, but is liable to be fatal to the child by causing displacement and con- sequent compression of the cord. It cannot be per- formed after the presenting part has engaged, nor after the escape of the waters ; it is much facilitated by lax abdominal and uterine walls, and by a condition of free mobility of the child, but, under opposite conditions, may be rendered possible by the free administration of an anaesthetic. If the performance of pelvic version by the external method be determined upon, the bladder and rectum should be emptied-as in all obstetric operations, the pa- tient should be placed upon her back, and the operator should stand by her side, and facing her. After care- fully mapping out the position of the child, he places one hand flat upon the abdomen, with its palmar sur- face as nearly as possible over the sacrum of the foetus, and the other in the same manner over the forehead ; and then, by simultaneous pushing movements of both hands, he endeavors so to change the position of the child as to convert it first into a transverse and then into a pelvic presentation. If a pain comes on during this process all movement of the hands must at once cease, and the operator must direct his whole attention to the attempt to hold what he has already gained. Gentleness and pa- tience are essential to success, as hasty or rough manip- ulations always excite contractions and so defeat their own purpose. When the breech has been brought to the inlet it must be held there by the hands, or, if this becomes too tedious, by a properly adjusted binder and 628 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Verruca. Version. compresses, until it has become engaged in the superior strait. The version may sometimes be aided by placing the patient, at the beginning of the operation, upon the side to which the breech is turned ; for as the fundus sinks to that side it carries the breech with it, and so tends to move the head toward the opposite iliac fossa. The subsequent treatment is that of an ordinary breech case. Cephalic Version.-Theoretically, cephalic version should be performed in all uncomplicated cases of breech or transverse presentation ; in practice it is, how- ever, limited to cases in which the diagnosis is made early, in which therer is no necessity for rapid delivery, and in which the other conditions are favorable to the performance of version by the external or bipolar method, for cephalic version by the internal method is usually more difficult and dangerous than internal podalic ver- sion. The performance of cephalic version by the external method differs in no way from the description of exter- nal version already given under the head of Pelvic Ver- sion. If cephalic version be indicated, and the use of the external method be possible, it should always be pre- ferred, as being the least meddlesome and dangerous operation. Bipolar Method.-In regard both to efficiency and to possible risks, bipolar version occupies an intermediate position between the external and internal methods. The conditions which make external version practicable render bipolar version easy, but it can often be per- formed when the external method is no longer possible, and with far less interference with the processes of nat- ure than is necessary to the performance of internal ver- sion at an early stage of labor. A moderate degree of engagement of the presenting part makes bipolar ver- sion more difficult, but is not necessarily a bar to its em- ployment. Cephalic version by the bipolar method is usually re- stricted to cases of transverse presentation in which the liquor amnii has not yet drained away and the present- ing part is but lightly engaged. A prolapsed arm, un- less previously replaced, would prevent its employment. Anaesthesia is not always necessary, but is always an advantage. Of the various methods which have been proposed, that of Braxton Hicks is alone employed at the present day. After the bladder and rectum have been emptied, the hand which is of the same name as the position (e.g., O. R. A. =the right hand) is introduced into the vagina, and two fingers are passed through the os to the present- ing part, which we assume to be a shoulder ; this is gently raised and moved toward the feet by the fingers of the internal hand, care being taken not to rupture the membranes, if they are still intact. So soon as the shoulder rises, the external hand begins to press the head toward the inlet until it can be received and guided to the os by the tips of the internal fingers ; it is then re- tained in its new position by the pressure of the external hand, while that which was internal is withdrawn from the vagina and used, if necessary, to complete the ver- sion by making upward pressure on the breech through the abdominal wall, as in external version ; or the in- ternal hand may be able to retain control of the head, while the other is transferred to the breech. After the completion of the operation the head must be retained in position by external pressure, as after ex- ternal version; or, if the os be sufficiently dilated, the membranes may be ruptured, in order to hasten the fix- ation of the head. The remainder of the delivery is left to nature. Podalic Version.-Podalic version is indicated in most transverse presentations ; in most brow and many face presentations, and in some other malpresentations of the head when arrested high ; in some cases of con- tracted pelvis, often in high arrest of the head in a nor- mal pelvis, whether from inertia uteri or from too tight adaptation ; and, in general, under any circumstances which call for the immediate delivery of a high head, unless the use of forceps be preferred. It may be performed by either the combined or inter- nal methods, but is of course beyond the power of external version. Bipolar Method.-This operation is not much used in head presentations, because podalic version is now gen- erally followed by immediate extraction, and therefore presupposes a degree of dilatation which admits of the introduction of the entire hand, but it is of value in some cases of placenta praevia in which there is profuse flow- ing at an early stage of labor. In such cases it is useful, both because it can usually be completed with less loss of time than is consumed in the preparation of the os for internal version, and because, after its completion, the pressure of the half-breech against the os is usually suffi- cient to control the haemorrhage until full dilatation has been accomplished. It may, however, be used in any case in which the mobility of the foetus is unimpaired at the time of operation. Its performance is rendered more easy by the use of an anaesthetic, which should be given to full surgical anaesthesia. In this country the patient is usually placed in the lithotomy position, in which case she should lie across Fig. 4559.-First Stage of Bipolar Version. (Galabin.) the bed, with the buttocks well over its edge. Each leg should be held by an assistant, and the operator should sit between them. The full observance of all possible antiseptic precautions is as necessary as in internal ver- sion. The exact position of the child and its extremities is carefully made out by abdominal and vaginal examina- tion, and, the rectum and bladder having been emptied, the hand of the same name as the position is passed into the vagina until two fingers can be inserted into the os to their full length. The fingers then raise the head and push it gently to the side toward which the occiput is turned, while the other hand pushes the breech byexternal manipulation in the opposite direction (Fig. 4559). This process is continued as long as the head remains within reach of the hand. The fingers are then moved toward the breech in search of a knee, which, unless the normal flexion of the child has been lost, is by this time well within reach (Fig. 4560). The knee is distinguished from the elbow by the fact that it points toward the head, while the elbow points 629 Version. Version. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. to the breech. The presence of the patella may also be recognized in some cases, and, if found, is of course conclusive. If by chance a foot be reached before the knee and surely recognized, it should at once be seized. The foot is distinguished from the hand by the presence of the malleoli and of the prominence of the heel, and by the fact that the great toe is of equal or greater length When the knee is fairly in the vagina and under con- trol, the foot should be brought down and examined, to guard against the possibility that an error has been made by mistaking an elbow for a knee. The version is then completed by traction upon the leg, in combination with external pressure upon the head (Fig. 4563). Fig. 4562.-First Part of Second Stage of Bipolar Version, when the Head is extended. (Galabin.) After the completion of the version the treatment is that of an ordinary footling case. Podalic version by the bipolar method is seldom per- formed in transverse presentations; for until it has be- come impossible bipolar cephalic version is generally to be preferred. In case it is done, the position at the be- ginning of the operation is that represented in Fig. 4561, and the procedure is in every way that which has just been described. Internal Method.-This operation differs from those pre- viously described in that its performance presupposes a degree of preparation of the soft parts which permits of an immediate extraction after the completion of the ver- sion. If preceded by artificial dilatation of the os, it is capa- Fig. 4560.-Second Stage of Bipolar Version. (Galabin.) than the others and placed in the same plane with them, while the thumb is shorter than the fingers and can be opposed to them. It may sometimes happen that the head becomes ex- tended under the pressure of the internal hand, and thus passes out of reach of the fingers before the external hand has been able to depress the breech sufficiently to bring the knee within their reach (Fig. 4561). In this case the fingers next come in contact with the shoulders and chest, which must be urged upward and onward to- Fig. 4561,-Second Part of First Stage of Bipolar Version, when the Head is extended. (Galabin.) ward the head, while the external hand continues to press the breech down until the knees are within reach. So soon as a knee is recognized the membranes should be ruptured, if still intact, and a linger hooked around the knee. The hand which has depressed the breech is then applied to raise the head, while the internal fingers draw the knee to the os (Fig. 4562). Fig. 4563.-Third Stage of Bipolar Version. (Galabin.) ble of effecting a rapid delivery in almost all cases, and at any period of pregnancy or labor. It is the most gen- erally valuable of all obstetric operations ; as Barnes says:1 " If we were restricted to one operation in mid- wifery as our sole resource, I think the choice must fall 630 Version. Version. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. upon turning. Probably no other operation is capable of extricating patient and practitioner from so many and so various difficulties." It is our main operative re- source in eclampsia, placenta praevia, concealed haemor- rhage, and many other of the gravest obstetrical emer- gencies. Internal version is not, however, an indifferent opera- tion. It exposes the mother to grave dangers, both of injury to the tissues by too rough manipulations, and from the introduction of infected material from without. It should not be attempted while the less dangerous methods are possible,* nor, in any case, without full anti- septic precautions. When this operation is to be per- formed, it is a wise precaution to procure the services of a second physician, who should administer the anaesthetic and assist in the extraction by suprapubic pressure. Before operating, the physician should see that ice, ergot, brandy, a hypodermic syringe, «and a sufficiency of hot and cold water are close at hand and in readiness. Several towels and two fillets should be rendered aseptic by immersion in a corrosive-sublimate solution. A sim- ilar solution and a nail-brush should be placed where they will be within reach of the operator during the op- eration. The forceps and catheter should be disinfected and laid at hand. The bed and fioor should be protected by rubber sheets, and a blanket should be wrapped around each leg of the patient. If the bed be low, it is better to place the patient during the operation on a table covered with a folded blanket. The rectum and bladder should be thoroughly emptied, and both arms of the operator should be bared and disinfected to the shoulder. The position of the child should be carefully mapped out by a repetition of the abdominal and vaginal examinations, and its condition should be ascertained by auscultation of the foetal heart. The patient should be placed in the lithotomy position, and the legs held by assistants. Internal Podalic Version in Head-presentations.-Every- thing being ready for operation, the hand of the same name as the position (e.g., O. L. A. =left hand) is well greased with an aseptic lubricant, preferably eucalyptus vaseline, 1-8, upon its dorsal and not upon its palmar aspect, and, with the fingers formed into a cone, is passed into the vagina. This should be done slowly and, if the vulva be narrow, by gradual dilatation, the direction of pressure being at first backward and toward the sacrum, but turn- ing forward into the axis of the superior strait as the hand enters the excavation. The cervix should be passed with the same care, and the upward movement continued until the palmar surface of the hand embraces the frontal end of the head. From the time when the hand enters the vulva, careful counter-pressure on the fundus must be maintained by the other hand of the operator or by a skilled assistant, in order to guard against the danger of rupture of the vaginal attachments of the uterus. The head is raised by gentle, steady pressure in the axis of the superior strait, until it leaves the inlet and glides into the iliac fossa. The hand can then slip by it into the uterus, but all its movements after it enters the cervix must be slow and gentle, and, in case a pain comes on, they must cease entirely and the hand must be flattened and remain passive while the contraction lasts. As the hand passes the thorax it is likely to come in contact with the foetal hands, and, as the feet may excep- tionally be extended into the same region, any extremity which is touched must be examined, and its character determined by the diagnostic marks already mentioned under the head of Bipolar Version. If, as is usual, the hand reaches the middle of the body before detecting a foot or knee, it should next search for the cord, both to obtain exact information as to the con- dition of the child by noting the rate and regularity of its pulsations, and in order to make sure that it is not twisted or looped about the child's limbs or body in such a way that it is likely to be compressed or broken dur- ing extraction. If it is found in such a position, it should be gently disengaged and placed by the side of the child and out of harm's way. I have repeatedly seen reason to eongratulate myself on having ob- served this precaution. When a foot has been reached and recognized as such it should be grasped, either by encircling the ankle with the thumb and fingers or, better, by seizing the metatarsus with the second, third, and fourth fingers, while the forefinger and thumb encircle the projection of the heel behind the ankle (Fig. 4564) which thus lies between the first and second fingers ; or a finger may be hooked into the flexure of the knee, if this be acces- sible. The hand, with the enclosed foot or knee, is then gently.withdrawn into the vagina. A handle for traction having been thus secured, the external hand is with- drawn from the fundus and placed upon the head, and the child is turned by traction upon the foot in the vagina, in combination with upward pressure on the head through the abdominal wall. The version is complete when the knee appears at the vulva, the head is felt at the fundus, and the examining finger finds the half-breech at the os. Internal Podalic Version in Transverse Presentations. -This operation differs from internal version in head- Fig. 4564.-Method of Grasping the Foot. Fig. 4565.-Neglected Transverse Presentation. (Lusk.) presentations only in the choice and method of intro- duction of the hand, in the frequent occurrence of a prolapsed arm, and in the method of raising an impacted shoulder. In raising the shoulder it is necessary to remember the mechanism of the method by which nature deals with * Whether an operator who has the right to feel confident of his asep- sis is at liberty to prefer internal version and extraction, for the sake of more speedily relieving the mother of her pain, is a question which as yet must be answered in the negative. 631 Version. Version. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. a neglected transverse presentation, that of spontaneous evolution. In this process the trunk enters the pelvis at the brim in an oblique diameter; but, as it is forced farther down, the shoulder rotates to the front and be- comes fixed there, while the thorax and abdomen are crowded into the posterior portion of the pelvis by flexion upon themselves (Fig. 4565). Now, so long as the position is still oblique, and if flexion of the trunk has not begun, the presenting part maybe easily raised by pressure upon the shoulder in the axis of the superior strait ; but so soon as the shoulder has rotated to the front, and the thorax has entered the pelvis, it is essential that the pro- cess of relieving the impaction should begin by the re- turn of the part which entered last, i.e., that portion of the thorax and abdomen which still lies opposite the sacro-iliac synchondrosis ; and no pressure must be ex- erted upon the shoulder itself until the trunk again oc- cupies an oblique position. It will be seen that the process of unlocking the impaction is by a direct rever- sal of the mechanism of spontaneous evolution. Of lacy of the theory which prompted it,2 the subject need be no more than mentioned here. Unless special care be taken to select the superior foot the lower is almost invariably seized. Difficulties and Complications of Internal Version.-The difficulties encountered in version are usually due to one of three condi- tions : Either to the pres- ence of an im- perfectly di- latedand rigid os ; to partial impaction of the presenting part; or to claspingofthe child, either generally by a dry and re- tracted u t e - rus, or locally by a spastic hour-glass contraction- a constriction- ring. Dilatation of the Os.- Though inter- nal version is theoretical 1 y indicated only in the presence of a dilated or perfectly dilatable os, it is sometimes necessary to resort to it at a time when the os is still small and rigid, and even in some cases before the appearance of labor. (See Eclampsia, Placenta Prse- via, Labor, etc.) In such cases it must be preceded by an artificial dilatation of the os, but this, though occa- sionally allowable, is not an operation to be undertaken lightly, nor without serious consideration of the very grave dangers which it involves. These are : The inflic- tion of severe and extensive lacerations during dilatation, version, or extraction ; increased risk of septic infection ; and greatly increased risk of col- lapse from shock. The gravity of the operation in any given case is proportionate to the rigid- ity and small size of the os, and decreases with each advance to- ward spontane- ous dilatation. Previous lacera- tion of the edges of the os is al- ways an unfavor- able element in such a case. If the operation be decided upon, manual dilata- tion is the meth- od which should usually be chos- en ; but in this operation, above all others, pa- tience and gen- tleness are abso- lutely essential to success, and should never be exchanged for even the least degree of force or hurry. If labor be absent, or but little advanced, at the time of operation, the hand is passed into the vagina, and the tip of the forefinger is inserted into the os as far as is possible without force, and is then held immovable un- til the os has relaxed sufficiently to admit its further pas- sage. When the second joint of the forefinger occupies Fig. 4567.-Direct Method of Seizing a Foot. (Lusk.) course, during this whole process the most careful coun- ter-pressure must be maintained at the fundus. In simple cases a prolapsed arm may be used as a con- venient handle by which to push up the shoulder, and in all cases it is well to begin the operation by noosing a fillet around the prolapsed wrist. This answers a double purpose : it may be used, at first, to draw the arm out of the way of the operating hand ; and, secondly, during the process of extraction slight tractions on the fillet will prevent the extension of that arm, and thus greatly facilitate the delivery ; but care must be taken to re- move the noose as soon as possible, for cases are on record in which sloughing of a member has followed the too prolonged or violent use of a fillet. In the search for a foot two methods may be used. The hand which corresponds to the position-i.e., right position, right hand-may be passed along the back and over the buttocks to the thigh and leg (Fig. 4566) ; or the other hand may be passed across the abdomen and di- rectly to the feet (Figs. 4567 and 4568). The first is the surest way, and should, as a rule, be preferred, but the latter method is often the easiest, especially in abdomino- anterior positions. When the foot is once reached the remainder of the operation, in easy cases, differs in no way from that al- ready described under Head-presentations. Much has been written on the advantage to be gained by selecting the superior foot, in version for transverse presentation ; but as this view has never obtained much credence outside of England, and as the latest British authority, Galabin, not only disapproves of this practice but gives a very convincing mechanical proof of the fal- Fig. 4566.-Indirect Method of Seizing a Foot. (Lusk.) Fig. 4568.-Direct Method of Seizing a Foot. (Lusk.) 632 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Version. Version. the cervical canal and is loosely grasped by it, the first joint should be hooked around the edge of the internal os, and a gentle but persistent effort made to insert a second finger. The insertion of this second finger should be as slow and forceless as was the introduction of the first. This is the most tedious portion of the operation, is often painful to the enclosed hand, and may require a long time. When two fingers are in position, and loosely held, a third and then a fourth are introduced by a rep- etition of the same manoeuvre. The four fingers are then held in position, but without any attempt at forcible ex- pansion until relaxation sufficient to admit the thumb has been secured. As soon as the size of the os permits the whole hand to be flattened out within it, the hand is passed gently into the uterus between the membranes and uterine wall, but especial care should be observed at the critical moment when the knuckles pass the os. After the insertion of the hand the cervix usually re- contracts about the wrist, and the closed fist should then be made to exert pressure against the os from within out- ward, in imitation of the physiological action of the head, by an attempt to withdraw the hand when at its maximum girth ; i.e., when the fist is tightly closed. Version should never be undertaken until the fist passes readily backward and forward through the os. Even this degree of dilatation is insufficient for the passage of an average head, and its delivery will be attended by more or less laceration unless the os be unusually elastic, and for this reason version and extraction after manual dilatation is always more dangerous than when the os has been fully dilated by the efforts of nature. In cases where a delay of a few hours is permissible, the earlier stages of dilatation may be more safely ac- complished by the use of Barnes's water-bags. Partial Impaction.-A well-flexed head already deeply engaged is usually a case for forceps rather than version ; but if, in such a case, version is decided upon, the head should be raised by pressure in the axis of the superior strait. There are, however, many cases of arrest from extended head, or of brow-presentation which are un- suited for forceps and must be treated by version, and in these cases it is essential that flexion should be re- stored, by pressure upon the forehead, before any at- tempt is made to raise the head ; for not only is the re- turn of an extended head, as such, a practical impossibil- ity, but the restoration of flexion usually unlocks the im- paction and makes the subsequent return of the head an easy matter. The treatment of a partially impacted shoulder has al- ready been described. It only remains to say that in a marked case the operation is always dangerous and should never be undertaken unless in the interest of a fairly vigorous child ; for it is always so protracted that there is but a small chance of saving a child whose vital- ity has already been seriously lowered, while decapita- tion offers a much safer means of escape for the mother. Retraction of the Uterus.-Bandl's Ring-Hour-glass Contraction or Constriction-ring.-The retraction of a dry uterus upon the child leads to a condition in which the uterine wall is rigidly applied to the surface of the child throughout the whole or a greater part of its ex- tent. It is well understood as being the inevitable result of a too early escape of the waters when followed by prolonged and powerful labor in the face of an efficient obstacle, and it is universally admitted that, both from the increased difficulties and dangers of any operation in such cases, and because of the impediment which is offered to the placental circulation, labor in a dry uterus should be more closely watched and operated upon more early than when a normal amount of liquor amnii is re- tained. The appearance of even slight retraction is sure evidence that the powers of nature are exhausted, and is in itself a sufficient indication for operative interference. The subject of contraction-ring, on the other hand, is one about which there is still much discussion and dif- ference of opinion-a discussion which, I think, has been much prolonged by the fact that two distinct pathological entities, both well recognized, but which occur under somewhat different conditions and are largely due to different causes, are still commonly spoken of under a single name. The true retraction-ring of Bandl (Fig. 4569), whether we believe that it is situated at the level of the internal Fig. 4569.-Bandl's Ring. os or above it, is, at all events, always due to passive distention and thinning of the less powerful lower portion of the uterus by the active contractions and retraction of the more powerful upper part ; it is frequently devel- oped in the presence of a normal or excessive quantity of liquor amnii, and, when seen in a pure state, it is due solely to the action of the longitudinal and not at all to that of the circular fibres. It is felt clinically as a mere ridge in the uterine wall, is in no sense a constriction-ring, and, like the general retraction of a dry uterus, it is the necessary re- sult of exhaus- tion of the ute- rine muscle by a too long contin- uance of labor in the face of an obstacle. It increases the dangers, but in itself does not increase the diffi- culties, of ver- sion. On the other hand, the spas- modic " hour- glass " constric- tion-ring of an irritable and ir- regularly c o n - tracted uterus (Fig. 4 5 70), though it may occur, as is some- times seen, in a uterus with un- broken mem- branes, is common only after a more or less complete escape of the waters. It is the result of an irritable rather than of an exhausted uterus, and, though it is most common after the uterine muscle has become tired, may occur at a very early stage of labor. It is due to the action of the circular fibres alone ; it Fig. 4570.-Constriction Ring about the Neck. 633 Version. Version. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. increases both the dangersand the difficulties of version, and may even clasp the child so closely as to make the operation an impossibility. Its most common situation is about the neck of the child, but it may occur in any horizontal zone of the uterus. The retraction of a dry uterus upon the child, if pres- ent in a marked degree, is almost always complicated by the coexistence of the retraction-ring of Bandl, and, in any degree, is usually accompanied or preceded, espe- cially in head-presentations, by one, or several, more or less localized circular constrictions or constriction-rings. The dangers of version are so greatly increased by the presence of any one or all of these conditions that the early diagnosis of their approach is a matter of the high- est importance, and one which is too often neglected. The first warning is to be found in the behavior of the pains. Whenever pains which have been strong, regu- lar, and intermittent for some hours, begin to decrease in force and to become tonic or unintermittent, the exist- ence of one or the other form of retraction should be feared ; and whenever strong and regular pains begin to be uncertain and irregular-i.e., when they begin to vary greatly in strength and duration-and to occur at irregu- lar intervals, a suspicion of the formation of a constric- tion-ring should be excited. When the existence of either of these conditions is sus- pected, the patient should be subjected to a thorough ex- amination, both abdominal and vaginal, and under ether if necessary. If the general retraction of a dry uterus be present, the close application of the uterine wall to the outlines of the child, and its rigid condition, may usually be ap- preciated by abdominal palpation. Bandl's ring can often be felt through the abdominal wall as a linear increase in the thickness of the uterine wall, lying above the brim of the pelvis and parallel to it. It may always be detected by inserting the half-hand into the vagina and cautiously passing a finger between the head and the symphysis pubis along the anterior ute- rine wall. The ring is then felt as a distinct transverse ridge in the wall of the uterus. A constriction-ring may generally be discovered by a careful abdominal examination, if made with this espe- cial aim in view. If situated about the neck, it may be felt by a digital intra-uterine examination. This exam- ination, however, is an operation in itself, and as a pre- liminary, the patient should always be etherized to the point of surgical anaesthesia, in order to secure the great- est possible relaxation of the uterus ; it should be con- ducted only during the intervals of the pains, and never without careful counter-pressure. That any or all of these conditions may occur after long labor, in the presence of an undilated os, is a fact which must not be overlooked. Treatment-Bandl's Ring.-The performance of ver- sion in the presence of Bandl's ring requires even greater gentleness and caution than is necessary in other cases, and careful counter-pressure is also of even more impor- tance ; but, apart from this, it presents no special diffi- culties. Constriction-ring.-The presence of a constriction-ring, on the other hand, is frequently the cause of some of the most troublesome of the difficulties met within version. If the hand, after passing the head, finds itself opposed by such a ring, the question of the abandonment of the operation at once arises ; and if the ring is so tight that even the fingers fail to pass it without dilatation, this question must usually be answered in the affirmative. If, how'ever, the fingers pass, and for any reason it is de- cided to persist in version, the ring should be gradually and carefully dilated by the hand, after the manner of a rigid os, until it permits the passage of the hand, after which there is usually no difficulty in drawing a foot into the vagina ; but before the foot reaches the vulva its progress is likely to be arrested by the engagement of the occiput in the ring, which now clasps the body of the child with the occiput caught below it, and the half- breech above and to the other side. No progress can now occur until the ring has been sufficiently dilated to permit the escape of the occiput from beneath it, and any attempt to overcome the obstacle rapidly and by force must surely result in rupture of the uterus. The first attempt at release should be by steady, gentle traction on the foot, which, if prolonged for some mo- ments, may gradually overcome the resistance of the ring, and dilate it to an extent which will permit the occiput to rise, after which the breech slips easily through ; but if this fortunate result does not occur, the operator must turn to other expedients, of which the best for this case is usually the following: A fillet is noosed around the foot, and, while the disengaged hand makes gentle, steady traction upon this, the hand which was before external is passed into the uterus, grasps the occiput in the palm of the extended hand (Fig. 4571), and, Fig. 4571.-Version by Combining Traction on the Foot with upward Pressure on the Occiput. by a gentle, pushing movement, attempts to lift it past the obstacle, and into the upper part of the uterus ; or more may sometimes be gained by repeatedly alternating trac- tion upon the foot with upward pressure upon the head. But neither of these manoeuvres should be undertaken unless in the presence of a trained assistant who is ca- pable of making efficient counter-pressure at the fundus. When the ring is situated about the neck the above expedient is usually the best, and, if persisted in, will rarely fail ; but occasionally it may be better to replace the foot above the ring after the application of the noose, and thus to lessen the tension on the ring before at- tempting to push up the head with the hand. In this case the disengaged hand should be used to press the breech downward, as in bipolar version ; but this method, though sometimes useful, is, on the whole, less powerful than the preceding, and, moreover, exposes the utero-vagi- nal attachments to somewhat greater risk. If the ring be situated higher in the uterus, and grasps the breech or body of the child, the foot often comes readily to the vulva, but recedes into the upper part of the vagina as soon as it is released. In such a case it will be found that the fundus turns to one side and descends with the breech into the lower part of the abdomen, but returns to its erect position with the enclosed breech as soon as the foot is released. This difficulty is generally best met by the reintroduction of the hand and the with- drawal of the other ieg, after which traction on both legs will usually release the breech. This expedient is also often of value when a child re- fuses to turn from general rigidity of the uterus, and in the absence of a constriction-ring. General Retraction of the Uterus.-Version is rarely 634 Version. Version. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. performed in head-presentations in a dry and generally retracted uterus ; but as this retraction is in effect merely a combination of the two preceding conditions in a dry uterus, it would be combated by the expedients just de- scribed if version was decided upon. In transverse presentations, however, version is the only conservative operation possible, and it must often be attempted in the presence of a high degree of retrac- tion. In such a case, if the child refuses to turn after the extraction of a single leg, the second and superior leg should be withdrawn, and traction should be made alter- nately on one or the other, or both legs. If simple trac- tion fails, it should be supplemented by upward pressure on the presenting part, employed either in alternation with the tractions or coincidently with them, and by the use of a fillet as described above. In some cases of completely transverse presentation success may be attained, after the failure of the preced- ing methods, by the application of the following manoeu- vre. A noose is placed around both feet, and the hand which corresponds to the breech is placed within the ute- rus with its palmar surface applied to the breech. An assistant then makes counter-pressure upon the head in the direction of the breech, while the operator's external hand makes traction upon the feet and his internal hand presses the breech directly toward the head (Fig. 4572). traction swings forward until it becomes nearly vertical as the hips clear the vulva. As soon as the knee is well outside of the vulva the grasp of the hand should be shifted to the thigh, as trac- tion on the lower leg is apt to overstrain the ligaments of the knee-joint. If there is any difficulty in bringing the breech to the vulva, its delivery may be assisted by hooking a fore- finger into the other groin as soon as it is within reach, and, as it distends the perineum, it should be drawn well forward and every effort made to prevent a laceration, precisely as is done in the delivery of the forecoming head. When the second knee appears at the vulva, it should be drawn along the side of the child and toward its back until the foot can be released by flexion of the leg upon the thigh, but during this process traction upon the shaft of the femur must be avoided, as it is always likely to cause fracture. Care should also be taken to bend the knee only in the natural direction. When both legs have been released and the hips are outside the vulva, one thigh should be grasped by the fingers of each hand, while the thumbs' lie along the sacrum (Fig. 4573), the line of traction should again be The child is thus doubled upon itself, and the breech is brought into the lumen of the inlet by flexion of the ab- domen upon the chest, and, as soon as the breech has fairly entered the superior strait, the head will rise spon- taneously to the fundus, or may be assisted to rise by gentle external pressure. This method, however, is not without its risks to the uterus, and undoubtedly exposes the viscera of the child to some danger of injury from compression. Extraction after Version.-As internal podalic version is usually followed by immediate extraction,* it is cus- tomary to describe the latter process under the head of version, although it is in reality a distinct operation. Extraction begins when the half-breech engages at the superior strait, at which time the knee is usually at or near the vulva. The leg should be wrapped in an aseptic towel and traction made upon it in a line which should at first be directed as far backward as the perineum allows, in order, to draw as nearly as possible in the axis of the superior strait; but, as the breech descends, the line of Fig. 4572.-An Expedient in Transverse Presentations. Fig. 4573.-Method of Grasping the Pelvis. (Lusk.) directed as far backward as the perineum allows, and the back of the child should be rotated gently to the front during each of the remaining tractions. A towel wrung out of a warm corrosive solution should still be wrapped around the breech, both to pre- vent slipping and because contact with the air is likely to induce premature respirations. As soon as the umbilicus appears at the vulva, a linger should be passed into the vagina and the cord drawn gently downward until enough has been gained to pre- vent any further dragging upon the navel. If the arms remain folded upon the chest it is an easy matter to hook a linger successively into each elbow and extract them ; but if, as is usual, they become extended above the head by friction against the walls of the canal, their release becomes a more difficult matter. In easy versions it is generally possible to bring the shoulders * It is now taught by some German authorities that a larger percent- age of children is saved by version if extraction is delayed for fifteen or twenty minutes after the version is completed, but this practice has not as yet been adopted here. 635 Version. Version. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. outside the vulva by simple traction upon the thighs ; the body of the child is then dropped toward the floor and drawn as far backward as the perineum allows, and two fingers are then passed over one shoulder and along the upper surface of the arm to the bend of the elbow. The arm is then pushed downward and backward across the face of the child by pressure in the bend of the el- bow, and as the elbow appears at the vulva the fingers and directly toward the floor (Fig. 4575). By this ma- noeuvre the arms, which lie by the side of the head, are pressed against the yielding and elastic sacro-sciatic liga- ments, the chin is arrested by the pelvic floor, extension occurs, the occiput appears at the vulva, the head is born by extension, and the arms follow. The advocates of the method believe that it never tears the perineum, and my own rather limited experience with it certainly sup- ports this somewhat astonishing claim. The ease and rapidity with which delivery can sometimes be effected by this manoeuvre is very surprising, but it is as yet a comparatively untried measure and further experience may develop contraindications to it. It is certainly inapplicable when the head and arms are ar- rested at the superior strait. After the delivery of the child the uterus should be watched by an assistant, and every precaution taken against post-partum haemor- rhage, which is peculiarly likely to follow a rapid emp- tying of the uterus under the profound surgical anaesthe- sia which is proper and necessary in the performance of version. Unless the child has reached the stage of pale asphyxia and feeble heart, it is well to hold it suspended by the feet for some minutes after delivery before cutting the cord. This promotes the return of blood to the brain, permits the normal influx of blood from the placenta, tends to drain away inspired liquor amnii or mucus, and is in itself a valuable method of resuscitation. In case it is thought necessary to proceed at once to more active treatment, time can often be saved by breaking tlie funis near the vulva, and at such a distance from the child that its end can be readily compressed by the hand which Fig. 4574.-Combined Traction on the Face and Shoulders. slide along the forearm to the hand and easily sweep it outside the vulva. The other hand of the operator then repeats the same procedure with the other arm. The child is then laid astride of one forearm, and the hand which belongs to it is passed into the vagina until its first and second fingers lie upon the canine fossae of the child, while the other hand is hooked over the shoul- ders with the neck between its first and second fingers and their tips upon the supraclavicular region. The as- sistant then presses the head dowmward by suprapubic pressure in the axis of the superior strait, and both hands of the operator make simultaneous traction as nearly as possible in the same direction, the internal hand at the same time exerting itself to preserve the necessary flexion of the head (Fig. 4574). As the head emerges the line of traction sweeps forward in the curve of Carus, until at the end of the extraction the body of the child rests upon the other forearm and along the abdomen of the mother. When the mouth appears at the vulva, all hurry ceases, and the operator's efforts should be directed to the pres- ervation of the perineum. All traction should cease, the upper hand should promote flexion by restraining the descent of the occiput, and the other should be used to shell out the head by pressure on the forehead through the perineum, or, if necessary, by passing two fingers into the rectum. This, which is known as the method of extraction by combined traction upon mouth and shoulders, may some- times be replaced with advantage by the method known as Deventer's, because introduced by an obstetrician of that name about the year 1715. This method was warmly advocated by Deventer, but fell into disuse and was practically forgotten, until within the last two years it has been revived and highly praised by several prominent American obstetricians. It is so simple and rapid a procedure that it is worthy of trial in any case in which the shoulders can be brought read- ily into view. By this method the after-coming head and the extend- ed arms are extracted together by simple traction on the feet and shoulders. When the shoulders appear at the vulva the body of the child is swung sharply backward, the feet are grasped by one hand and the shoulders by the other, and both hands make traction simultaneously Fig. 4575.-Deventer's Method of Extraction. holds the child. A broken cord rarely bleeds, and can be tied at the proper distance after all hurry has ceased. Difficult Extraction.-The difficulties met with in extraction are due to : (a) arrest of the head and arms at the superior strait; (5) arrest of an arm behind the occi- put ; (c) closure of a constriction ring or of an imper- fectly dilated os about the neck ; or, (d) to arrest of the head, by its excessive size, by extension, by a rigid per- ineum, or by contraction of the pelvis. Arrest of the Head and Arms at the Superior Strait.- When the child is large, or the transverse diameters of the pelvis are diminished, the wedge formed by the head and arms is often too large to pass the superior strait. 636 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Version. Version. In such a case the release of the arms must be effected before the head can enter the pelvis. The extraction of the arms from the superior strait is a much more difficult matter than their release after they have entered the pelvis, and is effected by a different manoeuvre. The arrest occurs at or about the time when the points of the scapulae appear at the vulva, and before the back is wholly turned to the front. If such an arrest is felt, and unless it can be overcome by very moderate efforts, all traction should be stopped, and the thorax should be grasped by both hands, pushed slightly upward to relieve the impaction, and rotated, if necessary, until the antero-posterior diameter of the child is nearly, if not quite, transverse to the pelvis. The feet should then be seized by the hand which corresponds to the back of the child and drawn firmly upward and to that side, toward the groin of the mother. This answers the double purpose of drawing the posterior arm further into the pelvis, and of making room for the passage of the oper- ating hand into the vagina. The free hand is then rap- idly passed along the abdomen of the child to the poste- rior shoulder, and one or two fingers are passed along the arm and hooked into the bend of the elbow, which is then drawn downward, and across the face, into the va- gina. The hand is then swept out of the vulva by press- ure upon the forearm, applied as near to the wrist as possible. The feet are then drawn downward, and to the same side as before; the same hand is passed over the abdomen to the anterior shoulder, and an attempt is made to pass two fingers behind the symphysis to the bend of the el- bow. If the elbow is reached, it is to be drawn downward across the face, as was the posterior arm ; but unless this attempt is at once successful, the hand should be with- drawn, and the back of the child should be rotated across the front to the other side, so that the retained arm becomes posterior. This rotation may be effected either by grasping and turning the thorax with both hands, or by drawing the prolapsed arm forward be- tween the labium and the back of the child. The hand which before entered the vagina then draws the feet upward and to the side, while the other hand is passed over the abdomen to the elbow', and draws down the arm in the manner already described. If the hand passed over the abdomen fails to find the posterior elbow, it may sometimes be reached by seizing the feet in that hand, drawing them strongly upward and to the other side, passing the hand which before held the feet along the back of the child to the posterior shoulder, and thence along the back of the arm to the elbow, which, as before, must then be pressed down across the child's face. In rotating the child it must always be remembered that the articulations of the neck are so arranged that, if the point of the chin be carried behind the point of the shoulder, dislocation of the atlas upon the axis is the result. For this reason the thorax should be pushed strongly upward whenever an effort at rotation is made, in order to free the head from the superior strait; and the hands of the assistant should watch the head, that he may warn the operator if it fails to follow the shoul- ders. Arrest of an Arm behind the Occiput.-It sometimes happens that the head rotates with the shoulders, but the arm is detained behind the pubes by friction against the walls. In such a case the arm crosses the nape of the neck, and if traction is made, becomes jammed be- tween the occiput and the symphysis. If the accident is discovered before traction has been made, prompt rota- tion in the reverse direction may unlock the arm, and in this case this reversed rotation should be continued un- til the arm becomes posterior, i.e., through 180° ; but unless the first attempt unlocks the jam, the child will probably be lost, and it is then perhaps best to make di- rect traction upon the shoulders, in the hope of extract- ing the head and arm together, at the risk of fracturing the humerus, after forewarning the bystanders that this must be the result, and that it is done in the interests of the child. Closure of a Constriction-ring, or of an Imperfectly Dilated Os, about the Neck.-The stricture of the canal, formed by either of these conditions, may embarrass the release of the arms, but does not otherwise affect the above-described manoeuvre ; except that any abrupt or too forcible movements of the hand while within the uterus are even more dangerous in these cases than in others ; the extraction of the head from the constricting band is, however, often a matter of great difficulty. Any attempt to overcome this obstruction by force ex- poses the mother to the most imminent danger of rupture of the uterus ; and, though steady traction upon the mouth and shoulders should be given a fair trial and may effect dilatation in time to save the child, it is in these cases that the application of forceps to the after-coming head is most often indicated. There can be no doubt of the truth of Lusk's observa- tion, that "the forceps will sometimes bring the head rapidly through the cervix, when traction upon the feet only serves to drag the uterus to the vulva." Care should, however, be taken that this rapidity be not so great as in itself to cause serious laceration. Arrest of the Head at the Superior Strait by Reason of Unusual Size of the Head.-Most German and Amer- ican obstetricians believe that the use of combined traction upon the face and shoulders is the best method to adopt in ar-, rest of the after-coming head, at any point in the pelvis ; and it should certainly be the first method tried in any given case ; but as cases frequently occur in which the head can be delivered with far greater ease by a rapid alternation between two or more methods than by the continued use of any one alone, it is for this reason, if for no other, well to be familiar with all the meth- ods which have been found to be of value. The Prague Method.-This manoeuvre is often of service in effecting the engagement of the head and its initial descent into the superior strait. This is es- pecially true in certain forms of contracted pelvis, and to opera- tors whose muscular strength is inadequate to the really severe strain which is sometimes im- posed upon the internal hand in the use of the combined method at the brim ; but it is usually inferior to the combined method after the great- est diameter of the head has passed the superior strait. Like all methods of manual extraction, it is greatly in- creased in value by the application of proper suprapubic pressure by an assistant. In its performance the feet are seized by one hand and the body drawn as far backward as the perineum allows ; the other hand is then hooked over the shoulders, and traction is made by both hands simultaneously (Fig. 4576). As the head enters the excavation the body is swung rapidly upward and the remainder of the delivery is accomplished by upward traction on the feet, while the hand upon the neck promotes flexion by retarding the descent of the occiput (Fig. 4577). If by any clumsiness on the part of the operator the abdomen of the child has been directed to the front dur- ing the liberation of the arms, and the chin is therefore Fig. 4576.-The Prague Method : First Stage. (Lusk.) 637 Version. Vertigo. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. arrested at the symphysis, the Prague method should be used throughout. In this case the direction of the first traction should be nearly horizontal, and as the occiput descends the body of the child should be raised until, when the head emerges from the vulva, the line of should be applied with the tips well over the frontal end of the head, and traction should be made until flexion has been effected. Arrest at the Inferior Strait or on the Perineum.- Cases in which manual extraction by the combined method fails to overcome a low arrest are extremely rare, but if forceps be required the application and ex- traction are always easy. Arrest due to Contraction of the Peiris.-In the ordinary forms of contraction the arrest is always at the brim, and after the head has passed the superior strait the subse- quent delivery is easy. Justo-minor Pelvis.-Version is contraindicated in justo-minor pelvis ; but if it has been done, the inevitable arrest at the superior strait should be met by extreme flexion of the head and the application of forceps, to be followed by craniotomy if not promptly successful. Flat Pelvis.-In all flat pelves, and in flat pelves only, the head enters the superior strait in the transverse diameter, and the passage of the strait is most easily effected in a somewhat extended position, in which the biparietal diameter is received by one of the sacro-iliac notches, while the lesser bimastoid diameter is opposed to the contracted conju- gate ; if, then, the hand, when it is passed into the vagina for combined traction, flnds the head transverse, it should allow exten- sion to go on until the face begins to approach the side wall of the pelvis, or until the greatest diameter of the head has passed the superior strait, and when this has occurred flexion should be promptly restored, and rotation and delivery will then rapidly follow. In simple flat pelves the application of forceps to the after-coming head is rarely successful after manual ex- traction has failed, but in pelves of the universally con- tracted flat type, if the transverse diameter is markedly diminished, the mechanism approaches that of a normal or justo-minor pelvis, and if version has been done and efforts at manual extraction fail, the application of the forceps may be tried ; such cases are, however, unsuited for version. Indications for Version.-Version may be per- formed in any case of head presentation in which speedy delivery becomes necessary, in the interest of either mother or child, before the head has passed the brim,* or in arrest of a head presentation at the brim of a nor- mal pelvis by inertia uteri or excessive size of the head. It is the preferable operation when a brow or a posterior Fig. 4577.-The Prague Method : Second Stage. (Lusk.) traction is nearly parallel to the mother's abdomen (Fig. 4578). The chief disadvantage of the Prague method lies in the fact that all the force exerted by the operator is expended upon the child's neck, and that the amount of force which can be safely applied is therefore less than in the combined method. Forceps to the After-coming Head at the Superior Strait. -The use of the forceps is generally believed to be the most powerful and certain means of over- coming difficult cases of high arrest of tbe after-coming head. The operation is, however, often difficult, and the time oc- cupied in the application of the forceps may be of vital importance to the child. Moreover, there are but few cases in which a skilled operator, aided by effi- cient suprapubic pressure, fails to deliver by manual extraction ; but as such cases do occasionally occur, the forceps should always be at hand before version is at- tempted. If forceps be used, the body should be raised to a nearly vertical position and the forceps should be passed into place beneath the abdomen of the child. An axis-traction model should be preferred. This is especially emphasized by a recent casein which a living child was delivered with ease by axis-traction forceps, after manual extraction and the ordinary Vienna forceps had successively failed to deliver, though in tbe hands of a skilled operator. Arrest from Extension of the Head.-This condition is rare in properly conducted versions, and when it occurs is usually easily overcome by internal pressure upon the face of the child, aided by suprapubic pressure upon the forehead ; but if these measures fail, the forceps Fig. 4578.-The Prague Method : Chin to the Front. (Lusk.) position of the occiput or face is arrested at the brim of the pelvis, in head presentations complicated by the prolapse of an arm or foot, and in contracted pelves of the flat type, unless the greatest diameter of the head * As in eclampsia, placenta praevia, concealed haemorrhage, prolapsed cord, etc. 638 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Version. Vertigo. has passed the conjugate at the brim. It is the only con- servative operation which is possible in transverse pres- entations. Contra-indications.-Version should never be per- formed in a justo-minor pelvis, upon the first of twins (unless transverse), or upon a dead child, unless under very favorable circumstances. It is impossible if the head is impacted. Choice between Version and Forceps.-The dis- cussion of the relative advantages of version and the for- ceps in each of the many cases in which a high operation is indicated is one that in itself might fill a volume, and the choice is, moreover, one which must, after all, be de- cided in most cases by the skill and predilections of the individual operator, and by careful balancing of the con- ditions of the individual case. All that can be attempted in this article is to describe briefly the conditions which are favorable or unfavorable to one or the other operation. In Normal Pelves.-In uncomplicated vertex presenta- tions in normal pelves the choice depends on the position of the occiput, the degree of engagement which has al- ready been effected, and the condition of the uterus and soft parts. Posterior Positions.-A posterior position of the occi- put increases both the difficulties of a forceps operation and its dangers to the child, but does not increase the difficulties or dangers of version. It is therefore an ele- ment unfavorable to forceps. Fixation of the Head.-If the head has become fixed at the brim the application of forceps is comparatively easy, while the introduction of the hand for version is more difficult than with a free and movable head. A free head is, therefore, favorable to version, and a fixed head to forceps. If at the time of operation the greatest diameter of the head is already in, or nearly in, the su- perior strait, the greater part of the resistance to the pas- sage of the fore-coming head has been already overcome ; and the head is, moreover, in all probability so far moulded to the position in which it finds itself that its rapid alteration, during extraction, to the configuration necessary for the passage of the after-coming head will expose- the child to grave risks of intracranial injury. This condition is, therefore, a strong indication for the use of forceps rather than version. Constriction-ring.-When a dry uterus has retracted upon the child, or a constriction-ring is present, the use of forceps is far less difficult and dangerous than ver- sion. Bandl's Ring.-When Bandl's ring occurs in the pres- ence of an undiminished quantity of waters, and in a pure state, forceps should be preferred, unless the child is very freely movable, and the head but lightly engaged; if it is complicated by the presence of a constriction-ring version is rarely possible. Rigid Soft Parts.-If the cervix or vagina is small and rigid, the use of the forceps permits of their gradual dilatation during the slow advance of the head, while the rapid extraction which is necessary in the delivery of the after-coming head exposes them to much greater risk of serious laceration. As was before said, the presence or absence of each of these conditions, and their relative importance, must be carefully considered before deciding upon either opera- tion in any given case. In Contracted Pelves.-When the head is arrested at the brim of a contracted pelvis, the choice between ver- sion and forceps should depend on the form of contrac- tion present. Justo-minor Pelvis.-Version should never be per- formed in justo-minor pelves. The general diminution of all the diameters makes the intrapelvic space so small that the release of the arms and the extraction of the head can rarely be accomplished in time to save the child. Forceps should be preferred, and if they fail, it is best to proceed at once to craniotomy. Simple Flat Pelvis.-In flat pelves, on the other hand, the mechanical conditions are such that if the transverse space be ample, the after-coming head adapts itself to the brim more easily, and can be extracted by much less force than is required for the delivery of the fore-coming head. In a simple flat pelvis the head in any case enters transverse and somewhat extended, and the bony resist- ance of the pelvic brim is exerted mainly upon the sides of the head. When in such a case the after-coming head is brought to the brim, the narrow base of the skull passes the conjugate with ease ; and when the wider bi- temporal and biparietal diameters have engaged, the head becomes elongated under the influence of the tractions, the ample transverse diameter of the pelvis offers no op- position to an increase of the occipito-frontal diameter of the head, and a compensatory increase in two direc- tions being thus provided for, the flattening of the third, which is alone exposed to pressure, is readily accom- plished, and the head passes. On the other hand, when the vertex of the fore-coming head meets the resistance of a flattened conjugate which is decidedly too small for it, the effect of the intra-uterine pressure upon the base of the skull is necessarily to shorten the vertical diameters of the head, a decrease which must, of course, be compensated for by a corresponding in- crease in both the other directions, not only in the unim- portant occipito-frontal, but also in the very diameters which are already too wide, namely, the bitemporal and biparietal. This pressure from above on the base of the skull, whether exerted by the uterus or by the tips of the forceps blades, tends to mould the head into a shape which is unfit to pass the brim of a flat pel- vis, while traction from below on the condyles of the after-coming head is a direct agent in effecting a fit con- figuration. In addition to this, the fact that in such a case the forceps must always be applied to the sides of the pelvis, or at best in an oblique diameter, and that in consequence the approximation of the blades must com- press the occipito-frontal, and therefore tend to cause still further lengthening of the bilateral diameters of the head, is another argument against its use. These theoretical considerations have been confirmed by the practical experience of the majority of obstetri- cians, and it may be laid down as a rule that the exist- ence of a simple flat pelvis is an indication for version, if any operation is necessary, and a contra-indication for forceps. Generally Contracted Flat Pelves.-As pelves of this type present every possible gradation from those in which the transverse shortening is hardly more than is common in the simple flat pelvis, to others which can hardly be distinguished during life from those of the justo-minor type, so, too, the mechanism of labor and the choice of operations vary with the proportions of the the individual pelvis between these two extremes. In doubtful cases the choice is often difficult ; but as forceps, if unsuccessful, can be followed by version, while an unsuccessful version means the loss of a child, it is usually good practice to give forceps the preference if doubt is felt. Edward Reynolds. 1 Obstetric Operations, page 114. 2 Manual of Midwifery, Append. II. VERTIGO, or dizziness, is a sensation in the head which causes stationary objects to appear to move, and the person affected finds it difficult to retain an erect posture. There is some doubt as to the extent of the part of the nervous system governing equilibrium. Flint1 says: " The theory that the disordered movements which fol- low injury of the cerebellum are due simply to vertigo, is not tenable ; and in only one of the cases cited is vertigo mentioned. There is a disease, involving the semicircu- lar canals and other parts of the internal ear, called Meniere's disease, in which there is marked want of equili- bration and muscular co-ordination, attended with and dependent upon vertigo. The vertigo is always very distinct, and is mentioned in all of these cases ; and al- though it is less in the recumbent posture, it is never entirely absent. A careful study of these cases, com- paring them with the cases of deficient co-ordination from diseases of the cerebellum, cannot fail to show a great difference between the phenomena following cere- 639 Vertigo. Veterinary Exam. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. bellar diseases and the muscular phenomena due to well- marked and persistent vertigo. " Meniere, of Paris, published several cases of loss of equilibrium accompanied by deafness, tinnitus, nausea, etc., which he ascribed to disease of the semicircular canals ; probably the cochlea was also affected. The au- ditory nerve supplies the cochlea and the semicircular canals. The former is solely for hearing, but the func- tion of the latter is, in part, at least, to regulate the movements of the head and trunk. Destruction of the cochlea on both sides in pigeons, in some experiments by Flourens, caused total deafness ; while crushing the semi- circular canals abolished the equilibrium. Landois, in his " Text-book of Human Physiology," 1886, says : " Section or injury to these canals does not interfere with hearing, but other important symptoms fol- low their injury, such as disturbance of equilibrium due to a feeling of giddiness, etc. The direction in which the patient tends to fall depends on the canal that is in- jured." It seems quite certain that changes in the blood-supply or in the pressure in the semicircular canals will induce dizziness; but it is perhaps doubtful whether some other portion of the nervous apparatus also has not the power to induce this symptom positively or negatively, i.e., by acting or by its action being impaired. For in- stance, the symptoms of sea-sickness may be ascribed to shaking up of the auditory nerve, or change in its blood- supply ; to constant motion of objects before the eyes ; or, to disturbance of the digestive organs, causing re- spectively aural, ocular, or stomachic vertigo, according to the theory chosen. But the probability is that the immediate cause of vertigo is labyrinthian, while the ultimate cause may act on the labyrinth through vascular or nervous channels. E. Woakes, of London, in " Deafness, Giddiness, and Noises in the Head," gives a very interesting and ingen- ious explanation of the sources of this symptom. He regards rolling of the head from side to side, in chil- dren, as the counterpart of vertigo in the adult, and as being due to derangement of the circulation in the laby- rinth or to pressure on its contents. The labyrinth receives its blood from the vertebral artery, while the external and middle ears receive their supply from the internal carotid; though Politzer says there are minute vascular communications between the tympanum and the labyrinth along which inflammation may be transferred, but which may have no effect on functional acts. The vertebral artery coming from the subclavian, and being supplied with nerves from the in- ferior cervical ganglion, by this means communicates directly with nerves from the brachial plexus and infe- rior cardiac nerves. Impressions affecting the heart may thus react on the labyrinth and induce fainting, and the feeling of dizziness is often accompanied by palpitation of the heart. Incidental to the above-mentioned nervous connection it may be recalled that Moorhouse, Mitchell, and Keen have stated that a person receiving a wound of the brachial plexus may fall suddenly without loss of consciousness. The labyrinth being at the periphery of the tract supplied by the vertebral artery is the first to feel suspended inhibition from the ganglion. Where vertigo seems to originate from the stomach it may be associated with the labyrinth through the pneu- mogastric nerve and lower cervical ganglion, and thence by vaso- motor nerves to the vertebral artery. We re- gard this dizziness as a warning against abuse of the stomach, as well as against immoderate use of alcohol, tobacco, and various drugs, such as quinine, salicylic acid, etc. Abuse of tobacco often induces giddiness, palpitation, praecordial distress, with aching and feebleness of the arms, then nausea, clammy sweats, evacuations from the bowels and collapse ; symptoms associated with disturb- ance of the entire tract supplied from the inferior cervical ganglion. Large doses of quinine produce dizziness, and tinnitus, and may even cause such trophic changes as desquamation. So these two substances may be regarded as having a paralyzing effect on the lower cervical gan- glion ; while the bromides, especially hydrobromic acid, have an opposite effect. Many of the persons subject to vertigo are, without rec- ognizing the fact, slightly deaf ; if aural catarrh has in- duced retraction of the membrana tympani and pressure on the oval window, a relatively slight change in the labyrinthine circulation may induce vertigo. Perhaps stomach vertigo may not attack persons entirely free from ear trouble. In this case there would be two ac- tive factors : (1) Direct local pressure upon the labyrinth from affections of the middle ear ; (2) supplementary waves of vessel dilatation, emanating from the stomach, or other organ, and passing upward to the cervical gan- glion, and thence to the vertebral artery (Woakes). The veins of the labyrinth empty into the superior petrosal sinus, which is connected with the cavernous sinus in front and the lateral behind ; hence obstructions to the venous circulation would retard the escape of blood, and induce symptoms of vertigo. If we wish to divide vertigo into classes in which the more prominent inducing causes give the name to the class, we may have (1) aural, (2) ocular, (3) stomachic, and (4) nervous vertigo. These again might be variously subdivided : In aural vertigo the exciting cause may be (1) on the drum-membrane, as a hair, wax, an insect, etc., producing contraction of the tensor tympani, re- traction of the ossicles, and pressure on the oval window ; (2) in the tympanum, as serum or pus, or swelling of the membrane ; or, again, retraction of the ossicles causing pressure ; or it may be (3) in the internal ear from direct pressure on the labyrinth by fluid or a clot of blood, etc. Ocular dizziness may be from affections of the exter- nal muscles or from errors of refraction, causing unequal action of the muscles of accommodation. Stomachic vertigo might include all cases of dizziness due directly or indirectly to errors of digestion ; as from an overloaded stomach, or from gouty and allied dis- eases. Nervous vertigo includes those cases which are due to epilepsy, sick headache, or brain disease. Ocular Vertigo.-In cases of insufficiency or paralysis of one or more of the external muscles of the eye, vertig- inous symptoms are not infrequent. These are loosely accounted for by saying that the patient sees double ; but this would probably soon pass off, as patients quickly ac- quire the power of suppressing the less acute image, that is, of not noticing it; just as a practised microscopist keeps both eyes open, but only observes what is seen through his microscope. Dizziness or head symptoms are often complained of where the patient denies the presence of double vision, and this not only in cases in which the external muscles are unequally active, but in cases of errors of refraction, especially of astigmatism, where possibly the muscle of accommodation may attempt, by successively contracting and relaxing, to render vision equally distinct in the two meridians at right angles to each other. In the same way, in cases of hypermetropia, the strain on the muscle of accommodation to secure distinct vision often causes headache and sometimes vertigo. Apparently it is a transferrenceof the irritation from the ocular muscles to some part of the nervous apparatus, probably the semi- circular canals, that induces this symptom. Trousseau speaks of it as a well-known fact that the operation for couching of cataract caused vertigo and nausea, and Brown-Sequard2 thinks that irritation of the auditory, optic, or any sensitive nerve may, by reflex action, cause convulsions, vertigo, and other symptoms of cerebral trouble. Stomach Vertigo (Vertigo a stomacho laeso).-Under this name Trousseau, "Clinique Medicale," graphically describes a condition accompanied by vertigo, and fre- quently recurring without sufficient apparent cause, which he ascribes to indigestion, other symptoms of ■which may or may not exist. He supposes that the symptoms are the result of reflex action on the cerebral circulation, induced by irritation proceeding from the stomach. There is a feeling of dizziness and emptiness in the head, or the temples seem constricted by a band of iron ; 640 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vertijjo. Veterinary Exam. sometimes there is an icy feeling ; some speak of a mist before the eyes ; things appear colored ; others have a red ring revolving rapidly before them. But the most frequent form is of gyrosa; when the patient is up everything turns around him, he has to close his eyes and stand perfectly still, for his legs weaken and he may fall. If lying down, his bed seems to turn. These symp- toms occurring in elderly persons with friable blood- vessels are often premonitory of apoplexy. In such cases Trousseau has great confidence in the use of quassia-water before breakfast, and in taking, after breakfast and dinner and at bedtime, a powder of bicar- bonate of soda and magnesia, aa gr. v. ; prepared chalk, gr. x., in sweetened water, for five or six days, and then to be omitted for a week. During the interval he gives about two glasses daily of Vichy, or a similar mineral water. Niemeyer (" Practical Medicine ") says that he has seen little benefit from this treatment, and while the first at- tacks have usually come after an indigestion, in none of his cases were there signs of indigestion during subse- quent attacks, which often recurred for years. He thinks the repetition may be due to psychical causes ; that the dizziness, having come under certain circumstances, may arise under similar conditions from the fear of it. Under the head of nervous vertigo we may consider those cases arising from epilepsy, sexual exhaustion, intracranial diseases, etc. Of course the possible dependence of epilepsy on di- gestive troubles might give this a questionable position in the preceding class. But in view of the progress of our knowledge concerning cerebral localization, it seems probable to the writer that there is a fixed location for VETERINARY POST-MORTEM EXAMINATIONS. The general method of making post-mortem examina- tions on animals is similar to that followed in human autopsies. Yet the differences in the size of the organs, together with some differences in the anatomy, make cer- tain special procedures necessary. The supero-inferior greatly exceeds the lateral diame- ter of the chest in all four-footed animals. The supra- spinous processes are greatly developed and the mus- cles which attach the limbs to the trunk are short and thick, bringing the scapula and humerus close to the chest and the femur close to the posterior part of the abdomen (see Fig. 4579.) The shape of the thorax, therefore, together with the way in which the legs are attached to the body, makes it impossible to keep the ani- mal upon its back without some support, or without loosening the muscular attachments; and, in the larger animals, even the loosening of these muscular attach- ments will not keep the body perfectly well balanced. In the smaller animals division of the pectoral mus- cles, allowing the fore limbs to lie flat upon the table, and of the adductors of the thigh, allowing the hind limbs to fall outward, will be found sufficient to keep the body flat upon its back (see Fig. 4580). For the larger animals, however, especial arrangements have been devised for holding them in place, and, though too elaborate for field-work, they can be made practicable in the city, where many dead animals are taken to one place. The methods here described will be based upon the supposition that the operator has appropriate ar- rangements at his disposal, and such substitutions as are necessary for ordinary field-work will be mentioned afterward. The horse will be taken as the type, and, un- less otherwise mentioned, the description refers to that animal. The Horse.-It is always better to have an animal on its back than on its side. It is also better to have the body on a platform so high that the operator can work the origin of vertigo ; and, so far as we at present know, this location would seem to be the semicircular canals. Therefore, whether the im- mediate cause be aural, op- tic, or otherwise, whether the action be immediate or reflex, the symptom may be assumed to be due to some disturbance in the region just referred to. Chas. E. Ilackley. 1 Text-book of Human Physiology, edition of 1876, p. 718. 2 Lectures on the Physiology and l'athology of the Central Nervous System. 1860. VERVAIN (Verveine offici- nale, Codex Med.), Verbena officinalis, Order Verbenacea, an annual or biennial herb, common in dry, sterile fields in Europe, now and then cul- tivated in this country, for- merly popular as a domestic " herb," now fast becoming obsolete. It is mildly astringent, and a slight tonic. Dose indefinite. Verveine odorante, Codex Med., the leaf of Lippia citri- odora Kunth, in the same order, is the pleasant lemon verbena of the flower gardens; it is used in cheap per- fumery. Several species of verbena appear in endless hybrid varieties, as most lovely garden flowers. The medical properties of the order are entirely insignificant. W. P. Bolles. Fig. 4579.-Skeleton of a Horse, showing the Shape of the Thoracic Cavity. conveniently. It is, moreover, desirable to have the plat- form movable, so that the position of the body may be changed at will. For the above purpose a carriage or truck, similar to that used by railroad porters, may be made (see Fig. 4581). This truck should be about eight feet long by three feet wide ; the platform should be about two feet from the ground, and above the top of the four wheels w'hich must support it. Iron sockets should be placed 641 Veterinary Exam, Veterinary Exam, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. near the edge of the platform, and sunk into the wood so that the top will come even with the floor of the platform. These sockets must be so placed that they will come op- posite each of the four limbs. They should be of just the right size to allow the uprights to fit into them. These uprights should be iron bars about four feet long and one inch thick. They should have a shepherd's crook on the end, to which the cords which hold the legs in place may be secured. These bars should fit loosely into the sockets, so that they can be removed easily at any time. The animal can be hoisted on to the truck by means of a Yale pulley. When placed in position, the iron bars The general inspection having been completed, a special inspection of the exterior should now be made to determine : 1, The condition of the visible mucous mem- branes ; 2, the condition of the glands in the submaxil- lary region, and in the parotid, axillary, and inguinal regions ; 3, the condition of the skin over the jugular vein about midway of the neck (any cicatricial tissue giving evidence of the animal ever having been bled) ; 4, any prominences on the limbs-in short, any pathologi cal conditions which can be made out by the eye or fin- ger before any cutting has been done? The above in- spection has generally to be made before the animal has been placed upon the truck, as the hide is saved by those who dispose of the ani- mal.* After this inspection an incision through the skin over the sternum is to be made. In human autop- sies the knife, firmly grasped in the right hand, is drawn toward the oper- ator's body and the prim- ary incision, begun at the chin, is carried to the pu- bis. In the lower animals, on account of the hair and dirt, such a procedure would take the edge off the knife; consequently it is better to adopt the method used by butchers, of making a small incision in the skin along the median line, then insert- ing the knife under the skin, cutting upward through the skin, and away from, instead of to- ward one's self. The inci- sion must extend from the mouth to the anus, passing to the right of the penis and testicles in the male, and between the mammae in the female. A second incision, begun just in front of the penis, should be carried to the anus, passing to the left of the penis. Incisions through the skin should be made transversely to this longi- tudinal incision from the middle of the pubis along the inside of the thighs nearly to the hocks, and from the middle of the sternum, along the inside of the forelegs, nearly to the carpus. The skin should then be cut around the legs at the end of the last incisions, and the skin taken off from this part of the legs, from the trunk, and from over the trachea and lower jaw. The penis should then be examined and dissected back, allowing it to fall over the perineum. The mammae should be examined and excised if the ani- mal be a female. The abdominal muscles and the peritoneum may now be cut through from the sternum to the pubis, care being taken not to wound the intestines in the operation. About midway of the abdomen the muscles and perito- neum should be divided transversely, the cut extending Fig. 458U.-Post-mortem Examination on a Small Animal. can be put in and the legs secured to them, as shown in Fig. 4581. Everything is now ready. The animal is in position, the instruments are sharpened, and buckets of clean water and sponges are at hand. The first proced- ure is to make a general inspection of the animal : 1, As to color ; 2, sex ; 3, age ; 4, weight ; 5, general condi- tion ; 6, condition of abdomen, whether much distended or not; 7, any abnormal appearances about the skin, such as scars, abrasions of the surface, evidence of having been blistered, or of the actual cautery having been ap- plied ; 8, any abnormal prominences or depressions ; 9, condition of the hoofs ; in short, any abnormal appear- ances striking enough to be evident to the eye on general inspection. * If the hide is saved, it is removed by the knacker or butcher before the animal is placed on the truck. It is an advantage to have the hide first removed. - 642 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Veterinary Exam. Veterinary Exam. to the false ribs on either side. The flaps so made should he laid over on the chest and on the flanks, and the cuts should be made in the muscle crosswise, so that the flaps will lie flat (see Fig. 4581, c). While making the trans- verse cuts any abnormal contents of the peritoneum should be noted, together with the character of such con- tents ; also the condition of the peritoneum itself, and, in a general way, of the intestines. In making autopsies on the human subject most pre- cise directions are given to open the abdomen first, and to examine the contents without removing any organs ; then to carefully ascertain the position of the diaphragm and to open the thorax and proceed with the dissection of the organs therein contained. On account of the bulkiness and intricacy of the intestines in the horse, it is well to remove them as soon as possi- ble, else they will become involved in arrange- ment so as to make it difficult to straighten them out. It is there- fore better first to dissect the large in- testine, and the small intestine as far as the duodenum, in the horse, and in cattle to remove the stom- achs as well; then, to open the thorax and to remove the organs therein, and after- ward to go back and finish the abdomen. In the smaller ani- mals. such as dogs. divided into several areas ; these divisions are arbitrary, and anatomists do not all agree as to how they should be made. The one most generally adopted in the schools in England and America, and which is probably the sim- plest, is the following, taken from McFadyean's " Anat- omy of the Horse " (Edinburgh and London, 1884). Two transverse planes divide the cavity into three regions, then two longitudinal planes subdivide each of these regions into three parts. The first transverse plane passes through the lower end of the fifteenth rib. The second passes through the external angle of the ilium on either side. The two parallel longitudinal planes ex- tend from the pelvis to the sternum, passing through the cats, pigs, etc., the intestines do not interfere, and the procedure may be that followed in human post-mortem examinations, so far as the order of the removal of the organs is concerned (see Fig. 4580). We have now made a general inspection of the ani- mal, noted its color, sex, age, and weight, together with any abnormal appearances of the exterior. We have di- rected how the primary section should be made, and which part should be dissected first, and why. The ab- domen has been exposed and any abnormal contents have been noted, together with any abnormal condition of the peritoneum. We are now ready to begin the dissection of the intestines. For convenience of description the abdominal cavity is Fig. 4581.-Truck for Post-mortem Examinations, a, Double colon ; b, small intestine ; c, caecum. centre of Poupart's ligament on either side. The regions thus formed are, between the diaphragm and the trans- verse plane passing through the fifteenth rib, the left hypochondriac, epigastric, and right hypochondriac; in the region between the above plane and the transverse plane which passes through the angle of the ilium, the left lumbar, umbilical, and right lumbar. The regions posterior to the plane passing through the angles of the haunch are the left iliac, hypogastric, and right iliac. The first part of the intestine to be manipulated is the large or double colon. It starts from the caecum in the right hypochondriac region, passes forward to the dia- phragm, where it turns upon itself, forming the supra- sternal flexure. It then passes back to the pelvic cavity 643 Veterinary Exam. Veterinary Exam. REFERENCE HANDBOOK OF TTIE MEDICAL SCIENCES. with the caecum on the left of the body, as far forward as possible, so as to be out of the way of the operator. He, standing on the left of the animal, should now pull out the small intestines, allowing them to hang over the platform, attached by the mesentery (see Fig. 4581, a, b). He should then go to the right side of the animal, and, beginning near the anus, pull out the rectum and floating colon on that side (see Fig. 4582). The redo-duodenal liga- ment will now be exposed to view, and this indicates the situation where ligatures are to be applied to the intestine. One ligature is placed around the rec- tum near the corresponding extremity of this liga- ment (at a, in Fig. 4582). Another ligature, b, is passed around the duodenum just at the beginning of the jejunum ; i.e., at the inser- tion of the above-named ligament. The gut is cut through at this point, and the jejunum and ileum are dis- sectedfrom the mesentery, and, after being ligatured at the caecum, cut through (5, in Fig. 4583) and al- lowed to fall to the floor or into a receptacle placed there. The oper- ator now excises the rectum, as near to the anus as possible, and dissects forward until he comes to the liga- ture (a, Fig. 4583), where he cuts the gut through and allows it to fall. The next procedure is to free the ccecum, double colon, and what re- mains of the floating colon from their attachments. This is easily done by detaching the loose cellu- lar tissue with the lingers and by cutting the strong bands of perito- neum, the ineso-caecal ligaments- by which the caecum is attached to Fig. 4582.-Horse, showing Recto-duodenal Ligament, a, .Ligature around rectum; b, ligature around duodenum. and there turns again, forming the pelvic flexure, whence it passes forward to the epigastrium, forming a third flexure-the dia- phragmatic or gastro- hepatic, which is in contact with the dia- phragm and liver. It then passes back to the base of the caecum, to which it is attached, and, becoming sudden- ly smaller, passes on as the floating colon. The first and fourth and the second and third por- tions are attached to each other at the sides ; otherwise the gut is free from the time it leaves the caecum until it terminates in the floating colon, at which point, as mentioned above, it is attached by cellular tissue to the base of the caecum and to the pancreas. It will be seen that the free extremity of the double colon is at the pelvic flexure. This extremity must be grasped firmly with the hands and carried for- ward so as to obliterate the suprasternal and diaphragmatic flexures and allowed to fall Fig. 4583.-Abdominal Viscera of the Horse, a, Rectum, and b, ileum, ligatured and excised; c, stomach; d, spleen ; e, liver ; f, pancreas. 644 Veterinary Exam. Veterinary Exam, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the sublumbar region and to the colon at its origin-and the cellular tissue which attaches the double colon to the pancreas and to the wall of the abdomen. The attach- ments having been severed, the caecum and colon are allowed to fall to the floor. Now that the intestines have been removed, it is better to open the thorax and remove the organs, as that cavity should be examined before the liver is removed. If it is at- tempted to remove the liver first, there is danger of wound- ing the diaphragm, and there is also a disagreeable escape of blood from the sev- ered vessels. More- over, if the organs in the thorax have been removed, the dia- phragm may be freed from its attachments to the ribs, and, to- gether with the liver, may be allow'ed to fall forward into the abdom- inal cavity, thus giving more room to work at the other organs. Before open- ing the thorax the pectoral muscles should be divided, care being taken not to wound the main blood- vessels in the axilla. The cords attaching the fore legs to the iron bars may then be loos- ened, allowing the legs to fall outward, and giving the operator a chance to make a larger opening into the chest. This having been done, the muscle remaining attached to the sternum should be removed, and the ribs sawn through far enough from the sternum on either side to afford sufficient room to ex- amine the thoracic cav- ity and to remove the organs (see Fig. 4584). The ribs having been sawn through, the dia- phragm should be freed from its attachments to the sternum, the inter- costal muscles divided, and the tissues over the pericardium dissected as close to the sternum as possible. The ster- num having been removed, any abnormal contents of the pleural cavity must be noted. Adhesions should be sought for. The pericardium is then to be opened, beginning the incision at the base of this sac and extending it far enough to see whether there is any fluid present or not. If there is fluid present, it should be measured as accurately as possible. The in- cision is to be extended toward the base of the heart as far as possible, and any abnormal condition of the epi- cardium and pericardium should be noted. The heart is now to be examined. Make : 1. An inci- sion into the right auricle from the anterior vena cava to the auriculo-ventricular sulcus, and remove and examine the blood in the right auricle. 2. Make an incision along the right border of the right ventricle (or of the heart), beginning just below the au- riculo-ventricular sulcus and continuing to the apex of the right ventricle. The auriculo-ventricular sulcus is therefore left intact between the two incisions. Remove and examine the blood in the ventricle. 3. Make an incision in the left auricle, beginning be- tween the pulmonary veins and continuing to the auric- ulo-ventricular sulcus. Remove and examine the blood in the left auricle. 4. Make an incision along the left border of the heart, beginning below the left auriculo-ventricular sulcus and Fig. 4584.-a, Heart; ft, lung; c, diaphragm; d, liver; e, stomach; f, spleen. continuing to the apex. Remove and examine the blood in the left ventricle. 5. Insert the thumb and fingers into the incisions so as to grasp the heart firmly by the septum near the apex, and by broad sweeps of the knife cut the veins, arteries, etc., so as to remove the heart from the chest, dividing the vessels at a good distance from the heart. 6. Make an incision close to, and parallel with the septum, into the right ventricle on its anterior surface, the incision extending from the apex, where, it meets a 645 Veterinary Exam. Veterinary Exam. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. previous incision, into the pulmonary artery. Examine the pulmonary valves and the parts exposed. 7. Connect the incision along the right border of the heart with that in the right auricle, by dividing the, in- tervening part of the auriculo-ventricular sulcus. This exposes the tricuspid valve. 8. Make an incision on the anterior surface, close to and parallel with the septum, into the left ventricle, the incision extending from the apex, where it meets a pre- vious incision, into the aorta. This incision exposes the aortic valves and the interior of the left ventricle. 9. Connect the incision along the left border of the heart with that in the left auricle, by dividing the intervening part of the auriculo-ventricular sulcus. This incision exposes the mitral valve. The incisions into the ventri- cles make, therefore, triangular flaps. The heart having been removed from the body, any abnormality in general appearance must be noted ; also the condition of the epicardium and the size of the or- gan. In a medium-sized horse the larger axis of the heart is about 10| inches ; its antero-posterior diameter, measured near the base, is equivalent to 7| inches ; its lateral diameter does not exceed from 5 to 5| inches. The average weight is about 6| lbs.1 The pericardium should now be removed from the thorax, and the bron- chial lymphatic glands examined in situ, so far as possi- ble. After cutting through the trachea at its bifurcation, each lung must be removed separately. The pulmonary and costal pleurae must be examined. The lung must be pressed upon to see whether it crepitates or not. Several incisions should then be made lengthwise in the organ, in order to determine whether there are areas of consol- idation or other abnormalities. The lungs of the horse are so large that one is likely to overlook a small patch of pneumonia, unless many sections are made. The bronchi should be laid open, and the presence of muco- pus or other abnormalities noted. The pulmonary ves- sels can also be dissected out. The contents of the thorax having been examined, we now return to the abdomen. It will be remembered that we have left in situ the liver, spleen, stomach, du- odenum, pancreas, kidneys, suprarenal capsules, and the genito-urinary apparatus, together with the great blood-vessels and the mesentery. The diaphragm should be cut down on either side, close to the ribs so as to allow the liver to fall over into the thoracic cavity. The spleen should now be removed. It lies close to the side of the stomach. Its normal weight in the horse is about thirty-two ounces. It is attached by the sus- pensory ligament to the anterior border of the left kid- ney and to the sublumbar wall, and by the gastro-splenic omentum to the greater curvature of the stomach. The anterior extremity is thicker than the posterior, and is channelled by a slight longitudinal fissure which lodges the splenic vessels and nerves. The spleen having been removed and excised, the next procedure is to dissect away the loose fold of omentum attached to the stomach. This shows the pancreas in its relation with the stom- ach and kidneys. The pancreas weighs about seventeen ounces and is somewhat triangular in shape ; it lies be- hind the liver and stomach, in front of the aorta and posterior vena cava, and has an opening-the pancreatic ring-for the passage of the portal vein. Its principal excretory duct, the duct of Wirsung, leaves the organ by two or three branches which soon unite, and the main trunk enters the ductus choledochus. The acces- sary pancreatic duct opens into the duodenum opposite the duct of Wirsung. The duodenum should now be opened, starting on the side corresponding to the mesenteric attachment, then cutting across to the other side before the opening of the bile-duct is reached, and continuing the incision to the stomach. The bile-duct should now be examined to see whether it is pervious or not. The attachments of the pancreas, which are chiefly loose cellular tissue, may now be broken down with the finger, the ducts and vessels cut across, and the pancreas removed and examined. The duodenum and stomach may be removed from the body. The incision along the duodenum should now be continued along the greater curvature of the stomach to the oesophagus, the contents of the stomach removed, and the walls examined. The stomach of the horse, though classified as simple, is nevertheless divided into two parts, between which there is an abrupt line of separation. The left half is pale in color and the epithelial lining is of the pavement variety, being a direct continuation of that lining the oesophagus. The right half of the stomach is the true digestive part, the lining is very red, and the epithelium is of the columnar variety. What are termed hots-i.e., the larvae of the (Estrus equi-are often seen in the stom- ach and by many are supposed to be a very common cause of disease. They are not believed by veterina- rians, however, to be of any consequence in this regard. The kidneys should be removed next. They are sit- uated on either side of the vertebral column, in the right and left lumbar regions, the right kidney being a little more anterior than the left. These organs, in the horse, have essentially the same shape as in man. The right is heavier in horses, its weight being about twenty-seven ounces, while the left weighs twenty-five ounces. This is exactly the opposite of what is seen in man, in whom the left kidney is larger and heavier than the right. The kidneys having been removed from the body, they should be laid upon the table or a support of some sort, in order to make a proper sectiqn. To do this, place the palm of the left band upon the organ, then with a large, flat-bladed knife, held in the right hand, cut along the convex border, at the same time turning the kidney with the left hand toward the knife. The section should be continued through the organ into the pelvis of the kidney. See if the capsule is of normal thickness and easily removed. When we examine the cut surface of the kidney it will be seen that the arrangement differs somewhat from that in man, in that in the horse there is no division into sep- arate pyramids, the striae starting from every part of its exterior and converging toward the common pyramid. The suprarenal capsules, which can be removed either now' or in connection with the kidneys, are two in num- ber, and placed on the median border and anterior ex- tremity of each kidney. They are flattened, and meas- ure about two and one-half inches in length by one and one-half inch in breadth, the right being somewhat larger than the left, corresponding to the difference in size of the kidneys. Before removing the organs in the pelvic cavity it is necessary to saw through the symphysis pubis (as shown in Figs. 4581 and 4583); then, by loosening the cords at- taching the hind legs to the iron rods, the pubic bones will separate, leaving an opening large enough for the operator to insert his hand. The organs may then be re- moved en masse and dissected outside the body. The liver in a medium-sized horse weighs about eleven pounds. It has three lobes : The right, with a small ap- pendix, the lobus Spigelii; the left, which is largest; and the middle lobe, which is divided into several lobules. This organ must be removed by dividing the ligaments which attach it to the diaphragm (or it may be conven- iently removed in connection with the diaphragm), and then dividing the blood-vessels which enter it. It may be noted that there is no gall-bladder in the horse, the flow of bile into the duodenum being constant. The liver having been removed, the capsule covering it should be examined ; then the substance of the organ may be exposed by many cuts in different directions. Next remove the diaphragm (if not previously taken out with the liver), then the mesentery, and, finally, the large blood-vessels. It remains now to open the intes- tines; or, if preferred, they may remain until every- thing else is finished. The small intestine is to be opened, as in human autopsies, by an incision running the whole length at the mesenteric attachment. The same rule ap- plies to the large intestine, with the exception of the 646 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Veterinary Exam. Veterinary Exam. double colon, which is opened along the outer margin of the double coil. We next proceed to examine the neck and head. In examining the neck it must be noted that in horses what are known as the guttural pouches exist. These pouches are dilatations of the Eusta- chian tubes ; they are two in number, one on either side, and extend from the inferior face of the atlas to the an- terior part of the pharynx. The capacity of each is about three-fourths of a pint; but, in consequence of the exten- sibility of the mucous mem- brane, this is very variable. The pouches are situated im- mediately beneath the parotid glands and sometimes become tilled with pus and press upon the larynx, interfering with respiration. The thyroid gland is composed of two oval lobes situated immediately behind the larynx, beside the first two rings of the trachea. These lobes appear to be in- dependent, but close exam- ination shows them to be united by an intermediate portion, the isthmus, which passes across the anterior face of the trachea. They should be excised and removed. The parotid glands should next be removed and the gut- tural pouches laid open. The tongue, larynx, trachea, pharynx, oesophagus, and submaxillary glands should be removed en masse. Before doing this, however, Stenon's duct should be examined, the vertebral column so as to remove the larynx, trachea, and oesophagus in connection with the tongue and pharynx. The (Esophagus and pharynx are to be opened, and then the larynx and trachea. The submaxillary lymphatic glands must be examined and any enlargement noted. If the enlargement be cir- cumscribed and hard, glanders may be suspected. If, on the other hand, there is general swelling of the glands under the jaw with oedema of the connective tissue, and especially if the animal be young, the condition known as strangles may be present. We now come to the cranial cavity. This cavity must be opened with the least possible injury to the brain it- self and to the cranial bones. To take out an animal's brain, the head must be disarticulated from the body. This is done at the atlo-occipital articulation. A long- bladed knife is necessary. It is better to place a block under the pole or the point of the occiput. This will cause the head to point forward, and tend to make tense the muscles. The soft parts are then cut through, and the joint-ligaments severed. Place the head on the table, resting on the lower jaw, and dissect off the tem- poral muscles. With a saw make a transverse cut through the frontal and parietal bones, on a line about two inches above the upper border of the orbital cavity {a, in Figs. 4585, 4586, and 4587). Lines drawn from each end of this transverse cut to the lower border of the upper third of the occipital foramen will indicate the position in which the longitudinal cuts are to be made (i, in Figs. 4585, 4586 and 4587). Care must be used in making these longitudinal cuts not to saw too deeply over the parietal portion, as the bone here is only one- eighth to one-fourth of an inch in thickness, while at the occiput it is about one inch thick. Having, therefore, sawn carefully until, by want of resistance, we know that the parietal bones have been penetrated, we must change the angle of the saw so as to go through the occipital bone. We can then, by using a little judgment, make a continuous cut without injury to the brain. Any pieces of bone not sawn through must be broken with the chisel. Complete sec- tion of the skull-cap having been made, the anterior part must be lifted up, the dura mater cut through-if it is adhe- rent, which is generally the case, especially in old horses-and the cap pulled back. In horses there is a bony plate which separates the cerebrum from the cerebellum- the tentorium cerebelli,-so that care must be used not to injure the brain on this projection when pull- ing the skull-cap off. The skull-cap having been re- moved (see Fig. 4588), it should be examined for any alteration in structure on the inner surface; also as to any thickening of the dura mater. The general condition of the surface of the brain must be examined. The dura mater, if it has not been taken off with the skull-cap, must now be divided Fig. 4585.-Skull of Horse, show- ing the Lines of Incision for Removal of the Skull-cap. Su- perior view. Fig. 4586.-Skull of Horse, showing the Lines of Incision for Removal of the Skull-cap. Lateral view. as it is sometimes the seat of calculi. To remove the tongue, cut the muscular attachments extending from the tongue to the lower jaw ; then divide the articulation of the hyoid bone at the styloid cornua. This is easily done by inserting the hand along the side of the tongue and feeling for the flat styloid bone, which extends along the side of the tongue for the posterior two-thirds. By placing a knife against the inner surface of this bone and cutting toward oneself the knife will pass through the articulation without any trouble. Disarticula- tion having been accomplished, the knife should be placed close to the inner surface of the submax- illary bone ; then, cutting toward the pharynx, di- vide the muscular attachments. As soon as the muscular attachments are divided far enough to admit of it, take hold of the tip of the tongue and pull it through the submaxillary space. The mass can thereby be lifted and the cutting will be much more easily done. The section should be made deep enough to include the soft palate with the pharynx, and the incisions may now be carried backward close to Fig. 4587.-Skull of Horse, showing the Lines of Incision for Removal of the Skull-cap. Infero-lateral view. longitudinally and transversely. The head must be made to rest upon its base so that the brain will tend to 647 Veterinary Exam. Veterinary Exam. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. fall backward. Insert the third and fourth fingers of the left hand under the anterior part and gently raise the brain ; divide the olfactory lobes as far forward as possi- ble. These lobes are greatly developed in horses, and are hol- low', communicating directly with the lateral ventricles, differing in this re- spect from the hu- man olfactory lobes. These lobes hav- ing been divided, the nerves at the base of the brain must be severed while draw - ing the brain back- ward. This having been completed, the brain is easily re- moved from the cavity. After removal, a general inspection of the brain is to be made. The average weight of a horse's brain isfromtwenty- two to twenty-three ounces. When it is being removed from the cavity the con- dition of the blood- vessels at the base will be noticed ; also whether there are any adhesions between the membranes or not. For mak- ing the primary section of a brain, it iswrell to use a sharp knife with a thin, wide blade. After removal, the vessels and the pia-arachnoid mem- brane may be still further examined. The brain is now placed upon its base, the cerebral hemispheres drawn apart so as to expose the corpus callosum. An incision is made on each side, at the junction of the corpus cal- losum and the convolutions, into the lateral ventricle, which is to be laid open along its whole extent. Note the amount and character of fluid in the ventricles, and the presence or absence of tumors in the choroid plexus. One or more longitudinal incisions can now be made in an oblique direction outward into the medullary sub- stance of the hemispheres nearly to the cortex. After dividing the fornix, a series of transverse sections is to be made from before backward through the corpus striatum and optic thalamus, so as to expose all parts of the basal ganglia and the internal capsule. A longitu- dinal incision is to be made through the middle lobe of the cerebellum down to the fourth ventricle. From the fourth ventricle a median incision, dividing the roof of this ventricle and that of the aqueduct of Sylvius, is car- ried into the third ventricle. After replacing the parts, as nearly as possible in their normal positions, the brain is turned so as to rest on its convexity, and the pia mater is detached from the interpeduncular space and from the pons and medulla oblongata. A series of transverse incisions should now be made through the crura cerebri, the pons, and the medulla oblongata. This completes the dissection of the brain. The lower jaw must now be removed. It remains to expose the frontal and nasal sinuses by sawing the head in two vertically in the antero-posterior plane. The con- dition of the mucous membrane of the nasal cavities and of the sinuses must be noted. The spinal canal may be examined in sections of about two feet in length and the cord may be removed either by sawing through the laminae of the vertebrae and re- moving the section thus made, or by sawing obliquely through the bodies of the vertebrae from below, on either side, being guided in the incision by the articulation of the ribs, and removing the included piece of bone. By the latter method a much thicker piece of bone has to be sawn through, but there is the advantage of having less muscle to remove. Before attempting to take out the cord, the fore legs, with the scapula, must be removed from the body, the ribs and muscles divided about six inches from the vertebrae on either side, and the ver- tebral column sawn through just in front of the pelvis. The sections are then to be made and the cord removed by either of the before-mentioned methods. The re- moval of the cord is a tedious process and one seldom necessary. It now remains to examine the extremities. This can usually be done by general inspection, unless some espe- cial dissection is required. It may be well to call atten- tion to the anatomy of a horse's leg as compared with that of the human extremities (see Fig. 4579). In the horse's leg there is but one digit in place of five ; the last phalanx is in the shape of a truncated cone, and is called the os pedis ; it has tw'o projections posteriorly, be- tween which is placed a small finger-shaped, sesamoid bone-the navicular. This bone serves as a pulley over which the tendon plays which goes to be inserted into the inferior surface of the os pedis ; it is often the seat of dis- ease causing lameness, which is, in the majority of cases, incurable. Next comes the os coronae, then the os suffra- ginis. The articulation between the two latter bones is often the seat of an exostosis and anchylosis, commonly known as ring-bone. After the os suffraginis come in the fore leg the large metacarpal and the two smaller meta- carpal or splint bones ; then the carpus, or, as it is com- monly called in horses, the knee; then the radius, with the ulna, which in horses joins tlie radius at about the lower third ; next, the humerus, which extends diagonally upward and forward, articulating with the scapula to form the point of the shoulder ; lastly, the scapula, which extends upward and backward from the point of the shoulder to the part of the neck called the withers. In the hind leg we have the third phalanx, or os pedis ; the second, or os coronae; and the first, or os suffraginis; then large and small metatarsals and the tarsus. Next come the tibia or hock, with the rudimentary fibula, and the femur. Over the femoro-tibial articulation there is placed the patella, forming what corresponds to the true knee- joint in man, and known in veterinary nomenclature as the stifle. The femur extends backward and upward, forming at its articulation with the pelvis the point of the haunch, or, more properly speaking, the hip. The points to be noticed are the condition of the hoofs, especially in the fore leg: First, as to the shape of the sole, whether it is normal or concave, or whether it is less concave than normal-a condition known as flat-foot-or whether it is convex, a condition which is the result of inflammation with consequent separation of the horn from the sensitive parts beneath. Any abrasions of the surface must be noted. The wall must be examined and any cracks or seams, especially at the toe or on the quar- ters, noted ; as must also be the presence of irregular rings which come close together in front. Any loss of substance, with suppuration of the parts beneath, should be noted. Next, any enlargement and hardening of the lateral cartilage, to be felt just above the coronary band on either side, are to be noted ; then any exostosis at or near the articulation of the os coronae and os suffraginis ; then any exostosis between the large and small metacarpal bones ; finally, any alteration above this part. In the hind leg, in addition to the above, especial at- tention should be given to the hock and stifle. The hock, as is well known, is often the seat of an exostosis with, sooner or later, anchylosis, designated as a spavin. At the back of the hock there is also oftentimes a promi- nence known as a curb, being a thickening of the cal- caneo-cuboid ligament. If it is considered necessary to examine the foot in particular the hoof must be removed, an operation which is rather difficult to perform. The leg should be sawn through just below the fetlock, placed in a vice, and sec- tions of the hoof made in front and through the sole and, if necessary, over the quarters. The horn must then Fig. 4588.-Head of Horse with Skull-cap Removed. 648 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Veterinary Exam. Veterinary Exam. be loosened at the tops by dividing it from the coronary band. Then with the blacksmith's tongs the horn can usually be torn from the sensitive parts beneath. continuous with the colon. There is no division of the colon into the large or double colon and the small or float- ing colon ; but a greater part of it is turned upon itself in such a way as to make several spiral convolutions, con- tinuing from the last convolution in a straight line to the rectum. Differences of Procedure in Animals other than the Horse. -In cattle, while the intestines are less bulky than those of the horse, the stomachs are far more volumi- nous and occupy most of the abdom- inal cavity. It is best, therefore, to remove the stomachs (together with the spleen) first (see Fig. 4588). This is best done by dividing the oesophagus, pulling the stomachs out as much as possible from the cavity, freeing the attachments to the wall, and then dividing the duodenum and allowing the mass to fall to the floor. The stomachs in ruminants (see Fig. 4589) are gener- ally spoken of as four in number-the rumen, reticu- lum, omasum, and abomasum. The abomasum, however, is the only one which has digestive functions. The rumen, the first of the stomachs, occupies three-fourths of the abdominal cavity. Incomplete septa divide the cavity into two sacs, the right and the left. The mu- cous surface is covered with papillary prolongations. It has two openings, both situated in the left sac ; one leads to the oesophagus, the other to the reticulum or second stomach. An incision made in the rumen at the entrance of the oesophagus is carried forward to the end of the cavity, and a continuation of the incision poste- riorly along the lesser curvature of the reticulum opens the oesophageal groove and enters the omasum and the posterior part of the reticulum. An incision through the floor of the oesophageal groove and through the roof of the second stomach upon which this groove lies continues the opening of the reticulum. The omasum and aboma- sum can be opened by an incision carried along the greater curvature of these stomachs. The pancreas in cattle lies in a fold of the mesentery, and its duct, which is single, empties into the intestine from fourteen to sixteen inches beyond the ductus cho- ledochus. It is better, therefore, after opening the duo- denum and examining the common bile-duct, to remove the intestines together with the mesentery and including the pan- creas. The intestines having been removed, the pancreas should be freed from its attachments and excised. The mesentery should then be dissected off and the intestines opened at the place corresponding to the mesenteric attach- ment. The arrangement of the intestine is much simpler in cattle than in the horse. The caecum is without bulges or longitudinal bands; one extremity is rounded and floats freely in the abdominal cavity, while the other is Fig. 4589.-Cow; with Abdomen Opened, a, Stomachs: b, spleen ; c, diaphragm; d, intestines. The procedure for opening the thorax is exactly like that followed in the horse. The brain is removed somewhat differently ; the frontal Fig. 4590.-Stomachs of a Cow. A, rumen ; B, reticulum ; C, omasum ; D, abomasum. bone is greatly developed at the expense of the pari- etal and occipital. The frontal sinuses are enormously 649 Veterinary Exam. Veterinary Exam. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. developed in cattle (see Fig. 4592). The horns must be sawn off at the base. A transverse cut should be made through the skull about one and one-half inch in front of the crest situated between the horns, and the cut be continued in an oblique direction backward and down- ward so as to termi- nate at the occipital foramen (line a, Fig. 4591). Care should be taken to avoid in- juring the brain. After removing the bone separated by this incision, the pos- terior part of the cerebrum and all of the superior surface of the cerebellum and pons varolii, with the medulla oblongata, will be exposed. A second transverse cut (5, Fig. 4591) will now be made in a line about one-half inch above the eyes. This will enter the cranial cavity at the anteri- or extremity of the brain. Two longitu- dinal cuts (c, Fig. 4591) must now be made, one on either side, at about one and one-half inch from the median line. The incisions thus made will be completed with the hammer and chisel and the plate of bone lifted off (see Fig. 4592). The brain will then be removed as in the horse. The directions laid down for ^post-mortem examina- tions of cattle will apply to other ruminants. In dogs, pigs, cats, rabbits, etc., the brain is removed as in the horse. In all of these animals the other organs may throughout the greater part of their length are intimately adherent, and require much care in dissecting them apart. In carnivora the intestines are very short. The small intestine, suspended at the extremity of a mesentery similar to that of solipeds, rests on the inferior abdom- inal wall. The caecum forms only a small, spirally twisted appendix. The colon is scarcely larger than the small intestine, and is neither sacculated nor furnished with longitudinal bands. In its short course it is dis- posed much like the same intestine in man ; and, as in him, may be divided into the ascending, transverse, and descending colon, which is continuous with the rectum. Field-autopsies.-What has thus far been written in this article concerning autopsy methods is upon the assumption that the operator has suitable arrangements at his disposal. In the field no such conveniences are at hand, and the operator has to get along as best he can. Very often, moreover, as the time at his disposal will not allow him to make a thorough examination of all parts of the animal, he must take the clinical history into ac- count as to which organ he may wish to examine and adopt methods in accordance therewith. If, for in- stance, the animal died from intestinal trouble the main part, and probably all, of his observations will be confined to the abdominal cavity. It is very much better in this case to have the animal upon its back. This can gen- erally be done if a stake such as butchers use can be found, with an iron point at each end ; one end can be struck into the wall of the thorax while the other is pushed into the floor or ground. If this cannot be had, blocks or fence-rails will answer the purpose fairly well. They must be placed on either side of the body as far underneath as possible. The pectoral muscles should then be divided and the four legs allowed to lie out straight upon the ground. The adductors of the thigh will then be cut across, allowing the hind legs to fall outward. The incisions in the thorax and abdomen will then be made and the organs removed as directed above. Sometimes circumstances will not allow the operator to place the animal upon its back, in which case the fore and the hind legs of the upper side should be removed and as much of the abdomen as possible cut away (see Fig. 4593). The double colon should then be straight- ened out and carried forward. The small intestine must be pulled out as far as possible, thereby putting the ligaments which attach it to the vertebrae upon the stretch. The rectum should be pulled out and allowed to fall over the back and hip (see Fig. 4593). The recto- duodenal ligament will then be exposed, together with the upper part of the liver, the spleen, stomach, pancreas, one kidney, and the organs in the pelvic cavity. The intestines must be removed first, as in the ordi- nary manner. The thoracic wall on the upper side can be removed by dividing the ribs near the sternum, cut- ting the intercostal muscles from the sternum to the ver- tebrae, and forcing each rib upward and then backward, thereby loosening the costo-vertebral articulations (see Fig. 4593). The organs in the thorax and those remain- ing in the abdomen can now be removed and examined in the usual way. If the animal died of pulmonary disease, and it is de- sired to see the thoracic organs only, the operation is comparatively simple. The fore leg should be removed, and the intercostal muscles divided the whole length of the ribs ; the ribs are then divided with the costatome or saw, near the sternum. Each rib is then removed sepa- rately, as directed above. The heart and lungs can be removed together, or the top lung may be first removed at its base, then the peri- cardium opened and the heart-incisions made, and the organ removed. The lower lung may then be removed, and with it the bronchial lymph-glands. For the smaller animals no especial modification is necessary. The modifications here described should never be used unless the circumstances are such that this method is unavoid- able. It is too common a practice among veterinarians to depend upon the clinical history in determining just how far it is necessary to carry the post-mortem exami- nation. It is always better to complete the examination, Fig. 4591.-Lines of Incision Necessary for Removal of the Skull-cap in Cattle. Fig. 4592.-Head of Ruminant with Skull-cap removed. be removed in the same order as in man. In the pig the arrangement of the intestine bears some resemblance to that of the ox. In the small intestine is an immense Peye- rian gland which occupies the posterior portion of the canal, where it figures as a band measuring from five to six and one-half feet in length. The coils of the colon 650 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Veterinary Exam, Veterinary Exam, even if it has to be done roughly. Were all autopsies made for the sole purpose of verifying the ante-mortem diagnosis very little advance in pathology would be made. Records of Autopsies.-The results of the post- mortem examinations should be recorded. When it is possible, it is best to dictate to an assistant the descrip- tion of the various appearances as the autopsy proceeds. When this is not practicable, the protocol of the autopsy should be written as soon as possible after completing the examination, while the results are fresh in the mind. The description of the post-mortem appearances should be objective. It is not sufficient simply to say that such or such disease is found, but the changes in consistence. In the middle of the neck there is a slight thickening of the skin over the jugular vein on the left side. Upon removal of the skin a distinct dilatation of the vein, about the size of the end of a man's thumb, is seen. The wall of the vessel here is much thinner than that of the adjoining part of the vein. The swelling in the hind legs is found to be of a bony nature, but the joint is not involved. The abdomen having been opened by the longitudinal and transverse incisions and the flaps laid back, the exposed peritoneum, especially the part covering the diaphragm and that extending back over the inferior wall, is found to be covered with a thin layer of connec- tive tissue, which is detached with difficulty and leaves a Fig. 4593.-Field-autopsy on a Horse. color, size, and shape, which the diseased part presents should be objectively described. The appearance of each organ examined, whether it is diseased or not, should be noted in the protocol. The following protocols of autopsies recently made by the writer are introduced to illustrate the method of recording post-mortem examinations. These autopsies are also of considerable interest in themselves. Case I. Horse: Rupture of the Stomach and of the Dia- phragm ; Chronic Peritonitis; Alveolar Sarcoma of the Peritoneum.-The subject is a gray gelding, about twenty years of age ; weight, about one thousand and fifty pounds ; in good condition ; abdomen somewhat dis- tended. There are no abrasions of the skin, save slight ones made by the friction of the harness. There is a swelling on each hind leg over the os suffraginis. The mucous membrane of the nostrils is of a purplish color ; that of the mouth and eyes, rather pale. ragged surface. The cavity contains a large amount of bloody fluid. Near the extremity of the caecum, covering an area about the size of the surface of a man's two hands, is a layer of connective tissue, which is removed with difficulty and leaves a ragged surface. A little nearer the extremity of the caecum is a tumor six inches long by four inches in width and three inches in thickness, uniformly white in color and lobulated in appearance. This mass is firmly attached to the caecum and to the diaphragm by new tissue. Otherwise, the layer of peri- toneum covering the intestine is smooth and glistening. The colon having been straightened out and, with the caecum, allowed to fall out of the cavity, the small intes- tine is seen to be in part protruding through a hole in the diaphragm into the thoracic cavity. The intestines having been placed in position for dissection, the rupt- ure in the diaphragm is seen to be about eight inches in length, extending transversely through the muscle and 651 Veterinary Exam. Vichy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. situated in the epigastric and left hypochondriac regions. The edges of the rupture are quite smooth. The spleen is partly pushed through this hole, as is also a part of the stomach. On inserting the hand into the pleural cavity through the rent in the diaphragm, this cavity is found to contain a large amount of bloody fluid mixed with partially digested food. The intestines having been removed and opened, the mucous membrane is seen to have a slightly yellowish tint. On opening the thorax the pleural cavity is found to contain at least eight to ten gallons of bloody-colored fluid mixed with a large quantity of partially digested food. The lungs are retracted so as to expose nearly the whole of the pericardium. There are no adhesions to be felt. The surface of the pericardium is smooth and glistening, as is also that of the epicardium, but be- neath the latter are many points of ecchymoses on either side of the anterior ventricular groove. The heart having been removed and examined, the en- docardium is found to be smooth and glistening; the heart-muscle reddish brown in appearance, and firm. The costal and pulmonary pleurae are smooth and glistening; the lungs, light pink in color. On passing the hand over the surface of the lungs, solid nodules can be distinctly felt in the interior of the lung-substance, which are, on an average, about the size of a pea. These nodules are few in number and scattered ; otherwise the lungs crepitate throughout. On section most of these nodules have a yellowish-white appearance, with a small, opaque, apparently caseous centre. The rest of the sec- tion shows the lung-substance of normal pink color. The large bronchial tubes contain a considerable amount of mucus. The spleen, together with the fold of omentum cover- ing the stomach, having been removed, it is examined and found to be of normal size, the capsule smooth and glistening, the substance on section dark red. The dia- phragm is now cut away from its attachment to the ribs, so as to allow it, with the liver, to fall forward into the thoracic cavity. A rupture about six inches long is seen along the greater curvature of the stomach. The cavity of the stomach is nearly empty, and the rupture is seen to be confined to the pyloric or true digestive portion. The edges of the rent are smooth, and the wall is scarcely more than one-eighth of an inch thick. On removing and opening the stomach and duodenum, the mucous membrane is seen to be of normal appearance. The suprarenal capsules are studded on their surface with hard yellowish masses, on an average about the size of the head of a pin. These little masses are yellowish throughout and do not project much into the substance of the organ. There are none of these masses in the in- terior of the capsules. The capsule covering the kidneys is smooth and glis- tening, and easily removed from the substance of the kid- ney. On section the striae are distinct; the cortex, of nor- mal thickness and color. The liver is of normal appearance. The capsule is smooth and glistening, and the substance, as seen through the capsule, dark brown, while on section the surface ex- posed presents a lighter brown appearance and the lobules are distinct. There is a verminous aneurism, the size of an English walnut, of the anterior mesenteric artery. The aneuris- mal sac is filled with a firm reddish-gray clot contain- ing numerous strongyles. The muscular tissue of the wall of the artery on the central side is hypertrophied so that it measures one-quarter of an inch in the thickest part. The dura mater is firmly adherent to the skull ; the pia mater, smooth and glistening. The substance of the brain is firm and of a faint yellow color. On section the gray and white matter are of normal appearance. The spinal cord was not examined. The nasal mucous membrane is free from ulcerations and presents no abnormalities, except a cyanotic hue. Microscopic Examination.-The nodules in the lungs show on section a centre of cells which have undergone coagulation-necrosis and which do not stain, while around the edge of this necrotic centre is a mass of lymphoid cells which stain well. Around this area is a portion where the lung-substance is completely replaced by con- nective tissue. Around the nodules is an area where the air-cells are completely or partially filled with epithelial cells and fibrine. The tumor which is described above shows, on micro- scopic examination, a basement of connective tissue rich in cells enclosing alveoli in which are contained some spindle-shaped and many round cells. Cells similar to those in the alveoli are also found scattered in the stroma (alveolar sarcoma). The nodules on the surface of the suprarenal capsules show, on examination of that organ, a structure identical with that of the rest of the organ, from which they are separated by a band of connective tissue. They are therefore partially detached portions of the gland. The clinical history of this case, as far as it could be ob- tained, is as follows : The horse began to show symptoms of sickness about 11 a.m. He stopped frequently and tried to lie down. The owner finally got him home and put him in a field. Here the horse rolled about a good deal. The owner went to dinner, and when he returned the horse was dead. It was two o'clock in the afternoon when the horse arrived at the knackery, and, happening to be there at the time, I made the autopsy immediately. From the short duration of the illness, taken together with the age of the horse and the apparent atrophy of the wall of the stomach, together with the bloody ap- pearance of the fluid in the abdomen and, in consequence of the rent in the diaphragm, in the pleural cavity also, I am led to believe that the rupture in the stomach was ante-mortem, causing death by shock. Case II. Horse: Chronic Glanders.-This animal, a bay gelding in poor condition, of about one thousand pounds weight and about fifteen years of age, was de- stroyed for the above disease. He wras killed by bleed- ing. The external lesions are as follows : There is a thick muco-purulent discharge from both nostrils ; the mucous membrane of the nostrils is pale w'here it is not ulcerated. On both sides of the septum nasi is a large red patch covering nearly all that can be seen of the septum. The mucous membrane is ulcerated over this area and is ragged at the edges. There is considerable loss of sub- stance, apparently, of the cartilage, as evidenced by the depression on the surface. There are several.smaller ul- cers to be seen in the nostril, and a few tubercles, which are raised from the surface, red on the edge, and yellow- ish white in the centre. The submaxillary glands are enlarged, hard, not ad- herent to the bone. On the left side of the neck, at about the lower third, is an enlargement about the size of a pea, movable with the skin, but which does not discharge pus when squeezed. Similar nodules are scattered over the body, some of which discharge a thick yellow pus on squeezing them, while others have already ruptured, leaving ulcers. The skin being removed, the glands in the axilla and in the inguinal region on the left side are seen to be en- larged ; those in the axilla considerably, those in the in- guinal region less so. The peritoneal cavity contains about one quart of am- ber-colored fluid ; the peritoneum is smooth and glisten- ing. The intestine, as seen in situ, is of normal steel- gray color. The lymphatic glands in the mesentery are enlarged, some of them to the size of a walnut; the larger ones are soft. There are no adhesions to be felt between the pleurae. The pericardial sac contains about a teacupful of clear, straw-colored fluid. The pericardium is smooth and glistening, as are also the epicardium and the endocar- dium. The heart-muscle on section shows a light- brown color, and is firm. The lower third of the left lung is solid, and on sec- tion shows hepatized parenchyma of uniform dark-red color, with considerable interlobular exudation near the pleura. The pleura is smooth and glistening over the 652 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Veterinary Exam, Vichy. whole of both lungs. Throughout both lungs, other than the portion which is uniformly solidified, are hard nodules, varying in size from the head of a pin to a pea, which can be distinctly felt on passing the hand over the lun^s. On section some of these nodules show a red edge with a yellowish-white centre-in some cases case- ous, in others calcareous ; others of these nodules are red throughout. Most of them shell out easily. Those which are broken down in the centre have a smooth wall. The harder ones shell out en masse. The spleen is greatly enlarged, measuring ten inches in its widest part, twenty-four inches in length, and in places three inches in thickness. The capsule is smooth and glistening. On section the spleen-pulp is of dark- red color and normal consistence. The Malpighian cor- puscles are plainly visible. There is apparently consid- erable increase of the connective tissue. There are a few nodules the size of a pin-head on the surface of the left suprarenal capsule, and more on the surface of the right suprarenal capsule. These nodules are yellowish in color and firm. They do not project far into the capsule, which is of normal dark-brown color in the cortex and of yellow color in the medullary portion. The kidneys are firm. The capsule covering them is smooth and glistening. On section the cortical striation is coarse ; the glomeruli are very plainly visible. The capsule covering the liver is smooth and glisten- ing. The substance of the liver shows on section nor- mal brown color. There are three small, opaque white nodules in the interior of the organ, which are calca- reous in the centre. The bladder is normal. There is a verminous aneurism, the size of a hen's egg, of the anterior mesenteric artery. The aneurismal sac is nearly filled with moist reddish clot containing numerous strongyles. The brain is of firm consistency. The dura mater is firmly adherent to the skull. The pia mater is smooth and glistening. On section the brain-substance shows the gray and white matter normal in appearance. The mucous membrane of both nostrils is pretty well covered with ulcers and tubercles. This condition ex- tends as far back as the larynx. Case III. Cow: Acute Contagious Pleuro-pneumonia. -An Alderney cow, six years of age, of about seven hundred pounds weight, in fair condition, died with symptoms of the above disease. The autopsy was made six hours after death. There are no external lesions. The visible mucous membranes are pale ; the abdomen is slightly distended. The peritoneum covering the walls of the abdominal cavity is smooth and glistening, as is also that covering the stomach and intestines. The capsule covering the spleen is smooth and glistening. This organ has its nor- mal gray appearance, as seen through the capsule. On section it is firm and of normal brown-red color. The stomachs are of normal color, and on section the mucous membrane is found to be normal. The pleural cavity of the right side contains two or three gallons of clear serum mixed with flakes of lymph. There are no adhesions, but the pleura of the right side is covered with fresh exudation. The pericardial sack contains about a teacupful of clear fluid. The inner surface of the pericardium and the epicardium are smooth and glistening. The heart- muscle is reddish brown in color. The endocardium is smooth and glistening. The exudate covering the pleura of the right lung is about one inch in thickness, and is mixed with serum. The right lung, throughout nearly its whole extent, is solid, greatly increased in size, and weighs forty-five pounds. On section clear serum follows the knife. The hepatized parenchyma varies in color from a very bright red to almost a black. The interlobular tissue is filled in most places with coagulated lymph, giving if a white appearance. In places, especially near the base of the lung, the interlobular substance is quite firm, giving it the appearance of increased connective tissue. In this area there is also an increased amount of grayish connec- tive tissue around the bronchus in the centre of each lob- ule. The blood-vessels, in the regions where the consoli- dated lung is blackish red, are plugged. The bronchial mucous membrane in the larger bronchi is clear. There is considerable yellowish-white exudate in the superior mediastinum, surrounding the large blood-ves- sels, the oesophagus, and the lymphatic glands. The mediastinal lymphatic glands are enlarged, cedem- atous, and on section show small yellowish-white opaque areas, having an appearance similar to the exudate in the interlobular tissue. The left lung is normal, and weighs six pounds. The pancreas is of normal size and consistence, and pale yellow in color. The intestines are of normal color, and the mucous membrane is normal. The suprarenal capsules are of normal size and con- sistence, brown in color, and on section brown in the cortex and yellow in the medullary portion. The kidneys are firm and of normal size, and the cap- sule is smooth and easily pulled off. On section the striae are a little cloudy in appearance. The bladder is of normal size and color. It is about half-full of clear, amber-colored urine. A. IF. Clement. 1 Chauveau's Comparative Anatomy of the Domesticated Animals. Translated and edited by George Fleming. New York, 1873. VICHY. This city, which is the best known and most popular of the French spas, and one of the most fre- quented in all Europe, is situated on the right bank of the Allier River, in the Department of Allier, at an ele- vation of a little over eight hundred feet above sea- level. The climate is mild and the season is long, extending from the first of May to the middle of October. During July and the first part of August, however, the weather is often very hot. There are numerous thermal springs in the place, some being natural and others artesian. The temperature of the waters varies much, running from 57° to 113° F. in the different springs. The waters are given both internally and externally, that of the Puits- Carre spring, however, being used only in baths. The most important and best known of the Vichy waters are the Grande Grille, Celestins, and Hopital, other less fa- vorite ones being the Puits-Chomel, Lucas, Puits-Bros- son, Source Lardy, Source du Parc, and Puits d'Haute- rive. There are several other springs of a similar com- position at Cusset, distant about two miles from Vichy, which are classed among the Vichy waters. The following is the composition of the three first- named of these springs, as given by Cyr in Jaccoud's " Nouveau Dictionnaire de Medecine et de Chirurgie Pra- tiques." The calculation is made in grammes per litre. Grande Grille. Cdlestins. Hopital. Sodium bicarbonate . 4.883 5.103 5.029 Potassium bicarbonate . 0.352 0.315 0.440 Magnesium bicarbonate . 0.303 0.328 0.200 Strontium bicarbonate . 0.003 0.005 0.005 Calcium bicarbonate . 0.434 0.462 0.570 Ferrous bicarbonate . 0.004 0.004 0.004 Manganous bicarbonate . trace trace trace Sodium sulphate . 0.291 0.291 0.291 Sodium phosphate . 0.130 0.091 0.C46 Sodium arseniate 0.002 0.002 0.002 Sodium borate . trace trace trace Sodium chloride . 0.534 0.534 0.518 Silica . 0.070 0.060 0.050 Total solids . 7.006 7.195 7.155 Temperature (Fahrenheit)... 107.6° 57° 86° The affections for which a course at Vichy is most com- monly recommended are diseases of the abdominal vis- cera, gout, rheumatism, and diabetes. Acid dyspepsia, the indigestion of chronic alcoholism, chronic catarrhal gastritis or enteritis in which there are no very acute symptoms, cystitis, and uric-acid gravel are among the abdominal affections for the relief of which the Vichy waters are said to be the best suited. They are recom- 653 Vlch y. Victoria. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. mended also in the treatment of chronic constipation, and to prevent the formation of gall-stones. In the latter af- fection the physicians at Vichy claim for the waters an absolutely curative power, asserting that they not only prevent the formation of gall-stones but even relieve the pain of an acute attack, restore the appetite, and cause the jaundice to disappear. In catarrhal icterus, also, and in hepatic congestion, the waters are not in- frequently resorted to, with great apparent benefit. In gout and rheumatism, and especially in lithaemia, a free use of Vichy water, even at home, is often of great ben- efit. The accommodations for visitors at Vichy are excel- lent, and the number of guests during the season often exceeds twenty thousand. The waters, as is well known, are largely exported, and artificial Vichy water, corre- sponding more or less imperfectly with the natural wa- ter, can be had at any soda-fountain. T. L. S. VICHY SPRINGS. Location and Post-office.-New Almaden, Santa Clara County, Cal. Access.-By San Jose Branch of Southern Pacific Railway or by South Pacific Coast Railroad to San Jose ; thence twelve miles by stage to the springs. Analysis.-One pint contains : Grains. Carbonate of soda 17.440 Carbonate of lime 2.878 Chloride of sodium 4.200 Sulphate of magnesia 1.500 Sulphate of lime 5.250 Oxide of iron 0.600 Silica trace Total 31.868 Cubic in. Carbonic-acid gas 29.85 Therapeutic Properties.-Very similar in composi- tion to the Grande Grille; mildly laxative and antacid. The use of the water is indicated in flatulence, lithiasis, gout, headache, etc. New Almaden is situated near the -west coast of Cali- fornia. about sixty miles south of San Francisco, and east of the Santa Cruz Mountains. The climate of this region is celebrated for its salubrity. There is a hotel at the springs. George B. Fowler. VICKSBURG. The accompanying chart, representing the climate of the city of Vicksburg, Miss., and obtained from the Chief Signal Office at Washington, is here Climate of Vicksburg, Miss.-Latitude 32° 22', Longitude 90° 53'.-Period of Observations, September 10, 1871, to De cember 31, 1883.-Elevation of Place of Observation above the Sea-level, 210 feet. Wl? BO : : : : : 3 > p Mean temperature of months at the hours of > gsssssssssaggs * " gg ..... .g^gtfgSBMp Mpn 8g?t0ttMp]| I Average mean temperature de- duced from Column A. | AA 8KMS g823£g^g8£g8 fl Mean temperature for period of ob- servation. 2&8gg S£3888$8§SS8g^ : : : : : aXaeowaabis^ | Average maximum temperature for period. * ..... Average minimum^emperature or period. 5 ..... g£8£SS2^ I S : : : : : : : : : : J ::::: : : : : : 8SS§g8«5S25Sejeg Greatest number of days in any single month on which tempera- ture was below the mean month- ly minimum temperature. £ : : : : : KSSSSStSgSSSES 1 Greatest number of days in any single month on which tempera- ture was above the mean month- ly maximum temperature. X .1 K L N O K S e. £ ■g 1 . 2 £ i. * . c go E'C oO &£ n relativ midity. rage num fair days si Ci|3 rage nu fair and .ys. .3 e Q be 2 vailing ion of wii rage ve wind per 52 8 £ O <d--' k S •< •5 Ph Inches. From Miles. January ... <0.0 71.4 9.9 6.9 16.8 5.27 N. 5.9 February .. 62.1 66.4 9.9 7.4 17.3 5.21 SE. 6.4 March 58.0 64.4 10.6 10.2 20.8 6.83 S. 6.8 April 59.0 66.3 11.8 10.8 22.6 7.12 S. 6.7 May 49.0 67.2 11.7 12.6 24.3 5.18 SE. 5.2 June 48.0 70.2 15.3 9.9 25.2 3.85 SE. 4.4 July 38.0 72.0 14.9 10.0 24.9 4.00 SW. 4.0 August 38.0 71.6 16.1 10.2 26.3 3.53 SE. 3.8 September.. 50.0 71.9 11.2 12.6 23.2 4.06 N. 3.9 October.... 59.4 71.6 10.1 14.3 24.4 3.71 N. 4.8 Novemlx'r.. 61.5 70.8 ll.l 9.5 20.6 6.05 SE. 6.2 December.. 67.0 70.8 10.2 8.8 19.0 5.28 SE. 6.2 Spring 68.0 66.0 34.1 33.6 67.7 19.13 S. 6.2 Summer.... 48.0 71.3 46.3 30.1 76.4 11.38 SE. 4.1 Autumn.... 75.0 71.4 32.4 35.8 68.2 13.82 N. 5.0 Winter 73.1 69.5 30.0 23.1 53.1 15.76 SE. 6.2 Year 91.0 69.6 142.8 122.6 265.4 60.09 SE. 5.4 introduced for convenience of reference and as a type of the climatic characteristics of the Lower Mississippi Valley. The reader's attention is called to the data of Column S, a comparison of which with those of the same column in the chart for Little Rock on the one hand, and, on the other, with those for the two Atlantic seaboard stations, Charleston, S. C., and Jacksonville, Fla., and the five Gulf stations, New Orleans, Cedar Keys, Punta Rasa, and Key West, is suggested as tending to show the re- markable freedom from wind enjoyed by the two rather low-lying valley-stations when compared with the still lower-lying coast-stations. H. It. VICTORIA. The general features characterizing the climate of the Colony of Victoria have been already set forth in the article on Melbourne (Vol. IV., pp. 705-708). In that article a reference was made to the local modifica- tions of the climatic type, and the data of the two charts herewith presented will serve in some degree to illus- trate these modifications. A chain of mountainsextend- ing from east to west across the Colony of Victoria, in 654 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vichy. Victoria. a direction approximately parallel to the coast-line, standing about sixty-five miles back from the sea and rising to an elevation of from one to five thousand feet above sea-level, is the one topographical feature of the country demanding attention on the part of anyone desir- ing to understand the chief cause for such local modifica- tions as exist in the general climate of the colohy. Beyond these mountains, to the northward, lies the great inland basin of Australia, the home and starting- point of the hot winds already described in the arti- cles on Melbourne and New South Wales. Between the mountains and the sea lies the narrow strip of coast- country-a country by no means flat throughout its entire extent ; for, as we are told by Mr. Ellery in his " Notes on the Climate of Victoria," even " along some parts of the coast-line, especially in the Cape Otway, Western Port, and Wilson's Promontory districts, the land rises to considerable altitudes (from 2,000 to 3,000 feet) by ranges generally well covered by timber to their summits." Nevertheless, in describing the country, both to the north and to the south of the "great dividing range," the same writer tells us that " it is moderately un- dulating or flat, consisting often of large plains, in some parts quite destitute of trees, but closely wooded in others; " and of the coast-line itself he says, that " it is for the most part comparatively flat, with a moderate elevation." The general topographical features of the colony, taken as a whole, and their influence upon the climate of different portions of the colony are thus summed up by the same writer: "An extensive sea- board, open to polar winds and oceanic currents, modi- fied, no doubt, by the presence of the island of Tasmania ; an extensive and wooded mountain-range running across the whole breadth of the colony, the higher portions of which are often clothed in snow ; and the generally arid subtropical Australian interior, dominating on its north- ern and western boundary, must each necessarily exer- cise considerable influence in producing conditions of climate varying with the locality." Of the two tables herewith presented, the first and larger one, Table A, is a counterpart of the table given in the article describing the climate of the neighboring colony of New South Wales. Like those in that table, its data are derived almost exclusively from Dr. Julius Hann's " Handbuch der Klimatologie." The ten stations are divided into five groups, of which the first, including five stations, represents the climate, as regards temperature, of the coast-line ; the second, in- cluding but a single station, Camperdown, may be taken as representing the coast-belt back from the immediate proximity of the sea ; the third, including two stations, typifies the transmontane region, at a short distance only to the northward of the dividing range; the fourth, including only Ballarat, shows the temperature of an elevated station close to the dividing range, but to the southward of its crest; and the fifth, including only Castlemaine, gives the temperature of a like station lying about twenty miles to the northward of the crest. The second table, presenting data copied from Mr. Ellery's pamphlet already cited, will serve to show the contrasts in variability of temperature and in humidity existing between the climate of the immediate coast, rep- resented by Melbourne ; that of the high-lying country to the south of the range-crest, represented by Ballarat; and that of the northern slope looking toward the great inland basin of Central Australia, represented by Sand- hurst. In studying these data we are struck by the slight degree of difference in regard to variability of temperature existing between three places so differently situated, while the temperature data of the first table Table A. Name of station. Latitude. Longitude. Elevation above sea-level. Distance from south coast Mean temperature. Average maximum of year. Average minimum of year. Absolute maximum of year. Absolute minimum of year. Jan. April. July. October. Year. Gabo Island Port Albert Melbourne 37° 35' 38° 38' 37° 50' S. S. S. 149° 55' E. 146° 41' E. 144° 59' E. Feet.* 40 30 91 Miles.t 65.30 65.30 66.38 61.52 56.48 58.64 50.90 46.94 47.66 56.84 55.22 56.84 58.46 56.48 57.38 106.34 30.02 111.20 2(i.96 Cape Otway Portland 38° 54' 38° 20' S. S. 143° 31'E. 141° 35' E. 300 37 61.16 66.56 57.20 62.24 49.28 53.06 53.06 59.54 55.04 60.26 108.86 108.86 Camperdown 38° 14' s. 143° 9' E. 770 30 63.14 54.68 45.68 54.32 54.68 Sandhurst Heathcote 36° 47' 36° 55' s. s. 144° 17'E. 144° 42' E. 778 789 112 95 71.24 70.34 59.36 57.38 45.86 44.42 57.56 57.92 58.46 57.38 108.14 107.60 31.10 26.42 117.50 27.50 Ballarat 37° 34' s. 143° 49'E. 1,438 62 65.30 55.04 43.16 53.78 54.32 104.36 27.86 114.08 22.10 Castlemaine 37° 4' s. 144° 14' E. 1,000 85 67.82 55.94 43.16 55.94 56.12 ♦ From Hon. R. L. J. Ellery's Notes on the Climate of Victoria. + Compass-measurements from maps of Victoria, New South Wales, and South Australia, in Putnam's Collegiate Atlas. Table B. (Table A) show, in like manner, a striking similarity in the mean temperature of places very variously situated as regards proximity to the sea, elevation above the sea- level, etc. ; so that it is evident that, while climatic con- trasts between different parts of the colony do exist, it was nevertheless quite justifiable in Dr. C. Faber (quoted in the article on Melbourne, Vol. IV., p. 706) to regard the climate of Melbourne as fairly representative of that of the whole colony. The reader desirous of a more complete understanding of the Victoria climate than can be conveyed by the meagre data of the two tables which accompany this article, is referred to Mr. Ellery's " description of a cycle of the seasons " in Victoria, quoted at length in the article entitled Melbourne ; and to what is said in that article concerning the climato-therapy of the colony it is not necessary in this place to attempt an addition. The transmontane stations are probably by far the best suited for the winter residence of invalids ; autumn and spring may be passed at Melbourne ; summer, in Australia, should not be tried by an invalid, on account of the hot winds frequently occurring during that season. Huntington Richards. j K § January February March April May June July August September October November December Greatest monthly range. CO Mean monthly range. CT 1 oooocooooooo Mean relative humidity. 1 M-1OOC-5OWOC0OO-3 Greatest monthly range. 1 * ggSSEgg^Sgg Mean monthly range. a oooooooooooo g35£g3SgSg£3 Mean relative humidity. a 3£8feft8£gp?g83 Greatest monthly range. o * £SS££S888;&8g CCOCCOC^OlOO^WiU Mean monthly range. c £ oooaoocoooco Mean relative humidity. 655 Vincetoxicu m. Viscera. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. VINCETOXICUM OFFICINALE Moench., Order Js- clepiadacece. (Asclepiad ou Dompte-venin, Codex Med.) A European perennial herb. The reddish, irregularly shaped and crooked rhizome and roots contain resin, fat, and essential oil, and, like most of the family, a purging and emetic constituent. They were formerly given for the two last-named qualities. Vincetoxicum is now de- servedly out of use. W. P. Bolles. VISALIA. [For a detailed explanation of the accom- panying chart, and directions as to the best method of using it, see article Climate, in Vol. II., pp. 189-191.] The town of Visalia, Cal., lies in the southern portion of the great inland basin which is enclosed between the Sierra Nevada Mountains on the east and the Coast Range Mountains on the west, and has its only opening toward the Pacific at a point about midway between its northern and southern extremities through a gap in the western or Coast Range wall, where the united waters of the Sacramento and San Joaquin Rivers find an exit to the ocean by way of San Francisco Bay. The Sacra- mento aiql its tributaries drain the northern half of the great valley,* the San Joaquin and its tributaries drain its southern half. Visalia lies two hundred miles southeast of San Fran- cisco (from which city it may be reached by rail), one hundred and forty miles almost due north from Santa Barbara, and about one hundred miles due south from the Yosemite Valley. According to the writer of Ap- pleton's "Handbook of Winter Resorts," the town "is situated in the midst of a forest of magnificent oaks which shelter it from the winds that sometimes sweep Climate of Visalia, Cal.-Latitude 36° 20', Longitude 119° 16'.-Period of Observations, July 1, 1877, to June 15, 1883. -Elevation of Place of Observation above the Sea-level, 327 feet. A Mean temperature of months at the hours of Average mean temperature de- * duced from Column A. > IC Mean temperature for period of ob- servation. Average maximum temperature for period. Average minimum temperature ' - for period. " E Absolute maximum temperature for period. F Absolute minimum temperature for period. Greatest number of days in any single month on which the tern- * perature was below the mean monthly minimum temperature, i Greatest number of days in any 1 single month on which the tem- m perature was above the mean H monthly maximum temperature. I January.... February... March April May June July August September.. October November.. December.. Spring Summer.... Autumn.... Winter Year 7 A.M. Degrees. 37.9 42.4 46.5 49.8 54.2 60.0 62.3 62.1 58.3 48.8 40.3 40.4 3 P.M. Degrees. 51.2 56.3 63.5 67.0 75.3 84.8 90.7 ■ 90.5 84.5 71.8 60.3 54.3 11 P.M. Degrees. 44.8 50.6 57.1 60.7 68.4 77.1 81.7 79.2 72.3 58.7 48.6 46.4 Degrees. 44.6 49.7 55.7 59.1 65.9 73.9 78.2 77.2 71.7 59.7 49.7 47.0 60.2 76.4 60.3 47.1 61.0 Highest. Degrees. 48.9 55.4 60.6 63.4 68.5 76.5 80.8 81.0 74.5 61.5 52.7 49.9 62.2 78.8 61.9 50.5 62.8 Lowest. Degrees. 41.1 45.5 49.1 56.5 63.8 71.9 76.5 74.2 67.0 56.1 46.9 44.5 56.6 74.2 57.6 44.5 59.7 ; Degrees. 54.5 59.7 67.0 70.8 80.4 91.9 97.0 95.7 88.6 74.7 62.7 56.8 Degrees. 35.0 39.3 44.3 47.7 52.0 61.4 61.5 59.5 55.6 46.2 37.8 37.4 Highest. Degrees. 70.0 79.5 91.5 91.4 101.0 109.0 107.0 108.0 102.0 95.5 78.0 73.0 Lowest. Degrees. 63.0 64.0 74.0 81.0 95.0 99.0 103.0 100.7 93.0 85.0 71.0 65.0 Highest. Degrees. 29.5 36.0 41.1 1 42.0 48.0 52.5 58.0 61.0 53.0 42.0 35.0 31.0 Lowest. Degrees. 18.0 17.1 30.5 34.0 37.1 46.0 49.0 48.5 44.0 30.0 26.0 21.5 23 29 29 18 22 28 22 24 16 24 21 25 24 22 25 26 25 20 18 24 19 21 24 21 January... February.. March April May J ft n 'o o 52.0 62.4 61.0 57.4 63.9 63.0 58.0 59.5 58.0 65.5 52,0 51.5 70.5 63.0 76.0 62.4 91.9 K o H s a 75.2 71.5 64.4 65.1 52.0 43.6 43.2 44.1 48.2 61.6 68.9 75.8 60.5 43.6 59.6 74.2 59.5 L H-q y ® o 12.5 12.0 9.5 9.5 6.7 4.6 1.6 3.2 3.4 7.2 9.0 10.3 25.7 9.4 19.6 34.8 89.5 M ® tea; > o <1 11.0 10.0 15.3 13.3 21.8 25.4 29.0 27.6 26.4 22.5 17.2 11.0 50.4 82.0 66.1 32.0 230.5 N 2^5 s a c3 £ 3 £ ®^& 23.5 22.0 24.8 22.8 28.5 30.0 30.6 30.8 29.8 29.7 26.2 21.3 76.1 91.4 85.7. 66 8 320.0 "5 g® F < 1.43 1.82 1.22 1.56 0.38 0.02 0.00 0.05 0.50 0.56 1.41 3.16 0.02 1.11 4.69 8 98 tionofwind. S S >> of S ®^§ rh 0><h * >0 3. 2.6 3.1 3.6 3.7 4.3 3.9 3.5 3.1 2.7 2.6 2.1 2.3 3.9 3.5 2.5 2.7 3.1 June July August.... September. October.... November. December. Spring Summer... Autumn... Winter Year * Amount inappreciable. mean temperature is about the same as that of New York City in April and in the latter part of October ; while Column K shows a relative humidity for the winter months at Visalia greater by several per cent, than that accompanying a like mean temperature at New York. Hence, during the winter season at least, it seems hardly permissible to grant to Visalia the possession of a " dry climate," in the strict sense of the term. Despite a very considerable nycthemeral range, indicated by the figures of Columns C and D, the less regular variations of tem- perature during the winter, spring, and fall months do not appear to be very formidable (see Columns E, F, and G) while the extraordinary freedom from cloud, the slight rainfall, the absence of extremes of low tempera- ture, even in January, and the wonderful freedom from wind certainly combine to render the climate during the winter, spring, and fall a desirable one for many in- valids. The sunshine record of Visalia far surpasses that of Denver, Col. The irregular variations of tempera- ture at Visalia appear to be less decidedly marked than they are either at Denver or at Colorado Springs, and the regular daily range is also less at Visalia than it is at Denver or at Colorado Springs ; except during the hot season, beginning with June or the latter part of May and over the broad San Joaquin plains ; " while its climate is described as " dry and healing," and as particularly beneficial to persons suffering from diseases of the throat. Columns C, D, E, and F of the accompanying chart (the data of which were furnished by the United States Chief Signal Office) show that Visalia's climate is decidedly variable so far as equability of temperature is concerned, and Column AA shows that in winter its * The most striking, and the most disagreeable, phenomenon of the San Francisco summer climate-to wit, its daily recurring cold, fog-filled, and dust-laden sea-wind-is entirely due to daily heating by the sun's rays of the air overlying this inland basin, and to the inrush of colder air through the only gap existing in the sea-wall of the basin, which gap, unfortunately for summer dwellers in San Francisco, lies almost directly back of that city. 656 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vincetoxicum. Viscera. ending in October, when the reverse is true, viz., that the daily range of Visalia becomes greater, and far greater, than that either of Denver or of Colorado Springs. As regards freedom from wind, the climate of Visalia is simply extraordinary, and is infinitely superior to that of the Colorado stations just mentioned. In mildness of winter temperature it is greatly their superior ; in dry- ness, and, of course, in " elevation," it is inferior to both. Huntington Richards. VISCERA, HOLLOW, MEASUREMENTS OF. The formation of a standard of measurements for the hollow viscera of the human subject is attended with the diffi- culty that the viscera themselves are variable in size, even in the same individual. A cavity or tube with soft, yielding, elastic, muscular walls, allowing expansion and contraction within wide limits, must be always changing in size with the changes in its solid, liquid, or gaseous contents. There cannot, therefore, be any fixed, deter minate standard ; but the size must be said to be about thus and so, varying not only with the conditions just stated but with the development of the individual. Any consideration of dilatations due to obstruction below, or of abnormal contractions due to disease of the part itself, is outside the scope of this article ; but these variations il- lustrate well the degree which expansion or contraction may attain. The basis of this article is mainly the work of previous investigators, supplemented by some work of my own. The latter has, however, been restricted by the season of the year in which this article is prepared. In determin- ing what should be considered hollow organs there was some difficulty, since all the vascular and mucous canals might be included. I decided to limit the article to the subjects mentioned below ; and, at the suggestion of the editor, have added the maxillary sinus. For measure- ments of the nose, mouth, heart, and womb and its ap- pendages, I would refer to the special articles in this Handbook, and to monographs and text-books treating of those organs. Much valuable information is obtain- able from Cruveilhier, Cloquet, Quain, Allen, Holden, Mackenzie, Todd and Bowman, and Richardson. Measurements of diameters may be understood as in- cluding the walls of the cavity or canal, which are usu- ally so thin as practically not materially to alter what, at the best, are variable results. In some cases, as in the investigations of Mackenzie on the oesophagus, plaster- of-Paris was run into the viscus and allowed to harden. The measurements were then taken upon the mould. I had intended to repeat some of the experiments with paraffine, wax, etc., but have not had the opportunity. Whatever material is used for filling or injection, it will, of course, be necessary to support the organ in water or other fluid, to prevent misshapement; even then I sus- pect that the best obtainable results would be only ap- proximately correct. The pharynx is a bag-like canal, closed above but con- tinuous below with the oesophagus, communicating in front with the nose, fauces, and larynx, and lying at the back against the first five cervical vertebrae. Its oeso- phageal end is usually opposite the cricoid cartilage in front and the body of the fifth cervical vertebra behind. Its length and diameters vary according as the organ is in a state of rest, or as deglutition or speech is taking place. It is subdivided into three portions: A nasal portion, or the naso-pharynx ; a buccal and guttural portion, or the oro-pharynx ; and the laryngo-pharynx. In the modula- tion of the voice the oro-pharynx is the part almost ex- clusively affected ; in deglutition, movements of both oro- and laryngo-pharynx take place. The length is usually stated to be from 4 to 4| inches (10 to 11| ctm.), which may be increased to 5|, or even 6| inches (14 to 16^ ctm.), by distention, or reduced to 21 inches (6£ ctm.) in the greatest possible contraction. Mackenzie gives the maximum length at about 5, and Allen at 5| inches (121 to 14 ctm.). Allen gives the length of the naso-pharynx at 11 to 2 inches (4 to 5 ctm.). The breadth varies in different parts. The superior transverse diameter, measured between the posterior margins of the internal pterygoid plates, is, according to Mackenzie, 1.6 inch (4 ctm.), to Cruveilhier, 1 inch (2| ctm.), and to Allen, 8 lines (16 mm.). This diversity of measurements shows wTell the great variation in size in different subjects. The diameter of the buccal portion, taken between the posterior extremities of the alveolar borders, is, accord- ing to Cruveilhier, about 2 inches (5 ctm.), but may be reduced to 1 inch by the contraction of the constrictors. The widest part of the laryngo-pharynx, opposite the greater cornua of the hyoid bone, measures 2 inches (5 ctm.). Cruveilhier, however, measuring between the summits of the greater cornua, found but 1 inch and 2 lines (3 ctm.) ; and between the superior cornua of the thyroid cartilage, 1 inch and 2 or 3 lines (3 ctm.). [A comparison of hyoid bones in different adults has given me distances, between the summits of the greater cornua, varying from 1,^ inch (33 mm.) to 1{§ inch (41 mm.).] The narrowest part, opposite the cricoid cartilage, is about 1 inch (2^ ctm.). Cruveilhier gives the breadth in the interval between the inferior cornua of the thyroid cartilage as about 11 or 12 lines (2| ctm.); muscular contraction here may obliterate the cavity. The antero-posterior diameter varies less than the ver- tical or transverse. It is increased when the larynx is carried upward and forward, and diminished when it is carried upward and backward ; generally, it may be said to depend on the length of the basilar process of the oc- cipital bone. Mackenzie gives it as f inch (20 mm.) for the naso-pharynx. The oesophagus varies in length according to the stat- ure of the individual. The canal extends from opposite the fifth cervical vertebra to the level of the tenth dor- sal. In the adult male it is from 9 to 11 inches (23 to 28 ctm.) in length. The diameter varies at different levels. It is narrow- est at the beginning, opposite the cricoid cartilage, and becomes narrowed also somewhat in passing through the diaphragm. Allen states that it is narrowed at the beginning of the thoracic portion, being there 1 inch (2| ctm.) in diameter. Mouton and Mackenzie made elabo- rate measurements, which show, among other things, that the transverse diameter is much greater than the antero- posterior. A comparison shows the transverse diameter at the beginning of the canal to be from f to 1 inch (21 to 25 mm.) ; six inches below this point, | to | inch (18 to 21 mm.). It then steadily increases until it reaches a point 16 inches from its origin, where it is about 1 inch (25 to 27 mm.). It is from $ to 1 inch (16 to 25 mm.) where the tube passes through the diaphragm, and then increases slightly. The antero-posterior diameter at its origin is | to inch (10 to 14 mm.); at one-third of its length below, | to t inch (12 to 19 mm.); at a point two-thirds of the way down, $ to | inch (15 to 20 mm.); at the lower end, to 1 inch (14 to 25 mm.). The method of examination is to fill the oesophagus with plaster-of-Paris. The stomach is a very mobile and distensible organ, is subject to prolonged distention, and may also contract much when empty. It is much larger in those who eat but one, and that a full, meal a day. In certain diseased conditions, as in stricture of the pylorus, it may become enormously distended. In long-continued abstinence it becomes much contracted. As the result of the action of strong acids, it is said to have contracted to the size of an ordinary gall-bladder. Its length, from the cardiac cul-de-sac to the pylorus, is from 9 ter 12 inches (23 to 30 ctm.); Todd gives it as from 13 to 15 inches (33 to 404 ctm.). The widest di- ameter is between 4 and 5 inches (10 to 12| ctm.) ; at the pylorus it measures 2 inches (5 ctm.), and for the whole organ 4 inches (10 ctm.). The total surface is about 1^ square foot ; capacity, about 175 cubic inches or 5 pints (24 litres) ; Allen estimates the capacity to be 62 oz. The greatest circumference is 13 inches (33 ctm.); the smallest, 3 inches (74 ctm.). The small intestine. It is probably impossible to 657 Viscera. Vision. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. measure the length of the small intestine with anything more than an approach to accuracy, because of its con- voluted shape. After the mesentery is cut away prelim- inary to the measurements the intestine becomes length- ened immediately on manipulation, so that the length is greater than it was before the section. The calibre, too, is very variable, according to the increase and decrease of gaseous and other contents. Its length is usually stated at 20 to 25 feet (6 to 74 metres). Its calibre gradually diminishes from the beginning to its point of junction with the large intestine. Some of the older anatomists, as Cruveilhier, stated incorrectly that the intestine was funnel-shaped. Sometimes, in ob- struction of the bowel, it becomes enormously dilated ; and at other times may be exceedingly contracted. When distended it is cylindrical; when empty it may be elliptical. The duodenum extends, in the shape of a horseshoe, from the pyloric end of the stomach to the left side of the second lumbar vertebra, opposite the superior mesen- teric artery and vein. It is named from its length, which is equal to the breadth of 12 fingers. Most authors give the length as from 10 to 12 inches (25 to 30 ctm.) ; Cru- veilhier and Richardson make it 8 or 9 inches (20 to 224 ctm.). It may be subdivided into three portions. The first, the ascending or hepatic, extends horizontally backward and to the right, and joins the second portion near the neck of the gall-bladder ; it is about 2 inches (5 ctm.) long. The second, or vertical portion, uniting at an angle with the first, descends vertically and a little toward the left, as far as the third lumbar vertebra. Its length is from 2 to 3 inches (5 to 74 ctm.). The third, or lower transverse portion, directly continuous with the second, is the longest and narrowest of the three ; its length being from 3 to 4 inches (74 to 10 ctm.), or, ac- cording to Todd, 5 inches (124 ctm.). The calibre of the small intestine is 1J to 2 inches (3 to 5 ctm.). My own measurements in the adult have given 14 to 1J inch (28 to 31 mm.), and in the new-born in- fant J inch (6 mm.). The circumference, as measured by Cruveilhier, was from 5 to 64 inches (124 to 16 ctm.) at the beginning of the small intestine, 4| inches (104 ctm.) at the middle, 34 inches (nearly 9 ctm.) a little above the ileo colic valve, and 44 inches (114 ctm.) at the valve itself. The large intestine, after removal from the cadaver, may readily be measured along its tapes. Its length is from 4 to 6 feet (1| to If metre). Distention is said to diminish the length. Its diameter gradually diminishes from its beginning to the end, except that there is a considerable dilatation just above the anus. In a general way, it may be stated to be from 14 to 2f inches (34 to 7 ctm.). The measurements of the individual parts are as fol- lows : The caecum is the largest part of the large intestine (it is small in the carnivora, large in the herbivora). Its length is 3 or 4 fingers'-breadth, from 2 to 4 inches (5 to 10 ctm.). Its diameter is about the same as the length. Cruveilhier made two measurements of its circumfer- ence, the caecum being moderately distended ; just be- low the ileo-colic valve it measured 11 inches and 3 lines (284 ctm.); in another subject, 94 inches (164 ctm.). The vermiform appendix varies greatly in length, being from 1 to 6 inches (24 to 15 ctm.). Its diameter is usually given as that of a crow-quill or goose-quill-about one- third of an inch (8 mm.). It is a little wider at the caecal junction. The ascending colon is about 8 inches long (20 ctm.); the transverse colon, 12 inches (30 ctm.) ; the-descending colon, 11 inches (274 ctm.); and the sigmoid flexure, 22 inches (56 ctm.). Cloquet states that the transverse colon is longer and larger than the ascending and de- scending portions, which are about equal to each other. The diameter of the ascending portion is less than that of the caecum, and greater than that of the transverse colon. The circumferences of the parts, according to Cruveilhier, are as follows : The ascending colon and right half of the arch, 8 inches 9 lines (22 ctm.) in one subject, 5 inches (12| ctm.) in another ; of the left half of the arch and descending colon, 6 inches (15 ctm.) in one, and 5| inches (14 ctm.) in the other. The sigmoid flexure was 5| inches (13| ctm.) in circumference. My own measurements give a diameter of from If inch (40 mm.) to 2| inches (64 ctm.) for the ascending and transverse portions and sigmoid flexure, and f inch (18 mm.) for the descending portion, which, in my experi- ence, is generally collapsed. In the infant, at term, the diameter of the colon was one inch (2| ctm.). The rectum is from 6 to 8 inches long (15 to 20 ctm.). The first portion, from opposite the sacro-iliac joint to the middle of the sacrum, is about 3 inches (7| ctm.) long ; the second portion, to the end of the coccyx, 2| to 3 inches (6| to 7| ctm.); the third portion, 1 to 1| inch (2| to 4 ctm.). Its diameter in the upper part is the same as that of the colon, gradually increasing downward and finally contracting suddenly. Quain says that the upper part is narrower than the sigmoid flexure. According to Cruveilhier the circumference is 3 inches (7| ctm.); in the lower part, 4 to 5 inches (10 to 12| ctm.). The gall-bladder is from 3 to 4 inches long (74 to 10 ctm.) ; and its diameter, at the widest part, is from 1 to 1| inch (24 to 4 ctm.) ; in the infant, at term, 4 inch (12 mm.). Its capacity is 4 to 14 ounce (48c.c.); it varies very much, and in some diseases may amount to 6 ounces (192 c. c.). The ureter measures 12 tol8 inches (30 to 45 ctm.) in length. In diameter it is equal to a crow-quill or goose- quill ; the most contracted portion is in the substance of the bladder. The urinary bladder is of a somewhat pyramidal shape ; in a fairly dilated condition it measures about 5 inches by 3 (124 by 74 ctm.); and its capacity is about one pint (4 litre), or, according to Allen, from 6 to 13 ounces (4 to $ litre). The female bladder is broader transversely and more capacious than the male. This may be partly due to the fact that women are more influenced by the customs of society than are men ; and it is broader, also, more often in women who have borne children. The bladder is said to be relatively larger before than after birth, and rela- tively smaller in children than in adults. This also may be due to habit. The temperament, nature of diet, temperature of the air, and position of the body, all may affect the size of the bladder. The vagina of the unimpregnated woman averages 4 inches (10 ctm.) on the anterior wall and 5 to 6 inches (124- to 15 ctm.) on the posterior wall ; according to Allen, the tube is 24 inches (64 ctm.) long, its posterior wall be- ing 5 lines (12 mm.) longer than the anterior. The walls may be separated in the virgin about one inch (24 ctm.). The larynx is said to be one-third larger in the male adult than in the female. The average length of the vocal cords is, in the male, 7 lines or f inch (14 mm.); in the female, 5 lines (10 mm.). The measurements in a number of male subjects did not vary the twelfth of an inch. In females the cords are about one-fourth shorter than in the male. The average length of the glottis is, in the male, 11 lines (23 mm.); in the female, 8 lines (16 mm.) The transverse diameter of the glottis is, in the man, 3 to 4 lines (6 to 8 mm.) ; in the woman, 2 to 3 lines (4 to 6 mm.). Mackenzie gives the diameter as 4 inch (12 mm.); in boys it is much less. The trachea extends from opposite the fifth cervical vertebra to the second or third dorsal. Its length is from 4 to 5 inches (10 to 124 ctm.), varying with the eleva- tion and depression of the larynx and the extension and flexion of the neck. There is a difference of from 2 to 24 inches (5 to 74 ctm.) between full extension and extreme contraction, the contraction being limited by the con- tact of the rings. Its diameter is directly related to the capacity of the lungs, and is greater in the male than in the female ; it is about the same throughout its whole extent, varying according to age and individual peculiarities, and is from I to 1 inch (18 to 25 mm.). In a man, aged about ninety, whose trachea I measured, it was wider in the middle 658 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Viscera. Vision. (namely, 1| inch or 31 mm.) than above or below, where it was 1 inch (25 mm.); antero-posteriorly the upper part measured 1 inch (2| ctm.), the lower part J inch (18 mm.). The right bronchus is about one inch long (2| ctm.); the left, 2 inches (5 ctm.). The right is much wider than the left, its diarheter being nearly as great as that of the trachea itself. In one woman whose trachea I meas- ured, the diameter was 10 lines (20 mm.); the right bronchus was 8, the left, 5 lines (16 and 10 mm.). The maxillary sinus, or antrum of Highmore, varies greatly in capacity ; it is relatively small in the young and large in the old. In a number of skulls of adults I found it to vary on the two sides. From its irregular shape I made no attempt to take its diameters, but only its capacity, which I obtained by crowding raw cotton against its connecting foramina and filling the sinus with mercury. In many measurements the capacity was found to be from 10 to 12 c.c. (2| to 3 drachms); in a few it was as low as 8| c.c., and in others as high as 15 c.c. (2.7 and 3.75 drachms). The external auditory meatus consists of a bony and of a cartilaginous portion. According to some authors these are nearly equal in length ; others, as Allen, state that the bony portion is twice the length of the other. The entire canal is about f to 1^ inch (18 to 37 mm.), a little longer on the floor than on the roof, because of the oblique direction of the tympanic membrane, the ante- rior wall and floor extending 3 to 4 lines (6 to 8 mm.) farther inward. The diameter varies very much. In some subjects the end of the little finger can be passed in for quite a dis- tance ; in others the canal will hardly admit a goose- quill. It is not of equal diameter throughout; narrow- est about the middle, although Allen states that it is widest at the junction of the bony and cartilaginous portions. The external portion is flattened from before backward, so that the vertical diameter (nearly i inch or 11 mm.) is nearly double the antero-posterior (J inch or 6 mm.). The middle portion is more cylindrical. The internal portion is flattened from above downward, mak- ing the antero-posterior diameter (f inch or 9 mm.) greater than the vertical (J inch or 7 to 8 mm.). The tympanic cavity communicates in front with the Eustachian tube, and behind with the mastoid cells. Its diameters are as follows : Antero-posterior, about } inch (12 mm.); Toynbee says, 4 inch (18mm.); the transverse diameter varies, in different portions, from to } inch (2 to 12 mm.), it is narrowest in the middle; the verti- cal diameter is | to | inch (6 to 12 mm.). The Eustachian tube connects the tympanum with the pharynx. It consists of an osseous and cartilaginous portion. The osseous portion varies very much in length, according to different observers, ranging from i to 1 inch (12 to 25 mm.); Allen says 14 lines (about 28 mm.). The length of the cartilaginous portion is about 1 inch (25 mm.) ; total length of tube about 1| inch (37 mm.) ; Toynbee and Cruveilhier say 2 inches (50 mm.). The pharyngeal orifice is wide and dilatable ; elliptical in shape ; about $ inch (12 mm.) in diameter. The re- mainder of the tube is so constricted that it barely ad- mits an ordinary probe. Sappey gives its vertical di- ameters as follows : Tympanic orifice, 5 mm. ; at osseo- cartilaginous junction, 3 mm. ; in middle of tube, 4 to 5 mm. ; at pharyngeal orifice, 6 to 8 mm. Transverse di- ameters : Middle of osseous portion, 3 mm. ; osseo-carti- laginous junction, 1 to 2 mm. ; middle of cartilaginous portion, 3 mm. ; at pharyngeal orifice, 5 to 6 mm. The mastoid cells vary very much in size in different individuals and at different ages, being always small in youth. In some individuals they occupy the entire in- terior of the bone behind the external auditory meatus for H inch (37 mm.) and have a vertical diameter of 2 inches (50 mm.). They are usually subdivided, and com- municate anteriorly with the tympanic cavity. The nasal duct, including the lachrymal sac, is about 1 inch long (25 mm.), the sac and duct proper being nearly equal in length, namely, about 1 inch each (12 mm.). The duct proper is directed downward, backward, and a little outward ; is rather ovoid in section ; its diameter varies greatly and is smaller than that of the sac ; it va- ries also on the two sides of the same individual. The upper part averages about | inch (2 to 3 mm.); the lower part is about half a millimetre wider. Noyes found in one case that the duct on one side was round and | inch (3mm.) in diameter; on the other, oval, and | inch (6 min.). The nasal terminus is somewhat dilated. The frontal sinuses vary much in size in different indi- viduals, and on the two sides of the same. They are always small in youth. The right and left are generally entirely separate, but sometimes communicate through a small opening. They are often subdivided into smaller cavities. My own measurements of capacity gave the following results : The right, | to 1| drachm (H to 6 c.c.); the left, £ to drachm (H to 4$ c.c.). As showing the dif- ference, sometimes, of the two sides, I found in one case that the left sinus was to the right as 70 to 95. Perhaps the best idea of the size they sometimes attain is formed from the fact that the larvae of insects, living centipedes, musket-balls, etc., have been found in these sinuses. D. S. Lamb. VISION, FIELD OF. The field of vision is the entire surface from which, at a given distance, light reaches the percipient part of the retina, the eye being station- ary, and the other eye being closed or otherwise ex- cluded from the visual act. This extent of space is called the unilateral or uniocular visual field. The vis- ual fields of the two eyes overlap only at their inner and central parts, so that binocular vision is impossible in the outer part of the field. Direct or central vision is confined to vision at the ma- cula lutea, within the physiological limits of the fovea centralis. Indirect or eccentric vision refers to vision at the eccentric or peripheral parts of the retina. According to Landolt, the limits of the visual field are given by the most distant points of the visual line which are capable of producing a luminous sensation, and they are dependent on several factors, as follows : 1. The eyelids ; the widening of the interpalpebral aperture by the lifting of the upper lid and the retreat of the com- missure enlarges the visual field in the corresponding directions. 2. The upper margin of the orbit, the eye- brorcs, the nose, and the inferior margin of the orbit may produce a marked limitation of the visual field, and the deeper the eye lies in the orbit the more pronounced will be this limitation. 3. The relative situation of the plane of the pupil to the margin of the cornea ; the farther the plane of the pupil is situated in advance of the corneal margin the wider will be the visual field. 4. The diam- eter of the pupil exerts a great influence upon the limits and functions of indirect vision ; other things being equal, the wider the pupil the more extended will be the visual field. Landolt, on the contrary, in experi- menting on his own eyes, found that his visual field was no wider in maximum dilatation of the pupil by atropia than it was in the maximum contraction produced by eserine. It may be conceded that the pupil does not modify the direction of the luminous rays which enter the eye, but it does modify their quantity. Charpentier has found that on examining the visual field of his own eye, after contraction of the pupil by a solution of eser- ine, the field had diminished in extent for each color of the spectrum, most for blue, less so for green, and least of all for red. The central sensibility was also dimin- ished, owing to the suppression of a certain number of luminous rays entering the pupil, but much less so than the peripheral sensibility. 5. According to Liebreich the visual field is widened during the act of accommodation, probably because the refracting power of the lens is in- creased, and the pupil approaches the cornea. 6. The shape of the eyeball influences the width of the field of vision. In an elongated eyeball the peripheral parts of the retina are situated farther from the plane of the pupil than in an eyeball in which the antero-posterior diameter is shortened. In the first case the peripheral 659 Vision. Vision. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. rays of light fall on a non-sensitive portion of the retina, while in the second case they fall upon a sensitive por tion. Uschakoff and Reich have in fact shown that the visual field is usually wider in hypermetropes than in myopes. 7. The extent of the sensitive part of the retina.- Uschakoff and Bonders have shown that the retina ex- tends farther forward on the nasal side of the eye than on the temporal, and that the peripheral zone of the temporal side of the retina is non-sensitive. Hence the visual field cannot extend as far on the nasal side as on the temporal side. Methods of Measuring the Field of Vision.-The primi- tive method of measuring the visual field consisted in making the patient fix a point situated in a vertical plane, on a level with his eye. On this plane objects were caused to move about in different directions as far as the limits when they ceased to be distinguished. These ex- treme points, connected by a line, were supposed to give the limits of the visual field. The campimeter of De Wecker is constructed on this principle. The apparatus consists of a vertical black-board, about one metre square. To this black-board is fastened a sup- is that the observer must stand behind the patient, and cannot therefore control the latter's fixation. If all the points of a retina are to be examined at equal distances, the test-objects should be on a spherical surface con- centric to the eye. This principle was first put in prac- tice by Aubert and Forster, and the instrument con- structed by Forster was called a perimeter. This consisted of a semicircular arc of brass, mounted on a stand. This arc was two inches wide and curved at a radius of twelve inches; and it revolved around a central axis, which permitted its being placed in different meridional posi- tions. Each half of the arc was divided into 90° ; 0° be- ing situated in the middle of the central axis, and 90° at each extremity. The object for testing the field con- sisted of a small black, movable knob having a white centre, which could be rapidly run along to any point of the arc by means of strings worked from behind by a winch. At the back of the central axis was a graduated disk, on which a needle indicated the various meridians in which the arc is placed, and its inclination to the ver- tical meridian ; also the degrees from 0° to 180° within these meridians. Small circular maps, which are copies of the disk and of the degrees of latitude within each meridian, accompany the instrument, and on these skele- ton-maps the extent of the field in any given case can be readily traced. In examining the field of a patient, the latter must fix with the open eye a little button placed 15° to the inner or nasal side of the centre, so as to bring the blind spot op- posite the latter. A modifica- tion of Forster's perimeter has been devised by Mr. Brudenell Carter, which consists of a sim- ple tripod supporting a hollow' stem (Fig. 4595, A) in which a second stem (B) moves up and down, and can be fixed at any desired height by the screw(C). At the top of the stem (B) is a short horizontal axis (D), carrying the quadrant (E E ), which turns in a com- plete circle, but remains wherever it is placed. On the quadrant is a travelling slide (F) with a white spot; and a second independent axis is inserted in the axis of the quadrant at G, and carries a short tube in which may be placed a stem to support the fixing point. The second or inner axis makes a complete revolution without affecting the position of the quadrant, and without being affected by it. At its attached extremity the quadrant terminates in a circular disk (E') which is graduated in degrees at the back, and a fixed index allows the exact position of the quadrant to be read off. The quadrant is also graduated from ten degrees to ninety on its concave face. The fixing point may be either an ivory knob at the end of a wire, or a small disk with a central perfora- tion, as shown at H, through which the patient looks at an object on the other side of the room, and thus does away with the fatigue of accommodation. The travelling slide (F) may be made to carry a spot of any color or size desired, and is furnished with a ring at the back by which it may be moved without the hand of the operator being seen. The perimeter devised by Scherk consists actually of a hollow hemisphere, w'ith a radius of one foot, attached tangentially to a vertical rod at its pole, blackened inside, and divided into meridians and concentric circles. The hemisphere is divided in the vertical meridian, and the two quadrants can be pushed aside from each other to admit of more light. Landolt's perimeter consists essen- tially of a metallic semicircle of thirty centimetres radius, Fig. 4595.-Brudenell Carter's Modi- fication of Forster's Perimeter. port for the chin, the graduated standard of which indi- cates the distance of the eye from the black-board. In the centre of the black-board a small white cross is painted, and as this constitutes the object of fixation, it should be at the level of the patient's eye. Metallic wires radiate from the point of fixation in every direc- tion to the frame of the black-board, and on these wires are small ivory balls, which can be made to glide along the wires by mechanical arrangement behind the black- board from the periphery toward the centre. These little balls are white on one side and black on the other. By this method it is easy to determine the exact point on each wire where the white ball is first perceived. The ball is then turned round so that the white side is con- cealed. When the examination is completed, the visual field is thus found mapped out on the board. One objection to this method of examination is that different parts of the retina are examined at different dis- tances, owing to the black-board being a plane surface. A visual field which, in the normal condition, extends in several directions to 90° and upward can never be cor- rectly circumscribed upon a plane surface, since the tan- gent to 90° is infinite. Another objection to this method Fiq. 4594.-De Wecker's Campimeter. 660 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vision. Vision. blackened on its inner surface, and graduated on its pos- terior surface in degrees ; the zero of the division being at its summit or apex. The arc is joined at its apex to a vertical standard, around which it may be rotated in a complete circle. The position of the arc is marked by a pointer, and the two move together around a dial which is fastened to the posterior surface of the head of the standard. Two mov- able black frames are attached to the arc, destined to hold ec- centric objects, such as figures, or bits of white or colored pa- per. The distance of the test-object from the summit or apex scheme for preservation. The other side of the black- board is divided into a system of rectangular co-ordinates, so that if desired the visual field may be measured on a plane surface. The diopsimeter of Houdin for exploration of the visual field, consists of a small wooden cylinder, at one end of which is a sort of shell for the reception of the eye of the patient, and at the other end is a graduated dial. The needle of this dial is so placed as to maintain a vertical position, and thus give the degrees of inclination to the horizon of the movable stem. In the middle of the cyl- inder is a little tube, 2 or 3 millimetres in diameter, which runs through its entire length. This tube is designed to determine the fixed position of the optical axis, a wafer placed upon the wall in front of the observer serving as the object of fixation. The cylinder is freely movable around its axis, and contains a slit about six millimetres wide. In this opening, supported upon two arms, and in the plane of the slit is a movable ivory band, which may be placed in all meridians from the axis to 160° from the axis. The movements are measured upon the dial, and the movements in this plane and that of the cylinder itself around its own axis, by their combinations, may place the ivory ball in all meridians of a sphere concentric with the eye. Badal's perimeter likewise consists of a tube with lateral slit, and a movable portion for measur- ing the inclination of the meridians. To this is added a quadrant of a circle, with a radius of 15 centimetres, placed on end at one extremity of the tube. The other end is bell-shaped and is placed against the eyelids. The quadrant is graduated in spaces of 5° up to 90°, and on the quadrant runs a cube the four sides of which are painted a different color-white, red, green, and violet- which may be presented in turn toward the eye of the patient. Beyond the disk is a tube by which the instru- ment is to be held. During the examination the patient holds the instrument by the handle, while the bell- shaped end is placed against the eye to be examined, the other eye being kept closed. The examiner stands be- hind the patient and moves the ivory cube until it is seen of the arc is indicated on the subdivisions of the latter. The eye of the patient should be placed at the centre of the hemisphere described by the arc. For this purpose a second standard, smaller and shorter than the first, is placed in front of the latter. It is destined as a support for the head, and has at its upper extremity a support for the chin, which is suffi- ciently broad to admit of the chin being placed on the right or left of a small shaft or stem which rises from the top of the standard. The upper end of this stem is curved forward and rests against the inferior orbital margin of the eye under examination. The stem itself is immova- ble, but the chin-support may be raised or lowered as may be desired, and may also be rotated round its vertical axis to avoid causes of error due to prominence of the nose or of the superior orbital margin. The observer stands in front of the pa- tient and moves eccentric objects along the arc from its extremities toward the apex, while he notes the degree at which the patient begins to see the object. Dr. W. H..Carmalt, of New Haven, has devised a modification of Forster's perimeter, which is of very simple construction, and has the great ad- vantage of being of very moderate cost. A de- scription of this instrument may be found in the " Transactions of the American Ophthalmological Society " for 1879, and also in the fourth Ameri- can edition of J. Soelberg Wells's "Treatise on Diseases of the Eye," 1883. The apparatus employed by Snellen is a com- bination of the perimeter and black-board. The black-board is placed vertically, and to the mid- dle of this is attached a flat semicircle of metal, rotating round its apex. Opposite, and at a dis- tance of 35 ctm., arise two supports for the eyes of the patients. By means of a branch, the sup- port of one inferior orbital margin is connected with a similar support for the other eye, and thus the head is fixed. This support may be rotated round its vertical axis, so that the little apparatus serves equally well for measuring the field of both eyes. The metallic semicircle is used precisely as the perimeter is used, but the surface of the black-board is divided throughout its whole extent into tangents to the hemisphere, and serves to represent anomalies of the visual field situated within 45° of the point of fixation. The projection diminished 25 diameters and transferred to paper by means of a stamp reproduces the same Fig. 4596.-Boudin's Diopsimeter. Fig. 4597.-Meyer's Perimeter. by the patient. The figures inscribed upon the quadrant and on the movable disk give the meridian in which the examination has been made, and the limit of the vis- ual field in the corresponding meridian. Meyer's perimeter combines the advantages of the field- measurement and of perimetry. The instrument con- 661 Vision. Vision. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. sists of a quadrant which, rotating round its summit, describes a hemisphere, at the centre of which the pa- tient's eye is to be placed, and should be fixed on the mark at the apex of the arc, the other eye being closed. The arc of the perimeter being placed in a given plane, the observer moves the carriage (C) slowly from the pe- the visual field is very different. The instrument con- sists of a strong brass wire, blackened, starting from the point of central fixation and running in an increasing spiral until a well-supported concave hemisphere of 25 centimetres radius is found. This is firmly supported by a vertical iron pillar, at the base of which is a crank, so placed as to be conveniently reached by either patient or surgeon. Inside this wide hemisphere is a curved arm of hard rubber, which is revolved by the crank fixed to the base of the pillar. On this arm is a traveller which follows the wire, sliding in a slot running the length of the arm. On the traveller is fastened the ec- centric object. A double chin-rest insures the fixation of the eye in the centre of the hemisphere. The degrees are marked on both sides of the arm and the periphery, so as to be read from any position. The movement of the instrument is inside the pillar, and the spindle (A) which carries the rubber arm also moves a registering apparatus at the back. The latter consists of an arm (B) to which is attached a pencil-point (C). This point is, guided by a groove in the back-board (D), which is a plane spiral, having the same number of turns as the spiral of three dimensions which guides the white spot on the arm of the instrument. The chart is attached to the shelf (E), and can be pressed at will against the pencil-point when passing over a scotoma. The method of examination is as follows : The patient is seated before the instrument, with his chin in the rest and his eye fixed on the central object. The eccentric object is started from the periphery by the crank, and, following the wire, moves in ever-decreasing circles until it reaches the centre. If the object is perceived throughout its entire course, any limitation of the field, central or eccentric, may be excluded. The object slides in a groove on the traveller, so that it will meet the half- distance between any two wires. In this way any and every point of the field can be tested. The meridian is indicated by the arm on the circle, graduated to 360°, which forms the outer edge of the perimeter. Both ob- jectives are held by a small bulb-pointed pin which is clasped by springs. They are made of card-board and can be of any size or color desired. A card, 5 centime- Fig. 4598.-Meyer's Perimeter ; posterior view. riphery toward the centre by means of an endless chain, which runs on the back of the arc and is set in motion by a small crank (M) which is invisible to the patient. The movement is stopped as soon as the patient recog- nizes the object, and the examiner reads off the number of degrees marked on the back of the arc and correspond- ing with the situation of the carriage, and indicates by a chalk mark on the black slate on the back the degree thus found. The black slate represents the projection of the sphere of the perimeter ; the side toward the patient is black ; on the other side a series of concentric circles divided by radii is drawn. The radii indicate the posi- tion of the arc, which the observer may ascertain at any moment on the small card (D), on which a needle (J) moves. One of the most practical perimeters in use has been devised by Priestley Smith, the registration being auto- matic. The base of the instrument is a strong wooden stand, 19 inches long by 8 inches wide. It contains a drawer in which lie the charts, test-objects, and colored pencils for outlining the field. At one end of the base is a short metal support, carrying a wooden pillar which ends above in a round knob. The patient rests his face lightly against the pillar, so that his eye stands verti- cally over the knob. At the other end of the base is a strong metal column bearing the axis which carries the quadrant, hand-wheel, pricker, and chart-holder. The quadrant resembles that in other instruments, and the test-object is held in a little clip which slides on the quadrant. The revolving axis has fixed to its other end a wooden disk or hand-wheel, eight inches in diameter, by which it is rotated, and is weighted so as to counterbal- ance the weight of the arc. The arc can be fixed at any point of the circle by means of a set-screw. On the pos- terior surface of the hand-wheel is the pricker, a pointed steel pencil, which slides in a brass plate in the meridian corresponding to the quadrant. This brass plate is graduated from 0° to 90°. Behind this wheel is the chart-holder, hinged at the bottom, and kept in position by a spring-catch, and which is easily brought into con- tact with the pricker by the thumb of the operator. Dyer's instrument for measuring the field of vision is a combination of the arc-perimeter of Aubert-Forster, and the hemisphere of Scherk, but the method of testing Fig. 4599.-Priestley Smith's Perimeter. tres square, with parallel lines fixed to the traveller may be used to show the meridian in astigmatism. This perimeter gives the means of making a quantitative test of the sensitiveness of the retina. In many cases where the retina is non-sensitive to the common test of a small w'hite object, it may be excited by a bright light, such 662 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vision. Vision. as the electric light. The brass spiral wire serves as one conductor, and a strip on the ann as the other. The ite distance the point from which emerge the lines of projection. These, therefore, become parallel to each other and perpendicular to the plane of projection. The direction of the meridians is always the same, but the intervals between the concentric circles which corre- spond to every ten degrees of the meridian diminish steadily as the periphery of the sphere is ap- proached. In many cases, where it is only neces- sary to determine the limits of the visual field, it suffices to make the perimetric measurements in four meridians separated by 45°, but in all cases where there is a peripheral or central lim- itation of the field present, the perimetric meas- urements must be taken in meridians separated from each other by only 20°. Limits of the Visual Field.-In measuring the field of vision all conditions which might influ- ence the extent of its limits must be carefully considered. The first in importance among these factors is the shape of the orbit and of the soft parts which surround the eye. The effect produced by these parts upon the extent of the visual field has been well shown by Lan- dolt in the following figure. He first deter- mined the visual field of his own eye, the point of fixation being the zero of the perimeter, and the head erect and immovable. This gave the visual field represented by the inner curve of Fig. 4602. The point of fixation was then trans- ferred to a point 30° in the direction opposite to that in which the first measurement was made, in this manner eliminating any limitation of the field which might be caused by the neighboring parts. This second measurement gave the visual field repre- sented by the outer curve in Fig. 4602. The influence of these neighboring parts upon the limits of the visual field of course varies in different persons, and also in the two eyes of the same person, owing to a varying degree of de- velopment. The nar- rowing of the visual field which is due to the nose is the least Fig. 4600.-Dyer's Perimeter. lamp is two centimetres in diameter, with a ground-glass dial covering the loop of No. 42 platinum wire. The diameter of the dial is 1.5 ctm., that of the loop 1 ctm. A Grenet zinc and carbon battery of three small cells is easily accommodated on the base of the instrument, under the spiral. This, with full immersion, will bring the loop to a white heat equal to seven-candle power. The intensity of the light is proportinate to the degree of immersion, and the candle-power is read off on a scale attached,to the battery. The self-registering perimeters of Stevens and Mc- Hardy are excellent instruments for the rapidity, ac- curacy, and facility with which they can be employed (see "Transactions of Seventh International Medical Congress," London, 1881, and Juler's "Ophthalmic Sci- ence and Practice," 1884, page 234). Methods of liepresenting the Outlines of the Visual Field. -In order to make a drawing of the visual field and its measurements as made by perimetric observations, we project a hemisphere upon a plane surface, and transcribe the necessary data upon this plane diagram or chart. Several methods of projection have been suggested, but to all of them objections may be offered. The plan of projection by tangents has the same faults as the determi- nation of the visual field by means of a plane surface ; that is, it is inconvenient owing to the rapid increase of the tangents, especially beyond 50°, and it becomes en- tirely inapplicable when the visual field extends to 90°, since the tangent of 90° is infinite. The plan of equidis- tant polar projection, proposed by Forster, is open to the objection that it does not correspond to what actually ex- ists in nature, inasmuch as the space which separates the different radii is greater than it really should be. The plan proposed by Hirschberg approaches nearer the true condition and consists in the orthographic projection of the sphere. This scheme may be obtained by removing to an infin- Fig. 4601.-Dyer's Perimeter; side view. constant but yet the most important, because simulating a pathological irregularity of the visual field. Hence it 663 Vision. Vision. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. is well to have the head-support of the perimeter rotate around its own axis. In examining the field of vision of the right eye the head should be turned slightly to the left; and in examining the field of vision of the left eye the head should be turned slightly to the right; in both instances the point of fixation should be the zero of the perimeter. In certain cases of ptosis, or of hypertrophy or swelling of the upper lid, or of considerable develop- ment of the eyebrows, it is better to raise the upper lid or the region of the eyebrow with the finger before test- ing the field of vision. Uschakoff aud Reich have found the visual field narrower in myopes and wider in hyper- gotten, in tins connection, that the portions of the visual held which extend upward and inward are of much less importance for orientation and the protection of the individual than the rest of the visual field. Lateral ori- entation is of much more importance ; on the right side this is done by the internal or median portion of the ret- ina of the right eye, and on the left side by the median portion of the retina of the left eye. The external halves of the two retinae are therefore less exercised, and conse- quently less sensitive than the inner halves. This view has been confirmed by some experiments instituted by Donders in connection with Grossmann and Mayerhau- sen, which also prove the correctness of Uschakoff's statement. These views do not, however, suffice to explain the difference of more than 40° which ex- ists between the internal and external limit of the visual field, and hence it must be admitted that on the temporal side a portion of the retina for several millimetres, starting from the ora serrata, is non-sensitive. Mariotte's Spot, or the Blind Spot.-There is a constant gap in the visual field, correspond- ing to the point of entrance of the optic nerve into the eye. The latter enters the eye a lit- tle to the nasal side and above the macula lutea. In the vis- ual field the corresponding gap would be outward and down- ward from the point of fixa- tion. This has been called the blind spot of Mariotte, after the author who first described it. The distance which sepa- rates the macula lutea from the optic disk varies in differ- ent individuals and in different eyes. After a careful consid- eration of the variations in the distance between the nodal point and the retina which are met with in different degrees of ametropia, both Landolt and Dobrow'olsky have dem- onstrated that the distance which separates the macula from the optic papilla is, in the great majority of cases, greater in hypermetropia and smaller in myopia than in emmetropia. The size or ex- tent of Mariotte's spot may be accurately measured on the perimeter. The patient should direct his eye steadily toward the point of fixation, and the observer should move some sharply contrasting object slowly from the outer periphery toward the point of fixation, and mark the point at which it ceases to be seen. Then the object is carried still nearer to the point of fixation, and the point noted at which it reappears. These two points de- note the limits of the blind spot in that particular meridian. This examination may then be made in all the meridians, and thus the limits of the blind spot be accurately marked out. The Functions of Indirect or Eccentric Vision.-The peripheral or eccentric parts of the retina have, like the centre, three different functions : 1. The sensitiveness for light; 2. The sensitiveness for colors ; 3. The ap- preciation of the form of objects. 1. The sensibility to light of the eccentric portions of the retina has been most carefully studied by Aubert, who from his observations and experiments has concluded that it is of the same degree for all parts of the retina. These conclusions have been corroborated by Landolt and Charpentier in their investigations upon the mini- mum of light necessary to produce an impression on the retina. These observers found that it required the same Fig. 4692.-Limiting Effect upon the Visual Field of the Parts about the Eye. metropes than in emmetropes. From a very large number of measurements Landolt has deduced the following fig- ures as representative of a minimum or smallest normal field of vision : 0° upward 55° 45° upward and outward.. .70° 90° outward 90° 135° outward and down ward. 85° 180° downward 60° 1^5° downward and inward.55° 90° inward 55° 45° inward and upward... .55° It dos not follow that every visual field of this extent is normal, but it does mean that a field of vision of nar- rower limits than here designated would be regarded as pathological. The very marked narrowing of the visual field upward, inward, and downward gives it an irregu- lar form which has been noted by all observers. It can- not fail of recognition that the narrowest parts of the visual field are those in which it is limited by the projec- tion of the orbit and nose. But, after the effect of these obstacles has been allowed for, the visual field does not become circular, but is widest outward, and outward and downward. Uschakoff has demonstrated that the retina extends farther forward on the median side of the eye- ball than on the external side. Landolt has ascribed the limitations upward and inward of the visual field to a lack of exercise of the corresponding parts of the retina, to a sort of amblyopia ex anopsia. It should not be for- 664 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vision. Vision. amount of minimum intensity of light to produce a lumi- nous sensation at all points of the retina. It is possible that the most extreme limits of the visual field may be less sensitive to a luminous impression. The parts near- est to the fovea centralis are even more sensitive to light than the fovea itself. 2. The Sensitiveness for Colors.-Experiments relating to the perception of colors by eccentric portions of the retina have all proved that the impression produced by a color depends, throughout the entire retina, upon the same conditions as prevail for the sensitiveness to color by direct vision; viz., upon the adaptation of the eye, upon the saturation, intensity, and extent of the color, upon the illumination, and upon the mobility or immo- bility of the colored test-object. But one important factor, to which, until recently, not much attention has been paid, is exercise. The faculty to distinguish colors may be considerably developed in any observer by fre- quent repetition of the tests. Attempts have been made to determine the limits of the perception of colors by means of the perimeter, and these experiments have proved that colors of a given intensity and extent are distinguished at a varying distance from the point of fix- ation. These results of the experiments of numerous observers have been tabulated, and all show that the color-field for blue has the widest limits. Next to blue comes yellow, then orange, then red, then green, and the narrowest is violet. The color-fields and the visual field for white are almost concentric. Moreover, all colors, on being brought from the periphery toward the point of fixation, appear at first of a more or less clear gray, and then pass through a varying zone, where they convey an impression of color without being recognized as of their real color. Even when the tint of a color is recognized by an eccentric part of the retina, it does not make as pronounced an impression on the eye as in cen- tral vision. All the colors, with the exception of blue, appear of greater saturation in direct vision than in indi- rect or eccentric vision. The theories of Schelske and Woinow in regard to the total or partial achromatopsia of certain regions of the retina, and the hypothesis of the relation of the rods and cones of the retina to the chromatic sense, cannot, in the light of our present knowledge, be regarded as tenable. The experiments of Landolt and others have demon- strated that the eccentric parts of the retina are neither partially nor wholly color-blind, but to produce a sensa- tion of color a much more intense impression is required for the eccentric portions of the retina than for the cen- tral portions. Landolt and Charpentier have also car- ried on experiments to determine the connection which exists between the chromatic sense at the centre of the retina and that at the periphery, and carried them far enough to confirm the existence of individual variations of considerable degree in the perception of colors. This examination of the color-sense in different parts of the retina is of very great value in the diagnosis and progno- sis of many diseases of the optic nerve and of obscure cases of amblyopia, and should always form a part of the examination of such cases. In determining the limits of the visual field for the different colors we usu- ally employ small squares of colored paper or card-board, with a diameter of two centimetres. These squares of paper are introduced into the object-carrier of the pe- rimeter, and the latter is illuminated by a uniform light. The carrier should always be moved from the periphery toward the centre of the arc, and never in the inverse sense. 3. The Appreciation of the Form of Objects ; the Form- sense at the Periphery of the Retina.-The faculty which the eye possesses to distinguish two separate points is called by Landolt the form-sense or visual acuity. The simplest method of determining the visual acuity of the eccentric parts of the retina is by the perimeter, in which the test-objects are placed in the traveller of the instru- ment and made to move from the periphery toward the centre, as in testing the other functions of the retina. Aubert and Forster have drawn the following conclusions from their experiments : 1. The visual acuity diminishes considerably from the centre toward the periphery of the retina. ' It does not, however, diminish regularly in concentric circles around the macula, but more rapidly upward and downward than inward and outward. 2. Small figures close together are distinguished at a greater peripheric or eccentric distance than large figures farther apart, but seen under the same visual angle as the small figures. 3. The limits of indirect or eccentric visual acuity are not always exactly the same in both eyes of the same person. Landolt's own researches have con- firmed the observation of Aubert and Forster that, in ad- dition to the spot of Mariotte, there are in the fundus of the eye certain other parts non-sensitive to light, smaller than the blind spot and corresponding probably to the principal vascular branches of the retina. In comparing the extent of retina which possesses the power of dis- tinguishing form with the general limitations of the visual field, it is found that the two are most approxi- mated inward, and inward and downward, and that they are at the greatest distance from each other outward, and downward and outward. Comparative researches upon the visual acuity of different parts of the retina show that it is most highly developed at the centre. Starting from the fovea centralis, it diminishes very rapidly, so that at forty degrees from the centre it is al- most entirely wanting. This diminution does not follow the same course in all the meridians of the eye, and the maximum and minimum of extent are not always the same in all persons. The eccentric or indirect visual acuity may be increased by practice, but, even under the most favorable circumstances and after long years of ex- ercise, it remains still very much inferior to the acuity of central vision. The experiments of all observers have shown that the sensitiveness for colors and the vis- ual acuity steadily diminish as we go from the centre toward the periphery of the retina, and we now know that these two functions also diminish for direct vision when the illumination diminishes. Recent experiments have shown that under diminished illumination the functions of an eccentric part of the retina are not equal to those of the centre. As a matter of fact, the visual acuity resists the diminution of illumination much longer than it does the removal of the object from the point of fixation ; on the contrary, the faculty of per- ceiving colors diminishes much more rapidly as a conse- quence of diminution of the illumination than in conse- quence of the eccentric position of the color. There is an essential difference between the functions of the centre and those of the eccentric parts of the retina. While the light-sense is about the same throughout the entire extent of the retina, the color-sense is much less vivid at the eccentric parts than at the centre, and di- minishes progressively as the periphery of the visual field is approached. The visual acuity of the form-sense diminishes still more rapidly than the color-sense, in go- ing toward the periphery. This discovery proves that the three functions of the retina are distinct, the one from the other, and cannot be reduced to a single func- tion. It would be more rational to admit that these three functions of the eye are presided over by distinct nervous elements, distributed differently throughout the retina. Anomalies or Defects in the Visual Field.-Defects in the field of vision may be of two kinds : 1, Peripheral limitations or narrowing of the visual field-sometimes concentric in character, at other times irregular and lim- ited to a certain section of the field ; and, 2, scotomata, or blind spots, which are interruptions in the continuity of the visual field. These interruptions, when situated at the centre of the field of vision, are called central scotomata. When they are situated toward its periphery, they are called eccentric scotomata. A third variety is known as paracentral, or annular or ring-shaped scotom- ata, and consists of a band or ring round the point of fixation in which the field is defective, while the ad- jacent portions of the field are unaffected. Under the head of peripheral limitations may be properly classed the cases of what is called hemiopia or hemianopsia, in which the defect consists in the loss of one-half the visual 665 Vision. Vision. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. field. It usually occurs in both eyes, and is then indica- tive of some lesion at or posterior to the optic commis- sure or chiasm. When only one eye is affected, the line of separation between the part of the visual field which is lost and that which is retained is generally irregular ; and the affection is then probably the result of some lesion of the optic nerve in front of the chiasm, or of the retina itself. It is probable that the terminal fila- ment of each optic-nerve fibre presides over a definite spot in the visual field, and when a fibre is distorted or pushed out of position a change in the psychic relation of this fibre to its function is produced. Every inter- ruption or loss of function in a nerve-fibre will be fol- lowed by a corresponding defect in the visual field. From this and other existing symptoms we are often enabled to locate the seat of the lesion somewhere in the course of the optic-nerve fibres. From numerous ob- servations and experiments made by various writers, it may be asserted that the nerve-fibres situated at the pe- riphery of tlie optic-nerve trunk, at least shortly before their entrance into the eye, preside over the periphery of the retina. From numerous observations of Mauth- ner, Michel, von Graefe, Liebreich, and others, the fol- lowing conclusions as to the course and distribution of the optic-nerve fibres may be drawn : 1. The greater portion of the nerve-bundles which run in the periphery of the optic-nerve trunk end at the periphery of the ret- ina. 2. The fibres of the so-called fasciculus cruciatus cover the fibres of the so-called fasciculus lateralis, and from the papilla to the macula lutea run next to the vitreous, and hence, when the fasciculus cruciatus is atrophied, the entire papilla appears as if atrophied. 3. The so-called fasciculus lateralis runs just in front of the chiasm on the temporal side of the optic nerve, and. when hindered in function, a defect in the nasal half of the visual field of the corresponding eye is pro- duced. 4. An injury of the inner half of the optic nerve probably causes a defect in the temporal half of the visual field of the corresponding eye. 5. Partial atrophy of a section of the papilla, which is visible with the ophthalmoscope, may produce a correspond- ing defect in the visual field. 6. No positive state- ment is as yet possible in regard to the position of the nerve-fibres in the trunk of the optic nerve which pre- side over the functions of the macula lutea. Finally, the investigations of Kellermann and Samelsohn have demonstrated that the nerve-fibres of the optic nerves do not always run parallel with each other, and that their arrangement in the chiasm differs from that near the eye. Peripheral Defects of the Visual Field.-A careful ex- amination of the periphery of the visual field will often enable us to distinguish between the various forms of amblyopia and atrophy, which are so numerous. A dis- tinct discoloration of the papilla does not necessarily indicate a progressive disease with defect in the visual field, neither does an apparently normal disk exclude the possibility of the existence of such a visual defect. Malignant cases of amblyopia soon lead to narrowing of the field, or, at least, to a marked diminution of the acuity of eccentric vision. Benign forms of amblyopia show a normal visual field, even if the central vision is decidedly bad. Where the amblyopia has lasted for some considerable time and the visual field shows a concentric limitation proportional to the diminution of central vision, the case will probably end in amaurosis or loss of sight, owing to a continuance of the cause. In this category may perhaps be classed all cases of toxic amblyopia, and those resulting from defective or insufficient nutrition. When there is an irregular pe- ripheral limitation of the visual field, the case is almost sure to be progressive. This class includes most of the cases of intracranial origin, such as those marked by hemianopsia. Usually, here, one eye becomes seriously involved before the second is attacked. The defect in the visual field usually occurs first on the nasal side, and there is also a marked tendency to symmetrical defect. These cases of hemianopsia appear suddenly and sym- metrically, and do not pass beyond the median line. In all these cases, in testing the periphery of the visual field, we should always test the color-sense also, as the re- sults thus gained are often of very great value, both as to diagnosis and prognosis. The value of these tests lies in the fact that the color-sense does not extend toward the periphery equally for all colors. The degrees of sensi- tiveness vary for the different colors, and vary also with the diminution of eccentric vision. It is to be assumed, from numerous observations, that the color-sense is affected by morbid processes, just as is the form-sense, and, therefore, when we meet with a diminution of the color-sense at the periphery we naturally conclude that there is also a diminution in the acuity of eccentric vi- sion. The acquired color-blindness due to disease bears no definite relation to the central acuity of vision, but it does to eccentric vision. This is seen in progressive simple atrophy of the optic nerve, and also in the atrophy following optic neuritis. The first symptom is a reces- sion of the limits of the color-sense from the periphery, which amounts to a widening of the color-blind zone ; next, the field for green becomes narrowed ; and, finally, green is no longer recognized. The next step in the progressive atrophy is a difficulty in recognizing red and yellow, which eventually cannot be recognized at all. The final step is that blue is no longer recognized, and complete color-blindness manifests itself. In all cases, however, in which blindness for green is present Fig. 4603.-Represents the Common Binocular Visual Field in Relation to the Different Tracts, and illustrates Von Graefe's view in regard to lat- eral hemianopsia. The part included within the dark shading repre- sents the blended visual field, common to the two eyes. M, is the mac- ula lutea projectea of each eye. F, is the point of fixation. <S<S, is the vertical meridian of the common visual field, running through the point of fixation. In this blended visual field common to the two eyes, all that lies to the left of the perpendicular «SS, belongs to the right optic tract, and all that lies to the right of the perpendicular £$, be- longs to the left optic tract. (From " Die Lehre vom Gesichtsfelde und Seinen Anomalien," by Wilhelm Schoen, Berlin, 1874.) there is a narrowing of the field for red, and in cases where there is blindness for all colors but blue the field for the latter is also narrowed. It must be conceded that color-blindness is always a symptom present in atro- phy of the optic nerve, and that it passes through the usual stages from partial to total, unless the atrophic process is of very rapid development. In many of these cases it should not, however, be forgotten that central vision is relatively more acute than might be expected in comparison with the condition of the color-sense. Our conclusions in regard to the changes in the field for color, in atrophy of the optic nerve, may be formu- lated as follows : 1. Acquired color-blindness due to disease cannot be compared with congenital color-blind- ness. 2. The optic nerve-fibres or elements which pre- side over the color-sense are affected by morbid pro- cesses in the same way as are those which preside over the form-sense. 3. The atrophic process acts in the same manner upon the color-nerves or elements, without distinction as to color. 666 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vision. Vision. Partial Atrophy of the Optic Nerve.-It is very neces- sary to be able to distinguish between the favorable and the unfavorable forms of atrophy and amblyopia. It is customary to call the progressive forms of atrophy by the name of total atrophy, and to designate the favor- able forms of amblyopia by the name of partial atro- phy. Some authors include in the latter category all cases in which one optic tract or optic nerve is pressed upon or partially destroyed by some extraneous cause, such as haemorrhage, a tumor, encephalitis, exostosis, per- iostitis, circumscribed basilar meningitis, circumscribed optic neuritis, or direct injury of the optic nerve. In all these cases there is a disturbance of function in a portion of the optic-nerve fibres, from some extra- neous cause, while the remaining fibres remain intact and are capable of performing all their functions. The question of the decussation of the optic-nerve fibres in the chiasm has been settled, for the majority of oph- thalmologists, by von Gudden. According to the lat- ter : 1. In all animals in which there is no common bi- nocular visual field the nerve-fibres undergo a total de- cussation in the chiasm ; but in all others, inclusive of man, in which there is a common visual field, the de- cussation is partial. 2. There is no anterior commissure with it is, according to Leber, generally due to retro- ocular neuritis, and must be distinguished from the cen- tral scotoma due to changes in the external layers of the retina in the region of the macula lutea. It resembles the scotoma met with in the ordinary form of acquired color-blindness, and its shape is that of a horizontal oval. This, according to Leber, is due to a special participa- tion of the fibres of the fasciculus cruciatus, which sup- ply the corresponding part of the outer half of the retina. These fibres pass in a horizontal direction out- ward, while the fibres of the other fasciculus run in an oblique direction upward and outward, curve round the region of the macula, and then run in the horizontal meridian. Leber offers the following explanation of the occurrence of this scotoma : Assume that the fibres which supply the macula and space between it and the optic disk lie next each other in the optic nerve ; the discoloration of the temporal half of the disk proves that they are situated in this part of the nerve. Now these fibres, which end around the disk and in the mac- ula, run in the optic nerve next the sheath, while those which supply the anterior part of the retina run in the centre of the optic nerve. This is a recognized anatomi- cal fact. Hence the central scotoma occurring in dis- eases of the optic nerve is due to an isolated lesion of the bundles of fibres next the sheath, which would naturally and easily result from an inflammation of the sheath. This pathological condition is actually not infrequently found in micro- scopical examinations of the optic nerve. If marked amblyopia or loss of vision oc- cur early in the course of optic neuritis, due to intracranial morbid processes, the defect in the visual field is progressive, beginning generally on the nasal side and extending thence gradually over the field to the point of fixation, so that, finally, the field is limited to a small section situated at the outer pe- riphery. If the narrowing of the field does not take place in this way, it may be concen- tric or confined to the lower half, or else represent a true hemianopsia. In idiopathic optic neuritis there may be a marked central scotoma of the field alone, or the latter may be accompanied also by a peripheral narrow- ing of the field of vision. In these cases the affection is usually unilateral. In chronic retrobulbar neuritis; ending in partial atrophy of the optic nerve, there may be a pro- nounced central color-scotoma without much loss of vision, or the reverse. In all affections of the optic nerve the central scoto- mata are of a horizontal oval, except in rare instances. They are not directly seen by the patient as dark spots in the visual field, as is the case in scotomata due to reti- nal disease, because in lesions of the optic nerve there is relatively but little diminution of the light-sense. In pure central scotoma the periphery of the visual field usu- ally retains its normal color-sense, but in some cases the latter also suffers, even though the eccentric vision is normal. Sometimes the central color-scotoma is sur- rounded by a normal zone, which is, in its turn, surrounded by an abnormal periphery, in which there may be both defective eccentric vision and disturbance of the color- sense. Here it should not be forgotten that central scoto- mata may also occur in non-inflammatory processes of the optic nerve, as in many varieties of toxic amblyopia. Progressive Atrophy of the Optic Nerve.-Progressive atrophy is distinguished from the more benign cases of partial atrophy by the early appearance of general dis- coloration of the papilla and the narrowing of the field of vision. The latter, when taken in connection with a simultaneous disturbance of the color-sense, is of pathog- nomonic significance. The discoloration of the papilla usually progresses hand in hand with the narrowing of the field of vision. Distinction should here be made be- Fig. 4604.-Represents the Two Views of the Partial and the Total Decussation of the Optic Nerve Fibres. The cut on the left represents the theory of partial decussation, and that on the right represents the theory of total decussation. In both cuts the little circle marked 3 shows the seat of the lesion in temporal hemianopsia. The little circle 2 shows the seat of the lesion in homonymous hemianopsia (paralysis of the right half of each retina). The little circle 1, in the cut on the right, shows the seat of the lesion in nasal hemianopsia. The latter cannot be explained by the theory of semi-decussation. (From "Die Lehre vom Gesichtsfelde und Seinen Anomalien," by Wilhelm Schoen. Ber- lin, 1874.) in the chiasm ; 3. There is a posterior chiasm, but it has no connection with the optic nerve. The chief objection to the theory of total decussation is that, if it be true, a sharply defined limitation of ho- monymous hemiopia is not possible, and that, in consider- ing the course of the latter affection, sufficient impor- tance is not given to the frequent occurrence of cerebral haemorrhages, nor to the consideration of the subject of a favorable prognosis as to blindness in this form of hemiopia. In optic neuritis the field of vision is more or less affected, even when central vision is still perfect. This is a point of much prognostic importance, for experi- ence has taught us that where there is a contraction of the visual field, in cases of optic neuritis, it is a sign of a partial atrophy of the optic nerve and retina. Still, the visual field may remain unrestricted. If, however, it is affected, it may be found to differ from the normal in various ways. The central scotoma, corresponding to the blind spot, is usually enlarged. The field for white may be but slightly, if at all contracted, while the field for green may be much narrowed or entirely lost. The field for red may also be narrowed. These changes in the visual field become more marked as the atrophic changes become more pronounced. The appearance of a central scotoma for colors is rare, but when it is met 667 Vision. Vision. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tween actual defects of the visual field and simple in- distinctness of eccentric vision. The narrowing of the periphery of the visual field is in many cases regularly concentric, and seldom reaches a high degree ; but the defect is more frequently marked in some particular di- rection, assuming more of a sector-like shape, which may be either symmetrical or different in the two eyes. The defect in the field may appear in any or every direction ; it may be on the nasal or temporal side in both eyes, or in the upper or lower halves of the field. In other cases the defect is in the form of a central scotoma, with sometimes an additional peripheral limitation. A still rarer form of defect is a steadily increasing con- centric limitation, which finally ends in total blindness. Disturbance of the color-sense is an almost constant ac- companiment of progressive atrophy, varying from slight disturbance, through all the stages, to complete color- blindness. If the defect in the visual field for white be peripheral, the limitations for color are also peripheral. If the defect be a central scotoma, the color-defect is also central. Still, there is no constant relation between the degree of disturbance of the color-sense and the degree of amblyopia. The field for green is the first to be af- fected, and that for blue is the last to yield. The dis- turbance in the color-sense merely indicates that, with a definite diminution of central vision, without any dimin- ution of peripheral vision, the disturbance is not confined to the fibres which end in the macula, but extends also to other fibres. Central Defects or Scotomata.-There are two kinds of central scotomata, the negative and the positive. Posi- tive scotomata occur in lesions of the macula from chorio- retinitis centralis circumscripta and from retinal haemor- rhage. These lesions produce a black spot in the central field, and patients affected with these troubles see much better in a bright light. Negative scotomata are due to lesions in the conducting parts of the retina or optic nerve, and are called negative because they cannot be ob- jectively seen. They are known to exist because ob- jects in space coming within their limits disappear from view. They extend from the point of fixation outward toward the blind spot of Mariotte. The scotomata due to disease of the macula in progressive myopia are at first so small that they cannot be demonstrated by the usual means. The first symptom is usually a wavy or distorted appearance of the lines of type in reading, which has been called metamorphopsia. This appear- ance is due to a distortion of the cones in the retina caused by exudation between them, or by stretching. Embolism of a branch of the central retinal artery will sometimes produce this-same symptom. In some of these cases a favorable prognosis as to vision may be given, and they may be distinguished from the progres- sive forms by the extension of the limits of the color- fields toward the periphery. The central scotomata without lesion at the macula are due to toxic amblyopia or to progressive atrophy of the optic nerve, and are almost always color-scotomata. They often exist with good central vision, and we can readily understand this, if we remember that the color- sense at the macula is more highly developed than at the periphery. The elements of the macula are much more sensitive, and the central after-images are more intense. In toxic amblyopia the irritability of the elements is ab- normal, and the duration of the after-images is shortened, owing to the retina becoming easily fatigued. These scotomata are never of very regular outline, and often vary in extent in the same individual on different occa- sions, sometimes extending over the whole field. There is, in this form of scotoma never any ophthalmoscopic change at the macula. In toxic amblyopia the scoto- mata are usually present in both eyes and develop sym- metrically. The shape is usually that of a horizontal ellipse, and, unless atrophy of the optic nerve is present, the periphery of the visual field is not contracted. If, however, the scotoma involve the blind spot, there may be a slight narrowing of the visual field. The scotoma is not absolute but merely relative, but at its centre there is usually a small absolute scotoma. The acuity of vi- sion and the light-sense are diminished in the scotoma. The disturbance in the color-sense is very marked, blue and yellow being the only colors which are correctly rec- ognized. The value of the perimeter in these cases is in mapping out the contours of the scotoma, after it has been recognized. Peripheral scotomata are usually due to some disease of the choroid, with lesion of the perceptive layer of the retina, though they may be caused by extravasation of blood and by detachment of the retina. Most peripheral scotomata are due to choroiditis disseminata. In this dis- ease the infiltrations in the choroid bring about the sco- toma by pressure on the basilar layer of the retina, and, if the choroidal process is not stopped and the infiltra- tion partially or wholly absorbed, the outer layers of the retina are included in the cicatricial shrinking process, and then the scotoma becomes permanent. These sco- tomata are usually situated in an intermediate zone be- tween 10° and 40° removed from the blind spot. Ring or Annular Scotoma.-The ring or zonular sco- toma forms a band round the point of fixation, while the adjacent portion of the field is unaffected, and the scotoma may easily be overlooked unless the field be very carefully tested. It is of rare occurrence, and is due to some lesion of the retina or of the choroid, with injury to the perceptive layer of the retina. It has been observed in chorio-retinitis pigmentosa. The cause prob- ably lies most frequently in the external layers of the retina. The prognosis in these cases, as in the case of peripheral scotoma from choroidal disease, depends upon the course taken by the disease. If the retinal or cho- roidal process is stopped, and absorption of the extravasa- tions is brought about, the defect may grow smaller and even entirely disappear ; but if the cicatricial shrinking once ensues, the defect in the visual field remains per- manent. Most of the pathological processes in the retina are ac- companied by more or less demonstrable defects in the field of vision. In embolism of the central retinal artery the obscuration of the field is usually so rapid and com- plete that it is impossible to map out any defect. If the obscuration proceed more slowly, it is described as be- ginning at the periphery genetally, more rarely at the centre. If, however,* the embolism is in one of the branches of the retinal artery the defect in the field is sector-like, corresponding to the region supplied by the arterial branch, is situated at the periphery, and is usu- ally permanent. Retinal hemorrhages are more apt to produce the symp- tom known as metamorphopsia, unless they are located at the macula, when they produce a more or less extensive central scotoma, corresponding to the extent of the haem- orrhage. Small peripheral defects are occasionally met with, due to peripheral haemorrhages, but these almost always disappear with the absorption of the extravasated blood. In purulent retinitis and retinitis albuminurica the vis- ual field is not usually affected, unless the disease is ac- companied by extensive haemorrhage. In the retinitis occurring in the course of diabetes the defect in the vis- ual field and the disturbance of the color-sense which are sometimes present are due to the fact that atrophy of the optic nerve is almost always present. In leucaemic retinitis the small eccentric scotomata sometimes met with are due to patches of exudation in the retina, and the same is true of the defects in the field seen in cases of retinitis due to progressive pernicious anaemia. In dif- fuse chronic retinitis the defects in the field may be both eccentric and central. They are always irregular in shape and usually of no great extent, and belong to the class of positive scotomata. In addition to the central and eccentric scotomata, ring-scotomata are said to have been observed in this disease. If a color-scotoma is present, the process has reached the stage of atrophy of the ret- ina and optic nerve. In syphilitic retinitis, in which the lesion is almost always central, the characteristic symp- tom is an irregular positive central scotoma, which may extend, sector-like, toward the periphery. This scotoma may at first be zonular and afterward assume the usual 668 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vision. Vision. form of a central defect. In diffuse retinitis of the exter- nal layers in and around the macula lutea the defect in the field may be either a simple metamorphopsia or a cen- tral scotoma. The former may present the appearances of both micropsia and megalopsia, the former being due to a straining and separation of the retinal elements, while the latter is due to a process of shrinking or con- traction. The central defect is a positive scotoma, unless the macula is destroyed, when it becomes a negative scotoma. Ring-scotomata have also been noticed in this disease. When the process is situated in the equatorial region the limitation of the field of vision is eccentric and irregular. In retinitis pigmentosa the usual form of defect of the visual field is a marked concentric limitation, beginning at the periphery and extending more or less rapidly to- ward the centre. In some cases the diameter of the visual field is so contracted as to measure from seven to ten degrees. In some cases, however, the main defect is central, while the peripheral portions of the field are merely blunted. These cases are, however, rare. Instill rarer cases the defect in the visual field is annular or zonular. The probable explanation of this ring-scotoma is that the conducting fibres of that part of the retina corresponding to the defect are intact, while the light- perceiving elements have been destroyed. The defects in the field of vision in this disease are due to a destruc- tion of the outer mosaic layer of the retina. The color- sense is, even in typical cases, normal or but slightly blunted outside the limits of the defect in the field. In detachment of the retina the defect in the visual field varies very much. Sometimes the function of the de- tached portion is absolutely lost, while in other cases it may be partially preserved. In partial detachment the defect in the field may be confined to the corresponding portion of the retina, and may present a sector-like shape or even an irregular loss of half the visual field. One of the characteristic symptoms is a blunting of the entire extent of the field, with more dr less metamorphopsia. In examining the field of such a case of detached retina with the perimeter, if we find that the limits of the field for color extend quite up to the edge of the detachment, this may be regarded as a favorable indication ; if, on the contrary, the color-sense is defective at some distance from the line of detachment, a further detachment of the retina is to be feared. There is a distortion of the outlines of objects, and a diffusion of the objects them- selves, which is peculiar to this form of metamorphopsia. There may also be not only actual eccentric defects in the field, but also blunted regions. In cysticercus celluloses the defect in the visual field may be either eccentric or central, according to the loca- tion of the animal between retina and choroid. If the cyst is still subretinal and the media are still clear the defect in the visual field maybe mapped out clearly ; but if the media are cloudy this becomes very difficult and wellnigh impossible. In cases of injury of the retina by a foreign body entering the eye and lodging in the retina, it is sometimes possi- ble to map out an irregular eccentric scotoma of the field, corresponding to the seat of injury, provided always that the media are sufficiently clear. These traumatic eccen- tric scotomata are almost always in the form of a sector- like defect. In rupture of the choroid, even though there be no rupture of the retina, the examination of the field of vision will show either loss of central vision, metamorphopsia, or a distinctly defined central scotoma, varying in extent with the extent of the rupture and the amount of blood extravasated into and beneath the retina. In the condition known as opaque optic-nerve fibres there is usually no disturbance of the limits of the visual field, either peripheral or central, but merely an enlarge- ment of the usual normal limits of the blind spot. In the congenital deformity known as coloboma of the choroid there exists a large scotoma in the visual field, either peripheral or central, corresponding to the extent of the coloboma. If the latter be eccentric, whether con- nected or not with a coloboma of the iris, central vision is usually fairly good ; but if the coloboma be central and involve the region of the macula, central vision is almost always abolished. A very rare anomaly is a coloboma of the sheath of the optic nerve, which is usually connected with a coloboma of the choroid, and here there is a very large central scotoma in the field of vision, which is usually of irregular outline. Scotoma Scintillans, or Teichopsia, or Amaurosis Par- tialis Fugax.-Under the above names has been de- scribed a defect of vision which resembles very closely homonymous hemianopsia, and the proximate cause of which has by some authors been located within the cra- nial cavity. The symptoms are certain peculiar hemian- opsic phenomena, usually accompanied by definite sub- jective visual sensations which are essentially transient in character, and are not connected with any profound alterations in the brain or spinal cord. The attack begins by the sudden appearance of a negative scotoma in the homonymous halves of the visual field of each eye, just outside the point of fixation. The scotoma extends rap- idly in every direction toward the periphery of the field, and then commence the phenomena of scintillation. These consist of luminous undulations, which appear and disappear rapidly at the periphery of the scotoma. The scotoma is surrounded by a scintillating crescent or luminous aureola of various colors and very irregular outline. Usually the scotoma involves the entire half of the visual field, but does not quite reach the point of fixation, unless in very exceptional instances. From fif- teen to thirty minutes after the appearance of the scotoma it begins to disappear, the scintillation usually ceasing before the defect in the field has entirely disappeared. The defect is always binocular, appearing in the two lateral homonymous halves of the two visual fields. In the same person the binocular scotoma may at one time appear in the right half, and at another in the left half of the binocular visual field. This form of ocular trouble has received the popular name of ophthalmic migraine. Alcoholic and Tobacco Amblyopia.-In this disease the visual defect usually appears simultaneously in both eyes and develops symmetrically, though in very, rare in- stances it may attack one eye. The defect in the field is very characteristic and consists of a negative central sco- toma, involving the point of fixation, but usually extend- ing more toward the blind spot, and thus resembling in shape a horizontal ellipse, with one of its foci at the point of fixation. The scotoma may extend throughout most of the visual field. If there be no atrophy of the optic nerve present, the periphery of the visual field is not affected, but if the scotoma extends beyond the blind spot, there may be some concentric narrowing of the field. The whole extent of the scotoma is not absolute, but at its centre there is usually a small absolute scotoma, with- in the limits of which there is absolute blindness. Throughout the rest of the scotoma the visual acuity is diminished, as is also the color-sense. Yellow and blue are recognized as such, but all other colors appear as gray or brown. Not only has the chromatic impression disappeared, but the luminous impression of these colors is also diminished. The light-sense is also diminished within the limits of the scotoma. The presence of the color-scotoma may be demonstrated in all cases of chronic alcoholic amblyopia. If the scotoma extend throughout the visual field, there may be complete achro- matopsia. In saturnine amblyopia, due to poisoning by lead, the de- fect in the visual field may be either a peripheral narrow- ing of the field, extending rapidly, or a central scotoma. In quinine amaurosis, where the blindness is not com- plete, there is at first a very marked concentric narrow- ing of the field, so that vision is telescopic. If the case prove to be favorable, the visual field gradually enlarges, but always remains permanently narrowed. In some cases of poisoning by opium we meet with metamorphopsia and dyschromatopsia, but the visual field is intact. In other cases a central scotoma is present. In some cases of uraemic amaurosis, where the blind- ness is not total, the existence of central scotomata have been demonstrated. 669 Vision. Vision. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. In diabetic amblyopia the defect in the visual field may be of three kinds : either a negative central color-sco- toma or an irregular concentric narrowing of the pe- riphery of the field, or else a combination of the two. In the latter case there is almost sure to be atrophy of the optic nerve. In the amblyopia and amaurosis due to intermittent fever the defect in the visual field, if it exist, may con- sist in either a peripheral scotoma or a concentric nar- rowing of the field. In the amblyopia and amaurosis resulting from loss of blood, if the blindness be not complete, there may be one or more irregular defects or scotomata in the visual field. They are not central, but are eccentric, and extend to tral scotoma, which may be transient or permanent ac- cording to the severity of the original injury. This cen- tral scotoma is, in cases of amblyopia due to some sudden explosion, replaced by an irregular concentric narrowing of the visual field. In hemeralopia the visual field is, in the majority of cases, normal, except at the immediate centre. The point of fixation is, however, usually covered by a small central scotoma. In some cases, however, there is a nar- rowing at the periphery of the field. In the so-called amblyopia ex anopsia, or amblyopia from disuse, there are two subdivisions to be made : 1, In one class of cases the patient sees well at first, but soon there appears an obscuration of the visual field, beginning at the periphery and trav- elling toward the centre; 2, in an- other class of cases the field of vision of the deviated eye is defective in that part which is common to the two eyes. There is no narrowing of the field in the strict sense, however, but a certain small portion of retina on the nasal or temporal side is blunted. The color-perception in this latter class is more or less blunted. In glaucoma the contraction of the visual field is quite characteristic of the disease. First the inner, and then the upper and lower portions of the field begin to contract, and this gradually extends toward the centre of the field, the central and outer parts alone remaining intact; and, finally, even this is lost. It is remarkable that the contraction of the fields for colors also appears to advance at the same rate as that for white, and thus they retain through- out a concentric arrangement similar to that existing in health. It is thus seen that the fields for color are only limited in proportion to the contrac- tion for white. The central visual acuity may remain for a long time relatively good, until the defect in the visual field extends beyond the point of fixation. In the prodromal stage of glaucoma there are periodic obscurations of central vision, and there may be actual defects in the visual field, either concentric or sec- tor-like in this stage, though these are not common. In glaucoma simplex there is a gradually increasing con- centric narrowing of the visual field, which is of an irregular, horizontally oval shape, with its longitudinal axis passing through the point of fixation. In acute inflammatory glaucoma the visual field, if it is possible to meas- ure it, is frequently found to be con- centrically limited, though it may be normal, or with a peripheral defect, while the centre is but slightly inter- fered with. In chronic glaucoma simplex the defect in the field of vision is a slowly progressing concentric lim- itation, beginning at the nasal side and slowly extending all around the periphery of the visual field. Hemianopsia; Hemiopsia; Hemianoptia ; Hemiopia.-Of the various terms employed to designate the loss of half the field of vision the word hemianopsia is the most cor- rect, and is the one which will be employed in this dis- cussion. The first subdivision is into uniocular hemi- anopsia and binocular hemianopsia, according as one or both eyes are affected. The uniocular form may be nasal (internal), temporal (external), inferior, or superior, ac- cording to the shape and location of the defect in the visual field. In binocular hemianopsia there are defects in the two visual fields, of very varying combinations. Homonymous hemianopsia is that variety in which two Fig. 4605.-Slight Central Scotoma met with in Toxic Amblyopia, due to Alcohol. The cut represents the field of vision measured with a perimeter and projected upon a plane black surface. The field is divided by four meridians, separated by an angle of 45°. The vertical meridian runs from 0° to 180° ; the horizontal from 90° to 90°, and the right angles formed by these two meridians are bisected by two others, one running from 45° to 135°, and the other running from 45° to 135°. The nine concentric circles represented by continuous white lines are distant 10° from each other. The irregular central white oval, Sc., represents the central scotoma. The other four irregularly concentric circles, shifted somewhat to one side, represent the fields for the different colors, white, blue, red, and green. (Taken from the article by Nuel, on Amblyopia and Amaurosis, in the Traite Complet d'Opthalmologie, Tome III., 3d fasciculus, by Wecker and Landolt, Paris, 1887). the extreme periphery of the field, and may involve the entire field. In reflex amblyopia, due to nervous irritation at some distance from the organs of vision, the disease is charac- terized by obscurations and transient narrowing of the visual field, which disappear when the eyes are rested. In hysterical amblyopia the field of vision is concentri- cally narrowed and, in addition, there are transient obscu- rations and actual central scotomata, usually transient, but sometimes lasting for a long period. The color-sense is blunted in proportion to the amblyopia and the nar- rowing of the field, and there may be complete color- blindness. In hystero-epilepsy there is narrowing of the visual field, especially of one eye, at first for colors, and after- ward for white. In the amblyopia due to compression or concussion of the eye the characteristic defect is the presence of a cen- 670 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vision. Vision. homonymous halves of the visual field-right, left, up- per, or lower-are wanting. When we speak of hete- ronymous hemianopsia, we mean that the two internal halves, or the two external halves, or one upper and one lower half of the field of vision are wanting at the same time. Heteronymous hemianopsia, in the horizontal sense, is therefore internal (nasal) or external (temporal). There might also be conceived a double internal or exter- nal (nasal or temporal) hemianopsia. In homonymous hemianopsia the binocular visual field is reduced one- half, but binocular vision is preserved in the other half. In heteronymous hemianopsia, on the contrary, the bi- nocular visual field is of normal extent, while binocular vision may be entirely wanting. No case has ever been reported of heteronymous hemianopsia in the vertical sense ; that is, absence of the superior half of the field in one eye and of the inferior half in the other eye. It is better to reserve the term hemianopsia for those cases in which the characteristic functional defect is due to some intracranial cause, and to employ the term sym- metrical scotomata in those cases in which the cause is intra-ocular or intra orbital. Homonymous Hemianopsia.-Right and left homony- mous hemianopsia are much the most frequent varieties. One of the most frequent causes is apoplexy. In a typical case the visual field is lacking in both eyes, in the corre- sponding halves in both eyes, the vertical line of demar- cation passing through the point of fixation. It may be right or left hemianopsia. Visual acuity and the color- sense are normal in the remaining half of the field. The vertical line of separation does not, however, always pass through the point of fixation ; it may be sinuous or ser- rated, or very irregular in its course, and may pass at some distance from the point of fixation, usually toward the defect in the field. In some rare cases there is in- sensibility of the macula lutea, and in these cases there is a peripheral narrowing of the rest of the visual field. In some cases the vision does not cease abruptly at the limit of the defect in the field, but there is usually a narrow zone left in which the vision is cloudy or blunted. Some authors include in this same class the symmetrical scotomata in both visual fields, but they are really cases of incomplete hemianopsia. These symme- trical scotomata sometimes appear in the form of sec- tors, the points of which touch the points of fixation and the bases extend to the periphery of the field. Some- times they are surrounded by an intact remaining visual field. Sometimes their points do not touch the point of fixation, and then they may escape the attention of both patient and surgeon. In typical cases of homonymous hemianopsia the color-sense is, as a rule, intact in the remaining half of the visual field. But in some cases there is complete color-blindness throughout the entire field, and here the hemianopsia is complicated with pe- ripheral lesions. The visual acuity is relatively good in homonymous hemianopsia, or but slightly diminished. The causes of homonymous hemianopsia are cerebral haemorrhages, cerebral softening, tumors, contusions of the head, injuries of one cerebral hemisphere, falls upon the head, meningitis, etc. Heteronymous Hemianopsia.-Heteronymous hemian- opsia is very much rarer than homonymous hemianopsia ; according to Mauthner, in the proportion of one to a hundred of the latter. 1. Lateral or temporal hemianopsia. Here the lateral or temporal halves of both visual fields are wanting throughout a varying extent; in typical cases the in- ternal or nasal halves of the fields should be intact. These cases are very rare, and the hemianopsia is not as closely defined as in the homonymous variety. Usually there are more or less considerable defects or lacunae in the temporal halves of the visual fields, and the line of separation between the defective and intact portions is clearly defined ; but in some cases there exists a zone of insensible transition. If the hemianopsia is typical and complete in one eye, it is very apt not to be so in the other eye. Another variation occasionally met with is a peripheral narrowing of the inner halves of the visual fields. Sometimes the scotoma commences in each eye by a small defect situated just outside the point of fixa- tion, which gradually increases in extent until it invades the half of the field. In other cases the visual trouble begins with complete blindness, which subsequently changes into hemianopsia. The scotoma may exist primarily in only one eye. The visual acuity is never intact, and in most cases steadily diminishes until the pa- tient is entirely blind. Hence the prognosis as to sight is much less favorable than in homonymous hemian- opsia, in consequence of the tendency of the scotoma to invade the entire visual field. Still the hemianopsia may be stationary. The cause of this variety of hemian- opsia is always some pathological process, a tumor, or basilar meningitis, which invades the chiasm little by little. An inflammatory process in the vicinity of the chiasm is sometimes induced by diabetes mellitus. 2. Internal or nasal hemianopsia. Here the two in- ternal or nasal halves of the two visual fields are want- ing. At first the defect in the visual field has no typical appearance, such as a vertical line of separation passing between the scotoma and the intact portion of the field through the point of fixation. Usually there is a simple defect in the field of vision of each eye, and the two are more or less symmetrical. The hemianopsia never ap- pears suddenly in its totality, but develops progressively. It has been known to follow a transient complete amau- rosis. The rest of the field of vision is more or less nar- rowed, and this tendency to narrowing increases. There are almost always marked changes in the fundus, either neuritis, or atrophy following neuritis. This variety of hemianopsia is, as a rule, accompanied by various cere- bral symptoms, among others by epileptiform attacks. The prognosis is grave as to both life and vision. The defect in vision usually ends in complete amaurosis. 3. Hemianopsia in the vertical sense. There have been several cases reported of defects in the visual field under the name of superior or inferior hemianopsia, but they are scarcely worthy of the name. The process of disease here is usually a neuritis due to some intracranial cause, which alw'ays occasions some defect in the visual field, either in the superior or in the inferior portion. Mauth- ner and Schweigger have, however, reported cases of de- fects in the upper half of the visual field, with normal acuity of vision, and no anomaly in the fundus. 4. Uniocular hemianopsia. Under the name of uni- ocular hemianopsia, external or internal, superior or in- ferior, have been described defects in the visual field confined to one eye. Sometimes the defect appears sud- denly as a result of apoplexy, sometimes it appears more gradually as a consequence of unilateral optic neuritis. Pathological Anatomy of Hemianopsia. Homon- ymous Hemianopsia.-In cases of this variety of hem- ianopsia an autopsy has revealed lesions both of the optic tract and of a cerebral hemisphere. 1. Where the lesion has been in the course of one optic tract the result has been due either to destruction of the tract or to an interruption in the nervous conductibility of the tract. A lesion of the left optic tract produces right hemianopsia ; a lesion of the right optic tract produces left hemianopsia. When the process invades the chiasm at the same time, the hemianopsia loses its typical char- acters. Vision is very much affected in one or both eyes ; the defects in the field are not absolutely symmetrical nor are they stationary, and the tendency is to complete blindness, with the ophthalmoscopic signs of neuritis or atrophy. 2. The hemianopsia may be due to a lesion of the ganglia at the base of the brain, the optic thalamus, or ante- rior tubercula quadrigemina. A lesion of the posterior half of the optic thalamus, especially of the corpus geni- culatum, may destroy all the fibres in an optic tract. 3. Homonymous hemianopsia may be produced by a lesion of the posterior third of the internal capsule, or of the radiating fibres directed toward the occipital lobe, or of the occipital lobe in its entirety, or of the occipital cortex. Lesion of one occipital lobe causes homony- mous hemianopsia on the side opposite the lesion. Heteronymous Hemianopsia.-1. Temporal heterony- mous hemianopsia. In some of the cases of this variety 671 Vision. Visual Centres. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. of hemianopsia the autopsy has shown a tumor upon the anterior part of the chiasm, or just in front of it, in the angle formed by the two optic nerves. In most of the cases reported there have been the signs of optic neuritis. 2. Nasal heteronymous hemianopsia. Here the au- topsies in published cases have shown various chronic pathological processes at the base of the skull, such as meningitis, atheromatous degeneration, or tumors, which were all situated upon or in the immediate vicinity of the chiasm. Localization of the Morbid Processes in Cases of Homony- mous Hemianopsia.--It is well known that each optic tract contains fibres destined for both eyes. Numerous ex- amples of typical homonymous hemianopsia produced by lesion of a single cerebral hemisphere on the side opposite to the hemianopsia, and located in the cortex of the oc- cipital lobe, as well as in the white matter, prove that all the optic fibres of one tract proceed from the hemisphere of the same side, from the cortex of the occipital lobe, which in man is the psycho-optic centre. The greater internal part of the retina of each eye is innervated by the fibres coming from the opposite cerebral hemisphere through the medium of the fasciculus cruciatus, and a smaller temporal part of each retina is innervated by fibres coming from the cerebral hemisphere of the same side ; a vertical line passing through the fovea separates the two retinal halves. At this limit, between the two parts of the retina, there is a zone in which the fibres of the two fasciculi intermingle, and the fovea is a part of this zone ; hence it is connected with both optic lobes. From all this it is seen that an homonymous hemianop- sia may be produced by a lesion situated in the optic tract, in the optic thalamus, in the posterior third of the internal capsule, in the fibres radiating from the optic thalamus to the occipital cortex, and in the occipital cortex itself. The hemianopsia is always on the side op- posite to the lesion. It may be regarded as definitely settled that typical homonymous hemianopsia is always the sign of a lesion situated in a more central position than the optic chiasm. In no case can a real hemianop- sia be produced by a lesion of the optic nerves. A lesion of the optic chiasm will not cause a real homonymous hemianopsia unless it is double, and defined by abso- lutely improbable limits. The existence of symmetrical scotomata is a symptom in favor of a pathological proc- ess located in the hemispheres, although, theoretically, a partial lesion of one optic tract might cause symmetrical scotomata. The general conclusion is that a typical case of homonymous hemianopsia, complete or incomplete, is always the sign of the existence of a central lesion, situ- ated posterior to the optic chiasm, either in one optic tract or in one cerebral hemisphere. If the lesion is in the optic tract, the hemianopsia oc- cupies the homonymous halves of both visual fields throughout their entire extent. It is usually absolute ; that is, the patient sees nothing within the limits of the scotoma, owing to a destruction of all the optic-nerve fibres. The preservation of a certain amount of vision within the scotoma, even mere perception of light, is in favor of the location of the lesion within the cerebral hemisphere. The hemianopsia is always negative. An homonymous hemianopsia from some basilar affection is complicated much more frequently and rapidly by intra- ocular-nerve atrophy than where the lesion is intra-cere- bral. In lesions of the optic tract there is said to be no con- junctival anaesthesia, on the same side as the hemianopsia. In lesions of the optic tract there may be both hemianaes- thesia and hemiplegia on the opposite side to the hemi- anopsia, though these complications usually imply that the lesion is intra-cerebral, and are then on the same side as the hemianopsia. Destruction of the optic thalamus should cause a typical homonymous hemianopsia, but no such case has been reported. The hemianopsia caused by a lesion in one or the other cerebral hemisphere is somewhat characteristic, and the exact locality of the lesion may sometimes be predicted. The usual causes are haemorrhages, spots of softening, ab- scesses, and tumors. The visual trouble is often distin- guished from that of basilar hemianopsia. The hemi- anopsia is frequently incomplete, both in extent and in- tensity. The defect may not occupy the entire half of the visual field. Symmetrical scotomata are usually caused by a lesion of the hemispheres. The defects in the field, whether they occupy an entire half of the field or not, are often relative ; that is, the visual acuity is diminished but not abolished. The hemianopsia may, however, be complete and the scotoma absolute, and in such a case there has been extensive destruction of all the optic fibres of one hemisphere. The existence or non-existence of certain complications is of the greatest importance as an aid in localizing the seat of the lesion. The existence of the symptoms of an apoplexy, of con- vulsions, of amnesia, joined to the absence of the symp- toms of a basilar lesion, all aid us in locating the lesion in the cerebral hemispheres, even when there is no ac- companying hemiplegia, hemianaesthesia, or aphasia. Homonymous hemianopsia, complete or incomplete, uncomplicated with hemianaesthesia, hemiplegia, or apha- sia, may be caused by a lesion in the occipital lobe, either in the cortex, in the white substance, or in both. The coexistence of hemianaesthesia and hemiplegia proves that the internal capsule is involved. If hemianaesthesia only is present, the lesion is probably in the posterior part of the brain, behind the lenticular nucleus. If in such a case the hemianopsia is complete, it is probable that the lesion occupies more or less of the occipital lobe and that it touches at some point the internal capsule, and this probability becomes almost a certainty if the hemianaesthesia diminishes while the hemianopsia per- sists. If, however, the hemianopsia improves while the hemianaesthesia remains the same, it is probable that the lesion is in the posterior third of the internal capsule, and the case would show the additional complication of a more or less pronounced hemiplegia. Sometimes the onset begins with hemiplegia and hemianaesthesia, and a small degree of hemianopsia, and the latter then disap- pears while the two former remain. In such a case the lesion is probably in the internal capsule, and possibly also in the corpus striatum and lenticular body. If the hemianopsia be caused by a lesion in the hemisphere, and be complicated by hemiplegia and hemianaesthesia, the latter will exist on the same side as the former. The combination of hemianopsia and paralysis or anaesthesia of the opposite side is pathognomonic of a lesion at the base of the brain. A complete hemiplegia indicates a lesion of the internal capsule. A monoplegia on the same side as the hemianopsia indicates either a cor- tical lesion in the corresponding psychic centres, or a circumscribed lesion in the radiatio medullaris cerebri which could not extend to the occipital lobe. It should not, however, be forgotten that in these cases there may be multiple circumscribed lesions, one of which may be in the occipital lobe. Lesions of one cerebral peduncle may give rise to homonymous hemianop- sia, with hemianaesthesia and hemiplegia of the same side, by extending to the optic tract. The coexistence of a paresis of the third nerve on the opposite side would cor- roborate the diagnosis. If, in addition to the hemianop- sia, there is hemichorea, the thalamus is probably the seat of the lesion. The aphasia which coexists so fre- quently with homonymous hemianopsia aids us in de- termining the extent of a lesion of the hemispheres. Where the hemianopsia is complicated with aphasia it is usually right hemianopsia, but it may be left. If the hemianopsia is accompanied by alexia and agraphia, the lesion is probably in the occipital lobe. In every case the visual defect caused by morbid processes located in the occipital lobe is always a hemianopsia. Localization of the Morbid Processes in Heteronymous Hemianopsia.-From clinical experience, and from a study of the morbid anatomy, authorities are united in locating the lesion in heteronymous hemianopsia at the base of the brain, in the vicinity or at the level of the optic chiasm. Hence the localization of the lesion is here relatively peripheral to that in homonymous hemi- anopsia. A single lesion, either of one optic tract or of 672 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vision. Visual Centres. one hemisphere, could not theoretically cause a heterony- mous hemianopsia, whether nasal or temporal, though a double circumscribed cortical lesion in a similar loca- tion might do so. Typical temporal hemianopsia might result from a lesion involving the median line of the chiasm, such as a tumor, an exostosis, or the distention of the supra- chiasmatic recess of the third ventricle. From our knowledge of the intimate interlacing of the fibres of the straight with those of the crossed fasciculus, we can readily see that lesions of one half of the chiasm might produce defects in the visual field, but they would not necessarily be typical. Typical nasal hemianopsia has never been reported, and it is not easy to imagine what lesion would cause it. The cases reported consist of defects of varying size in the nasal halves of both visual fields. Sym- metrical and partial lesions of both optic tracts might produce either nasal or temporal hemianopsia. The cases of so-called hemianopsia upward or downward, which have been sometimes observed, do not belong to the class of visual defects called hemianopsia. They are all cases of double optic neuritis with narrowing of the visual field, more pronounced upward or downward than in other directions. The cases of so-called uniocular hemianopsia which have been reported do not deserve the name, as they are all cases of optic neuritis. Amblyopia and Amaurosis due to Cerebral Lesions : 1. Lesions of the Chiasm.-In lesions of cerebral origin and localization the defect of vision sometimes begins by a typical temporal heteronymous hemianopsia. The scotomata soon invade the second half of the visual field, so as to produce an amblyopia with narrowing of this half of the field, and, finally, complete amaurosis. Usually the primitive hemianopsia is so irregular that it really does not deserve the name. One eye may at first be markedly amblyopic, with an extremely con- tracted visual field, while the field in the other eye is but slightly affected; but the case ends in complete amaurosis. This would indicate that the primary lesion involved half the chiasm, with perhaps the adjacent por- tion of the optic nerve. Amaurosis of one eye, with temporal hemianopsia of the other, indicates a lesion of a half of the cerebral chiasm and of the adjacent optic tract. As a rule, cases of amblyopia with considerable asymmetry of the visual fields point to an affection of the chiasm. 2. Lesions of Optic Tracts, Thalami, and Tubercula Quadrigemina.-Here we meet with double complete homonymous hemianopsia, ending in total blindness. 3. Lesions of the Internal Capsule.-It is probable that a lesion of the internal capsule, especially of the posterior third, would give rise to crossed homonymous hemian- opsia. Still, caseshave been reported in which there was no hemianopsia, but simply crossed amblyopia, or ambly- opia of both eyes, more marked in the eye on the side opposite to the lesion. These cases are usually due to apoplexy, and hemianaesthesia and hemiplegia are both present. The eye on the same side with the anaesthesia is usually more or less amblyopic; the visual field is narrowed, and there is more or less marked dyschroma- topsia, according to the degree of the amblyopia. The eye on the same side as the lesion often presents the same symptoms, but to a less degree. From a combination of these symptoms-hemianaesthesia, with or without hemi- plegia, amblyopia, and narrowing of the visual field on the side of the anaesthesia, with or without amblyopia of the second eye-Charcot diagnoses a lesion of the posterior third of the internal capsule on the opposite side. To this view of Charcot, however, there are some grave objections, especially one furnished by the numer- ous reported cases of hemianopsia due to lesions confined to a single occipital lobe. Charles Stedman Bull. VISUAL CENTRES IN THE BRAIN. The origin of the optic nerves in the gray matter of the brain, their connections with other parts of the brain, and the nature and the seat of the processes started in these centres by excitation of the optic-nerve fibres are the data upon which a theory of visual centres must be founded. An- atomical research has by itself not proved sufficient in unravelling the course and connections of the optic- nerve fibres in the brain. Its results, however, have been verified and extended by following, anatomically, the paths of the fibres after they have undergone pathological changes. For where the normal fibres of the optic nerve are lost to the eye in the mass of nerve- fibres of different origin and significance which accom- pany and surround them, it is still possible to identify and trace atrophied nerve-strands. Hence the atrophy which involves nerve-fasciculi, in either an ascending or descending direction, in consequence of an accidental or experimental lesion in their course or ganglia, fur- nishes a valuable method for recognizing a given set of fibres in the midst of a labyrinth of other nerve-fibres. This mode of research has been especially applied by Gudden and his disciples to new-born animals in which an arrest of development of the dependent nerve-paths and ganglia, in the form of well-pronounced atrophy, follows the destruction of the peripheral or central end of the optic nerve. Another source of information is the clinical study of the effect of brain-lesions upon vision, followed by post-mortem examination. But, in or- der to admit such clinical evidence as fully trustworthy, it must be exacted in every case that sufficient time (at least several weeks) has elapsed between the onset of those symptoms which persist permanently and death, in order to insure that the symptoms observed were due to the direct destructive effect of the lesion and not to any temporary influence of an irritant, mechanical, or inhibitory nature exerted by it at a distance. For simi- lar reasons the lesion, in order to be fully significant, must be localized and not diffuse, and the more limited the ex- tent of the morbid changes the more reliable are the con- clusions based upon them. Cerebral inflammations and tumors can influence parts not directly involved by press- ure or irritation, and hence do not furnish as instructive data for cerebral localization as apoplectic cysts and embolic foci of softening. Experimentation upon lower animals is not as trustworthy for the study of the visual centres as clinical research, combined with autopsy, in the human subject, on account of the difficulty of fully understanding the nature of a visual disturbance in an animal. The fibres of the optic nerve, the number of which is one-seventh to one-eighth that of the retinal cones, are not distributed uniformly to the different regions of the retina. In accordance with the greater visual importance of the region of the macula lutea, this small area is con- nected with a bundle of fibres constituting nearly one-half the mass of the optic nerve. Various observers-Samel- sohn,1 Nettleship,2 Vossius,3 Uhthoff4-have identified this bundle of fibres by its degeneration after having taken perimetric measurements during life of the central sco- toma produced by the nerve-atrophy (cases of retrobulbar neuritis and toxic amblyopia). It has the shape of a wedge at the level of the lamina cribrosa, with its base next to the nerve-sheath on the temporal side, but on re- ceding into the orbit it gradually gains a more central position in the nerve-trunk. In some other cases (Uht- hoff), in which fibres supplying a retinal quadrant from near the centre up to the periphery could be traced in microscopic sections by means of their atrophied state, they were found near the entrance of the optic nerve into the eye in a position corresponding topographically to the retinal region from which they originated. The various fibres change somewhat their relative position and intermingle to some extent as the optic nerve is fol- lowed up to the chiasm, probably on account of the rotation to which the nerve is subjected during the em- bryonic formation of the eye. The problem of the topography of the visual centres is intimately connected with the question, Is there a complete or only partial decussation of the optic fibres in the chiasm, and does each optic tract connect with the eye on its own side of the body or with both eyes ? The question can be easily decided in the case of fishes, in 673 Visual Centres. Visual Centres. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the lower orders of which the two nerves simply cross one above the other. In the higher fishes the two nerves separate into bundles which intersect each other in cross- ing, but can yet be isolated by the scalpel. But as we ascend in the animal scale the structure of the chiasm becomes more and more complex, on account of the di- vision of the nerves into smaller fasciculi, or simply into separate fibres which intermingle and interlace to such an extent that they cannot be followed in their course by dissection or teasing or in microscopic sections. Positive statements, based on purely anatomical meth- ods, have been made by Biesiadecki, by Mandelstamm, and by Michel5 to the effect that a complete decussation does take place in animals and man. The anatomical method is in this case, however, not sufficiently decisive to allow us to accept this view, when all clinical and, es- pecially, pathological and experimental evidence decides unequivocally in favor of a partial decussation. All other modes of research on the chiasm confirm the hypothesis which the great physiologist Johannes Mueller based on physiological reasoning ; viz., that each optic tract divides in the chiasm into two fasciculi, one crossing over into the nerve of the other side, the other remaining in the nerve of the same side, and that the proportion of the uncrossed to the crossing fibres depends on the extent of the field of vision common to both eyes. In the rabbit, whose optic axes diverge so that there is only a very limited field of vision common to both eyes, the uncrossed bundle is insignificant compared with the number of crossed fibres. In the dog, whose eyes diverge less than those of the rabbit, the uncrossed fasciculus gains in size compared with the former animal, though it is still smaller than the crossed fasciculus. In the monkey and in man, wfliose field of vision common to both eyes nearly equals in extent the monocular field, the uncrossed fibres consti- tute about one-half of the optic nerves. The incomplete decussation of the optic nerves is not an exception to the rule that each half of the brain controls the other side of the body. For, since each optic tract supplies the temporal half of the retina of the same side and the nasal half of the retina of the other eye, its excitation by optic images corresponds really to objects situated on the op- posite side of the median line of the body (on account of the optic inversion of retinal images). Loss of an eyeball or destruction of the retina is fol- lowed by ascending atrophy of the corresponding optic nerve. This is a very slow process in the adult, probably requiring years to ascend beyond the chiasm. But in the new-born animal the atrophy, or, rather, the arrested de- velopment, is sufficiently characteristic after the lapse of a few weeks to enable the observer to trace the atrophied fibres along the optic tract. By following the atrophied fibres in cross sections Gudden6 has proven the existence of an uncrossed bundle, very small in the rabbit, but larger in the dog and cat, while the direct fibres have been found constituting nearly one-half of the optic tract in man by Gudden, Baumgarten,' Kellerman,9 Purtscher,10 Marchand,11 and others. Descending atrophy follows le- sions of the optic tract or its central ends in the subcorti- cal ganglia. Utilizing this occurrence, the fibres of one tract have been followed down through the chiasm into both optic nerves by Gudden in dogs and by Hosch12 in the case of man. Longitudinal division of the optic chiasm in the median line would necessarily cause total blindness in case of complete decussation of all fibres. Indeed, in experi- ments by Brown-Sequard on rabbits and guinea-pigs and by Beauregard on pigeons this seems to have been the result. But in similar experiments by Nicati13 on cats and by Bechterew14 on dogs, made by cutting through the base of the skull, complete blindness did not occur, but insensibility of the nasal half of each retina. Simi- larly, the partial decussation was proven by producing hemianopsia on the other side of the body, and not blind- ness of one eye, by cutting one optic tract in dogs (Bech- terew) and monkeys (Ferrier). As far as man is con- cerned, the partial decussation is completely proven by the invariable symptom of uncomplicated lesion of one optic tract ; viz., homonymous lateral hemianopsia to- ward the other side of the body, blindness of the tem- poral half of the retina of the same side, and of the nasal half of the retina of the other eye. The dividing line between the sensitive and blind retinal areas passes, in uncomplicated cases of complete destruction of one tract, exactly through the centre of fixation, the fovea cen- tralis. The dividing line, however, was not necessarily vertical in every case observed ; it slanted a few degrees, in somes instances, toward one or the other side, and its upper and lower halves were not always in a straight line. The structure of the optic chiasm is complicated by the presence of two sets of commissural fibres not con- nected with the eye. The upper or Meynerts commis- sure on the dorsal and caudal side of the chiasm lies within the tuber cinereum, being separated from the chiasm by a layer of gray substance. The fibres, on emerging from the basal surface of the brain, run along the median and dorsal side of the optic tracts, still sep- arated from them by a thin layer of gray substance. They form part of the so-called inner root of the optic tract and dip in between the bundles of the pes pedun- culi, becoming apparently lost thereupon, while the rest of the optic tract winds itself around the peduncle. They probably connect with the ganglion of Luys be- tween the thalamus opticus and the tegmentum of the pe- duncle. The inferior commissure of Gudden consists like- wise of fibres which do not form part of the optic nerves peripheral to the chiasm. This commissure of Gudden forms the upper (dorsal! part of the optic tracts and can- not be distinguished from the optic-nerve fibres proper, except when the latter have undergone complete degenera- tion and this bundle remains intact. In the rabbit, how- ever, it can be identified even in the normal specimen in microscopic sections, since in this animal the fibres con- stituting it are finer than the coarse fibres of the optic nerves. In his latest communication Gudden15 claimed that the optic tracts contained, besides the optic fibres proper and the inferior commissure, another bundle con- necting directly with the hemispheres. It can be demon- strated in the atrophied condition after destruction of the hemispheres (in new-born animals), which lesion does not influence the integrity of the optic and inferior commis- sural fibres in the rabbit. Or, conversely, it can be iso- lated intact by causing atrophy of the optic and inferior commissural fibres by destroying the chiasm in the new- born animal. Further researches concerning this hemi- spheral bundle are yet wanting. Stilling16 claims to have demonstrated, by teasing, the existence of an exterior commissure connecting the two eyes by way of the chiasm, a view previously advanced by Hannover, but not supported by other investigators. Stilling also maintains that a number of fibres which pass along the optic nerve to the eye are not contained in the optic tracts, but enter the chiasm coming from the tuber cinereum and, perhaps, the basal optic ganglion of Meynert. These alleged short-route fibres have been described by Bechterew 11 as the centripetal part of the reflex arch controlling the movement of the iris. His ex- periments, however, are not convincing. The optic tract divides into a larger external and a smaller internal root as it winds itself around the pe- duncle. The external root flattens out on reaching the thalamus opticus, and a prominence is here created by the external geniculate body, the ganglion of the optic nerve, in which some of the fibres terminate. The re- maining fibres continue their way up to the pulvinar of the optic thalamus, which forms a second point of origin of the optic fibres, while still another set of fibres reaches the anterior corpus quadrigeminum, partly by passing thence directly through the thalamus, partly by way of the anterior arm (brachium conjunctivum anticum). The fibres ending in the pulvinar are partly lost in its surface, the stratum zonale, and partly enter into the deeper region. The inner root verges toward the internal geniculate body. Part of the fibres pass this ganglion or perforate it in order to reach the posterior tuberculum quadrigeminum, by way of the posterior arm (brachium conjunctivum posticum). These are probably the fibres 674 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Visual Centres. Visual Centres. of Gudden's inferior commissure. Another strand gets into the pes pedunculi, and probably represents the hemi- spheral fasciculus of Gudden, described in connection with the chiasm. Stilling18 claims to have followed some of these fibres, by teasing, down to the medulla oblongata, into the lower olivary body and pyramidal decussation, and another strand into the deeper gray strata of the pons. He hence speaks of a spinal root of the optic nerve. But it is not certain whether these fibres, or any of the fibres of the internal root, pass beyond the chiasm to the eye. Whether any of the optic-nerve fibres pass from the eye to the cerebral cortex, uninterrupted by any inter- mediate ganglionic station, is not yet settled. As re- gards those fibres of the optic tract which can be fol- lowed into the peduncle and thence upward into the cerebrum, it is still an open question whether they repre- sent part of Gudden's inferior commissure or a special hemispheral strand, as claimed by Gudden, or fibres of the optic nerve. The latter is not very likely, in view of the fact that the ascending atrophy due to enucleation of the eyeball in new-born animals does not extend beyond the subcortical ganglia (v. Monakow). There is, how- ever, a strand, known as Gratiolet's visual radiation, which connects the thalamus opticus with the occipital cortex and which represents the indirect continuation of the optic-nerve fibres up to the cerebral cortex. It is that portion of the corona radiata which emerges from the occipital lobe in a more or less sagittal direction, passes along underneath the rear of the parietal cortex, espe- cially underneath the angular gyrus, and converges to- ward the region of the pulvinar and the corpora genicu- lata. Before entering the gray substance of the thalamus it forms thus the posterior (caudal) part of the internal capsule. These statements concerning the origin of the optic nerves, generally accepted by brain-anatomists and fully supported by the evidence of experimental atrophy, have been opposed by Darkschewitsch.19 He examined the brains of rabbits and dogs in microscopic sections after staining the fibres individually according to the methods of Weigert and Freud. He claims that the optic-nerve fibers pass merely over and through the pulvinar and ex- ternal geniculate body, without terminating in them, and that their principal ganglion of origin is the anterior tuber- culum quadrigeminum. Some of the fibres, he claims, change their direction at the level of the external genicu- late body and run toward the ganglion habenulae and the pineal gland, being probably fibres concerned in the pupillary reflex and not in vision. Darkschewitsch de- nies, also, the existence of separate connecting fibres be- tween the occipital cortex and pulvinar and geniculate body. The fibres from the occipital cortex to the corpus quadrigeminum he claims to have traced partly into the superficial medullary layer of the latter, partly into the deep medullary layer, where they cross over into the deep medullary layer of the tuberculum quadrigeminum of the other side. There can be no doubt, however, that the staining methods used by this anatomist are not as trustworthy, for the purpose of tracing fibres through gray substance, as the method of following atrophied fibres, with the results of which the statements of Dark- schewitsch are not in harmony. The clinical evidence concerning the visual signifi- cance of the subcortical terminations of the optic nerves is not very explicit. On account of the vascular distri- bution in that region, narrowly circumscribed lesions are not very common, and from the study of extensive mor- bid processes it can only be learned that direct or indi- rect destruction of the optic tract or its central ends causes hemianopsia on the other side of the body. Phys- iological experimentation in this region, so full of inter- lacing fibres running in all directions, does not give very trustworthy results ; all the more so, as it is not a simple task to interpret correctly the nature of a visual disturb- ance. Older experiments by various physiologists, on birds and rabbits, showed that destruction of the region from the caudal end of the thalamus opticus up to the corpora quadrigemina results in blindness of the oppo- site eye. In dogs Bechterew20 claims to have obtained permanent hemianopsia on the opposite side by extensive lesion of the anterior and posterior tubercula quadrigem- ina of one side. According to his experiments the an- terior tuberculum qnadrigeminum is in connection with the uncrossed fasciculus supplying the temporal half of the retina of the same side, while the posterior tuber- culum quadrigeminum is the terminal station for the crossed fasciculus coming from the nasal region of the retina of the other eye. Section of the posterior region of the internal capsule, the visual radiation of Gratiolet, causes hemianopsia in dogs, according to the same ob- server.21 The most detailed information concerning the connec- tions of the optic nerves has been obtained by Von Mona- kow22 by the method of following atrophied strands. In rabbits whose one eye had been enucleated at birth, the corresponding (opposite) atrophied tract could be traced into the lateral and caudal parts of the external genicu- late body, the gelatinous ground-substance of which, as well as the surrounding white layer, had atrophied, while the nerve-cells of this body were intact. A second strand was followed to the pulvinar, where likewise the capsular white layer and the gelatinous substance, but not the cells, were reduced in mass. A third set of atro- phied fibres could be traced through the anterior bra- chium into the surface-gray of the anterior tuberculum quadrigeminum, where the atrophic process involved the superficial gray and white layers, including in this case part, but not all, of the cells of the gray substance. The same results were obtained in kittens, in which animal, however, the incomplete decussation in the chiasm causes the atrophy to involve both sides of the brain. A case of old atrophy of the optic nerve in man enabled the author to identify the same optic-nerve terminations in the human being. The connections between the sub- cortical centres and the cerebral cortex were traced by means of descending atrophy produced by excision of the gray matter of the occipital lobe. The atrophic changes involved in this case the part of the corona radi- ata known as Gratiolet's radiation, the posterior part of the internal capsule and the continuation of these fibres into the external geniculate body, the pulvinar, and the anterior tuberculum quadrigeminum, in which ganglionic bodies the atrophy pertained mainly to the nerve-cells. In the corpus quadrigeminum the atrophy was greatest in the deep white layer and in the brachium anticum. In the kitten the atrophy extended into some of the bundles of the optic nerves. The atrophy of the optic tracts and their ganglia could not be obtained by lesions of any region of the cerebral cortex except that of the occipital lobe. Conversely, it was only the occipital lobe which became atrophic when ascending atrophy was induced by division of the optic fibres in the posterior region of the internal capsule, and in this case the atro- phy involved only the third (large pyramidal cells) and fifth (multipolar ganglionic cells) layers of the cortical gray matter and not the other strata. Circumscribed ex- cisions of small areas of the occipital cortex in the cat demonstrated that the region near the median edge of the occipital lobe is related principally to the pulvinar and the lateral part of the external geniculate body and, ultimately, to the crossed optic fasciculus, while the lat- eral portion of the occipital cortex connects with the ba- sal ganglia nearer the median line ; viz., the anterior tu- berculum quadrigeminum and the median zone of the external geniculate body, and, ultimately, with the direct optic fasciculus. In the posterior capsule the fibres must hence intercross in such a manner that those coming from the median side of the hemisphere reach the lat- eral aspect of the subcortical ganglia, while the strands descending from the lateral cortical area pass over toward the more median ganglionic masses. A study of three cases of old occipital lesions in man, among them ope of antenatal embolism of the posterior central arteries in an infant, confirmed these data for the human brain. A relation of the occipital lobes to the optic tracts is strongly suggested by the atrophy which has been found a few times in the occipital convolutions in old cases 675 Visual Centres. Visual Centres. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. of blindness of peripheral origin. Huguenin23 has found in a man, blind in the left eye since youth, relative atrophy of the pulvinar, external geniculate body, and tuberculum quadrigeminum of the same side, with thin- ning and shrinkage of the occipital surface, both median and convex, around the occipital fissure of both sides of the brain. In another case of bilateral blindness both the subcortical ganglia and the occipital convolutions were reduced in size bilaterally. In other cases of long- standing blindness Burkhardt24 and Mickle25 found atro- phy of the angular gyri. The most positive proofs of the visual importance of the occipital lobes are, however, furnished by the clinical study of cases of hemianopsia followed by autopsy. With- in the last fifteen years, since which time the topic of cere- bral localization has received proper attention, numerous cases have accumulated in the literature in which visual disturbances observed during life found their only ex- planation at the autopsy in disease of the occipital lobes. Indeed, it can be definitely stated that no cases are on record in which any extensive lesion of the occipital lobes found after death did not produce visual failure dur- ing life, provided the subjects were of sufficiently sound mind to be accurately tested. Conversely, it may be stated that lesions of the brain interfere with sight per- manently only when they either affect the optic tracts or their ends in the subcortical ganglia directly or indirectly by compression or when they are seated in the occipital lobes. There are on record about thirty cases * of lesions limited to one occipital lobe in which permanent hemianop- sia on the other side of the body was observed with accu- racy during life. A considerably larger number of cases have been reported which sustain the same conclusion, but in which complicating lesions interfere with the re- liability of their evidence. While in some of these thirty cases the lesions-apoplectic cysts or embolic foci of soft- ening and a few instances of tumor-extended through- out the entire mass of the white interior or the gray surface of the occipital lobe, or even encroached upon the temporal or parietal lobes, they were quite narrowly circumscribed in some of the others. In six instances26 -Huguenin (cited by Haab), Fere,2T Seguin,28 Hun,29 Putzel30-the lesion involved principally or exclusively the lobule on the posterior part of the median surface known as the cuneus (bounded by the calcarine and pari- eto-occipital fissures). In the most circumscribed case (Hun) the destruction of the lower half alone of the right cuneus caused blindness in the inferior left quadrant of the field of vision in both eyes. In all the cases in which the cuneus was either directly involved in the disease or in which the fibres passing from it toward the basal gan- glia were affected by lesions in the interior of the white substance of the occipital lobe, the result was typical la- teral hemianopsia toward the other side of the body, with the line of separation passing vertically through the fovea centralis. In those instances in which the blindness did not quite reach up to the point of fixation, the cuneus and its efferent white fibres do not seem to have been completely destroyed by the lesion. Since the vision of the intact halves of the yellow spots was perfect in the typical uncomplicated cases of hemianopsia, it is to be in- ferred that each half of each macula receives fibres from the occipital lobe of the same side, relatively ; that is to say, the left half of the macula lutea both of the left and of the right eye is in relation with the left occipital lobe, and conversely. The correlation of the occipital lobes to the retinae is confirmed by a study of binocular occipital lesions,31 though such cases do not bring out the topographical re- lationship as clearly as instances of unilateral disease. A few cases which have been reported, apparently proving the possibility of blindness of one eye in consequence of disease of the occipital lobe of the other side,32 do not war- rant such a conclusion on critical examination of their significance. On the basis of all anatomical, pathological, and clin- ical data, well supported, moreover, by experiments on lower animals, the course of the optic-nerve fibres in man can hence be described as follows : From the tem- poral half of the retina the direct fasciculus passes into the optic tract of the same side, without decussation in the chiasm. It terminates in the gelatinous substance of the external geniculate body, especially its median por- tion, and in some of the cells of the surface-gray of the anterior tuberculum quadrigeminum. The fibres from the nasal half of the retina cross in the chiasm, in order to pursue their course in the optic tract of the other side, and terminate in the gelatinous substance of the more lateral region of the external geniculate body and of the pulvinar of the thalamus. Above these gan- glia the physiological continuation of the optic fibres is represented by strands originating from the nerve- cells of these ganglia, viz., the external geniculate body, the pulvinar, and the anterior tuberculum quadrigemi- num, which pass through the posterior area of the in- ternal capsule, upward and backward, as the corona radiata of the occipital lobe, in order to terminate in the third and fifth (microscopic) layers of its cortex. The convolution known as the cuneus represents the most concentrated visual area of the occipital cortex, or, as Exner has aptly expressed it, the "absolute" cerebral field of vision, the destruction of which excludes the possi- bility of conscious sight in man, while the rest of the occipital convolutions may be regarded, according to Ex- ner's conceptions of cerebral localization, as the "rel- ative " cerebral field of vision-the area throughout which the visual fibres or their connecting net-work spread out in order to enter into connection with the other parts of the cerebral cortex. Each cuneus is re- lated to the macular halves corresponding to its side of the body. The median area of the occipital lobes is as- sociated, in all probability, mainly with the nasal half of the retina of the other side, while the lateral region, on the convexity of the brain, bears the same relation to the temporal half of the retina of the same side. A number of cases have been observed in which sud- den loss of color-perception occurred-either in both retinae completely, or in their homonymous halves- without diminished visual acuity, apparently in conse- quence of apoplectic or embolic brain-lesions. There are, however, no autopsies of such cases on record, and there is hence no actual basis as yet for locating in the brain a separate color-centre, distinct from the visual cen- tre, for the perception of light. Wilbrand33 has suggested the hypothesis of separate centres for the perception of color, of light, and of space (visual acuity) in different strata of the occipital cortex, but this hypothesis has not received any tangible proof. While destruction of the cortex abolishes conscious sight in man, the occipital lobe is not necessary for the reflex actions of the pupil. In some of the reported in- stances of bilateral occipital disease the persistence of pupillary movements was noted. It is, moreover, not uncommon to find clinical cases in which the blind- ness and the other symptomatic features suggest no other lesion but one of the occipital lobes, and in which the play of the pupil indicates integrity of the subcor- tical centres. While clinical evidence has decided absolutely on the correlation of each occipital lobe to the corresponding halves of the two retina} in man, there is still some un- certainty about the relation of eye and cerebral cortex in animals, although experimentation on animals first sug- gested the importance of the cerebral cortex as a visual centre. Of all experimenters, Munk34 has drawn the most positive conclusions. In monkeys and dogs he claims to have obtained permanent hemianopsia toward the other side of the body by removing the cortex of one occipital lobe. In the monkey the involvement of both retinae is about the same as in man. In the dog, however, the relatively larger size of the crossed fascic- ulus accounts for the fact that the larger part of the retina of the other eye, including the entire macula, becomes blind in consequence of a unilateral occipital lesion, while the narrow temporal blind zone of the retina of the same side occasions but little interference * The sources will be quoted in the literature at the end of this article. 676 Visual Centres. Visual Centres. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. with the animal's ability to get along. In fact, Munk, in his earlier publications, regarded his dogs as blind only in the crossed eye, but subsequently he acknowl- edged this as a mistake, and recognized hemianopsia. In the centre of the convex surface of the occipital lobe (the posterior part of the second convolution) in dogs Munk recognized a limited area the extirpation of which produced a disturbance of sight in the opposite eye of such a nature that the animal, without being blind, was no longer able to comprehend what it saw. This condition Munk termed psychic blindness. The dogs still avoided obstacles with the sound eye closed, with some certainty ; but they neither understood the significance of the whip nor that of threatening gestures, nor were they able to find bits of meat. The animal, however, recovers in some weeks from this condition of psychic blindness. Munk interprets these results by considering the occipital area referred to as the centre of visual recollections-the area in which visual memories are stored-and that on remov- ing this spot the animal is obliged to learn again the significance of impressions made on the eye involved. The suggestion by Mauthner and others that this oc- cipital area is the centre for the retinal region of acute sight-the macula-Munk does not consider as appropri- ate, for his dogs did not seem to suffer from a central scotoma in the eye. Extirpation of one entire occipital cortex, however, produced in Munk's dogs permanent blindness of the retina of the other eye, except in its nar- row temporal zone, and from this " cortical blindness," as he calls it, the animals did not recover. By extirpa- tion of small areas of the occipital cortex Munk claims to have demonstrated that the retina is projected topo- graphically upon the occipital surface in such a manner that the upper retinal region corresponds to the anterior part of the occipital lobe of the other side, the lower retinal region to the posterior part, the nasal border to the median area, and the macular region to the centre of the convex surface, while the extreme temporal zone of each retina is correlated to the extreme lateral zone of the occipital lobe of the same side in dogs. Munk's conclusions have not been fully confirmed by other experimenters. In the case of monkeys, Ferrier35 claims that the occipital lobes alone are not necessary for sight, but admits that extirpation of one occipital lobe, together with the angular gyrus of the same side, causes permanent hemianopsia. The angular gyrus he regarded in former communications as the true visual centre, but he states later that its extirpation produced only a temporary blindness of the other eye, from which the monkey can recover fully. He therefore enlarges the theoretical visual centre so as to include the an- gular gyrus. Schaefer,26 howrever, who repeated Ferrier's experiments, contradicts the latter, and sides entirely and fully with Munk. As to the dog, Munk's claims regarding the visual im- portance of the occipital lobe are, on the whole, confirmed by Ferrier, Luciani and Tamburini,31 Dalton,38 and Bi- anchi,39 though considerable discrepancies occur between these authors as to the limits of the visual centres and their connection with one or with both retinae. Very different statements, however, have been made by Goltz40 and his disciple Loeb.41 These observers claim that vis- ual disturbances may result from lesions of any part of the cortical surface, if only extensive enough. They admit, however, that they are more apt to follow lesions of the occipital lobe than those of any other cortical area, and that in the latter case they are more likely to be permanent. According to Goltz and Loeb, the visual disturbance pertains to the smaller temporal area of the retina of the same side, and still more so to the larger nasal retinal half of the other eye ; but it is not an abso- lute hemianopsia, but merely a visual inattention, which Loeb terms hemiamblyopia. They maintain that the ani- mal is not absolutely blind in the involved retinal areas, except, perhaps, during the first few days after the opera- tion, but that the impressions produced in these retinal areas do not influence the animal's conscious actions to the normal extent. This inattention in the involved field of vision they claim to have seen improve, if the animal lived long enough. Even after complete extirpation of one entire hemisphere, Goltz saw his dog's movements in- fluenced slightly by a strip of white paper in the ambly- opic field of vision in such a manner as to exclude total blindness. After circumscribed excisions in the occipital cortex, Loeb could not obtain any evidence of blindness limited to retinal sectors as described by Munk. In view of such contradictory statements, Munk's conclusions cannot be admitted as proven beyond doubt as far as they concern the relation of retina and oc- cipital cortex in the dog. But these doubts do not in- validate our knowledge concerning the visual centres in man, in which the clinical evidence is unequivocal. It must be remembered that the cerebrum plays a much greater role in the psychic domain and the conscious movements and actions in man than in the lower animals. This axiom is fully supported by anatomical evidence and measurements of the relative weight of the cerebral cortex and subcortical ganglia in man and various ani- mal species. In the case of the motor centres, also, the clinical evidence is absolute that in man their destruction means permanent exclusion of the corresponding mus- cles from the influence of the will. Yet in the dog or rabbit the removal of the cerebral cortex does not cause any permanent paralysis, although the existence of mo- tor centres can be demonstrated by cortical irritation, and inferred by the permanent interference with com- plicated volitional movements after their extirpation. Hence the claim of Goltz and his followers that dogs are not absolutely blind after removal of their occipital lobes does not alter the well-proven fact that conscious sight is no longer possible in man after destruction of the oc- cipital cortex. Although Munk's conclusions regarding the brain of lower animals do not seem to be as accurate as he ex- pressed them, they have led to the discovery of the vis- ual centre in man. Similarly, his views regarding the distinction between cortical and psychical blindness, whether strictly true of the dog or not, have led to impor- tant observations in man. It has been noticed by dif- ferent authors that in various forms of insanity, espe- cially general paresis, visual disturbances occur which can only be interpreted as inability to understand the significance of the objects really seen. The patient's vision seems not at fault, but his remembrance of pre- viously seeing such objects, and, hence, his recognition of them, is lost or interfered with. It is, of course, dif- ficult to analyze the mental processes in any form of in- sanity with defective intellect. But there are a few ob- servations on record42 according to which people in perfect mental health lost suddenly their remembrance of former visual impressions, so that all familiar objects seemed strange. They were forced to learn again, as in their earliest infancy, to interpret what they saw. This recovery of visual memory was, however, aided by the relatively intact memory of ideas. The inference can be drawn from these and similar observations that the visual memory may suffer while visual perception is not in- terfered with. Literature. The sources of information regarding the optic chiasm and central course of the optic nerves have been referred to in the text. Anatom- ical details on these subjects can be found in Meynert's " Anatomy of the Brain," in Stricker's " Handbook of Histology," and in the same author's more recent work on l' Psychiatry " (American translation by B. Sachs); also in Wernicke's "Lehrbuch der Gehirnkrankheiten," vol. i. (1881). The latter work, indeed, is also very explicit on the physiological aspect up to that date. The clinical data on hemianopsia in consequence of brain- lesions have been summed up by numerous authors ; for instance, Noth- nagel: *• Topische Diagnostik d. Gehirnkrankheiten," 1879 ; the writer in theJournal of Nervous and Mental Disease, January,1881; Exner: " Un- tersuchungen ueber die Localisation in d. Grosshirnrinde," 1881 ; Mar- chand : Archiv f. Ophthalmologie, Bd. 28. ii: Mauthner: " Gehirn und Auge," 1881; Starr : American Journal of the Medical Sciences for Jan- uary, April, and July, 1884; and Seguin : Journal of Nervous and Mental Disease, January, 1886. The subject of psychic blindness is treated at length in a monograph by Wilbrand (" Die Seelenblindheit als Heerder- scheinung," 1887). The physiological experiments of Munk were reported to the Berlin Physiological Society in 1878 to 1888, and reprinted as " Gesammelte Abhandlungen Ueber die Funktionen der Grosshirnrinde," 1881. The various other phy-iological researches confirming or oppos- ing Munk have been referred to in the text. A full review of physio- logical data can be found in Ferrier's " Functions of the Brain," 1886. II. Gradle. 677 Visual Centres. Vitreous Body. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 1 Von Graefe's Archiv. f. Ophthalmologic, Bd. 28, i. 2 Transactions Ophthalm. Society, vol. i. 3 Arch. f. Ophth., Bd. 28, iii. « Ibid., Bd. 32, iv. 5 Ibid., Bd. 19, i. 6 Ibid., Bd. 20, ii, ; Bd. 21, iii. ; and Bd. 25, i. and iv. 7 Centrablatt fur die medicinische Wissenschaften, November 31, 1878. 9 Zehender's klin. Monatsbl. f. Augenheilk Ausserord. Beilageheft, 1879. 10 Arch. f. Ophth., Bd. 26, ii. 11 Ibid., Bd. 28, ii. 12 Zehender's klin. Monatsbiatter f. Aug., xvi., p. 285. 13 Archives de Physiologic, p. 658, 1878. 14 Neurologisches Centralblatt, 1883. 18 Arch. f. Ophth., Bd 25, iv. 16 Untersuchungen ueber d. Bau d. opt. Centralorgane, 18S2. 17 Ptiueger's Arch. f. d. gesammte Physiologic, Bd. 31, p. 60. 18 Untersuchungen ueber d. Bau d optischen Centralorgane, 1882. 19 Archiv. f. Anat, und Physiologie, Anat. Abtheilung, 1886. 20 Ptiueger's Archiv. f. Physiologie, Bd. 33. 21 Centralblatt f. prakt. Augenheilkunde, January, 1884. 22 Archiv. f. Psychiatric, Bd. xiv., p. 699; Bd. xvi., p. 124. 23 Correspondenzblatt f. Schweizer Aerzte, November 15, 1878. 24 Centralbl. f. Nervenheilkunde, September. 1880. 28 Medical Times and Gazette, January 28, 1882. 28 Haab: Klinische Monatsbiatter f. Augenheilkunde, xx., p. 141. 27 Archives de Neurologic, March, 1883. 28 Journal of Nervous and Mental Diseases, January, 1886. 29 American Journal of the Medical Sciences, January, 1887. 30 Medical Record, June 2, 1888. 31 Berger : Breslauer aerztl. Zeitschrift, 1885, abstr. in Centralblatt f. prackt. Augenheilkunde, May, 1885 ; and Reinhard : Archiv f. Psychia- tric, Bd. xvii. and xviii. 32 Sharkey: Quoted by Ferrier in Functions of the Brain, p. 290. 33 Ophthalm. Beitraege zur Diagnostic der Gehirn Krankheiten, 1884. 34 Die Functionen der Grosshirnrinde, 1881. 38 The Functions of the Brain, 1886. 36 Brain, 1888. 37 Luciani in Brain, July, 1884. 38 New York Medical Record, 1881. 39 Rivista Sperimentale, 1883. 40 ffleber die Verrichtungen d. Grosshirns, Gesammelte Abhandl., 1881; and Ptiueger's Arch. f. Physiologie, Bd. 34 and Bd. 42. 41 Ptiueger's Archiv f. Physiologie, Bd. 34 and Bd. 39. 42 Charcot: Progress Medical, July 21, 1883; and Wilbrand : Die See- len blindheit als Heerderscheinung, etc., 1887. VITREOUS BODY OR HUMOR Anatomy.-Under the head of vitreous body is comprehended not only the transparent, gelatinous mass enclosed in the hyaloid mem- brane, and which tills the greater part of the interior of the eyeball; but also, from the stand-point of develop- ment, the capsule of the lens and the zonula ciliaris. In the eye of an adult, the latter presents a modified con- tinuation of the hyaloid membrane passing beyond the ora serrata, and being attached in a peculiar manner to the capsule of the lens. The vitreous body extends a certain distance in front of the ora serrata retina toward the zonula, but is separated from it by a species of capil- lary cleft. This cleft widens toward the edge of the lens, and thus separates the anterior surface of the vitreous body from the zonula. This cleft, surrounding the edge of the lens between the zonula and the anterior surface of the vitreous, and filled with fluid during life, is known as the canal of Petit, and communicates with the anterior and posterior chambers through fine openings between the fibres of the zonula. In the region of the ocular axis the anterior surface of the vitreous body is in close contact with the posterior capsule of the lens. Hyaloid Membrane.-This membrane and the zonula ciliaris are both parts of the same membrane, the pos- terior forming the hyaloid membrane and the anterior forming the zonula. The hyaloid membrane is the same as the membrana limitans retina of Henle and Iwanoff, and surrounds the entire vitreous body. It must be regarded as distinct from the margo limitans retina, and belongs exclusively to the vitreous. In the region of the ora serrata, the hyaloid membrane gradually becomes thicker and changes in structure, to become the zonula ciliaris. From here it forms the anterior wall of the canal of Petit. The posterior wall becomes identified with the anterior surface of the vitreous. There is no splitting of the zonula near the ora serrata into an ex- ternal and an internal lamina, as has been stated. Under the microscope the hyaloid appears as a clear, transparent membrane, which readily falls into folds, which are very distinct. It is closely attached by its internal surface to the vitreous body. The external surface toward the retina is always smooth. In the region of the ora serrata, the vitreous substance of the hyaloid membrane is finely striated, the striations running longitudinally. They begin at the equator of the eye, become more distinct toward the border of the zonula, and form the zonular fibres in the ciliary portion of the hyaloid membrane. The hyaloid membrane contains small flattened cells of irregular shape and indistinct limitation, and containing one or more nuclei. A finely granular mass of pro- toplasm surrounds each nucleus, of no defined limitation, but losing itself gradually in the vitreous substance. In some places the cells have a more regular spheroidal or fusiform shape, with indented edges. These cells have been found upon the inner and outer surface of the membrane. They are quite numerous in the embryo, but much fewer in the adult. Their distribution varies in different parts of the membrane, but they are more numerous in the region of the ora serrata and at the entrance of the optic nerve. Hecker regards these cells as nothing more than colorless blood-corpuscles, and thinks that their greater frequency in the anterior and posterior portions of the hyaloid membrane is explained by the proximity of the blood-vessels of the ciliary body and optic papilla in these regions. Vitreous Body or Humor.-The contents of the space surrounded by the hyaloid membrane is a vitreous, gelat- inous mass, which varies in consistence and chemical com- position with age. In the embryo the tissue of the vitreous is much denser and resisting than in the adult. The vitreous humor is now re- garded as composed of a consistent and a liquid part. It was formerly believed that the consistence of the vitreous hu- mor was due to the presence of mem- branes, which ran through the vitre- ous in various direc- tions, and divided it into sections or cells. Demours, Zinn, Briicke, Hannover, and others, all claimed to have discovered these membranes, and stated that they were arranged in a concentric manner, like the layers of an onion. But it is now admitted that all these membranes or concentric lamellae resulted from the reagents employed in preparing the specimens for microscopic study, No thin, defined, pliable membrane has ever been discovered in either a fresh or a preserved vitreous body, except on the inside of the central canal. Hence the view cannot be held that the substantia pro- pria of the vitreous body is contained in cells, or within membranes disposed in the shape of a fan. There is but a single space, filled with a gelatinous matter, and traversed by a central canal. It is probable, however, that the gelatinous mass contains spaces filled with fluid. Iwanoff has succeeded in demonstrating, in thin sections cut from a vitreous body hardened in Muller's fluid, a gaping or opening of the layers of the peripheral sub- stance into concentric lamellae, separated from each other by analogous clefts. He, therefore, describes the vitre- ous as consisting of a cortex in layers and of a homo- geneous nucleus. Stilling also holds similar views as regards the vitreous of animals. Iwanoff's view is now generally accepted. The central nucleus, however, in man is of extremely loose tissue, and easily destructible. The gelatinous tissue of the nucleus, under the influence of chromic acid, splits up in p, stellate manner, and con- tracts into a varying number of radiating partitions which are attached to the axis which contains the cen- tral canal. The Central Canal of the Vitreous.-In the adult human eye the vitreous body is traversed by a canal filled with a transparent liquid, which runs from the optic disk to- Fig. 4606.-Represents a Sketch made by Hannover from the Vitreous of Mammalia. It presents a lamellated and concentric structure, particularly at the periphery. The cut represents a vertical section of an eyeball, hardened in chromic acid, in which the lamellae of the cortex have retracted under the influence of the hardening fluid, leaving clefts or fissures which caused Han- nover to consider them as concentric mem- branes. (Traite Complet d'Ophthalmologie, Tome II, 2d fasciculus.-Wecker & Lan- dolt, Paris, 1884.) 678 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Visual Centres. Vitreous Body. ward the posterior surface of the lens, and is known as the hyaloid canal. At its posterior extremity it is some- what dilated (the so-called area Martegiani), but soon shrinks to a cylindrical canal, two millimetres in diameter, and finally ends just behind the posterior surface of the lens. The direction of the canal is somewhat eccentric, owing to the eccentric position of the op- tic disk. The mode in which the canal ends anteriorly is not as yet definitely known, nor is its point of termination always constant. The canal is lined with a vitreous membrane of a finely striated appearance. Flat- tened granular cells are scattered irregularly through this mem- brane, resembling the subhya- loid cells hitherto described. In the embryo this central canal contains the hyaloid artery, which finally expands in the fossa patellaris into a fine net- work. This artery frequently persists for some time after birth, and may be demonstrated with the ophthalmoscope. Fibres and Cells of the Vitreous Body.-The completely developed vitreous humor appears under the microscope as a perfectly transparent, homogeneous body, but in the vitreous of the embryo, and in some instances in the adult vitreous, cells may be occasionally seen. The same holds true of the fibrillary elements. Except in the region of the ora serrata, these fibres are excessively rare. The fibres described by Lieberkuhn are probably elastic, while those described by Iwanoff resemble the fibres of cellular tissue. Both varieties are much more frequently met with in the embryonic vitreous. The cells are more frequently met with in the peripheral layers than elsewhere. Iwanoff describes these principal forms: 1. Round cells with one or more nuclei, prob- ably derived from the white blood-corpuscles, isolated and few in number. 2. Fusiform or stellate cells, of ir- regular form, and provided with long processes carrying several globular enlargements ; these are found princi- pally in the cortex. 3. Small clear vesicles, containing the body of the cell, and possessing one or more pro- cesses. These vesicles are sometimes clearly defined, sometimes indistinct, but their contents are always clear and homogeneous. They are usually isolated, but some- times two are met with connected by a bridge of proto- plasm. The number, size, and shape of the nuclei varies considerably. Their number is from one to three. Their shape is spheroidal, oval, or kidney-shaped. The nu- merous intermediary forms between these three types of cells prove their identity. It is probable that they are all wandering lymph-cells. Hence we see that the vitreous consists mainly of embryonic cellular tissue (Fig. 4608). Nutrition of the Vitreous Humor.-For many years the vitreous has been the object of experimental researches by numerous observers. Prominent among these, Schwal- be, by injecting a non-diffusible coloring matter into the pial sheath of the optic nerve, proved the existence of a path of communication between the lymphatic spaces of the nerve and the central canal of the vitreous. Knies used ferrocyanide of potassium, and injected it either directly into the vitreous or subcutaneously. Leplat holds that no definite conclusions can be based upon the results obtained by injections into the vitreous, believing that such injections must necessarily cause increase of tension in this body, the effect of which must be to set in motion a current from the vitreous to the aqueous, since it is known that a difference in tension in these two humors cannot be maintained for any length of time. There is, however, nothing to indicate that such a cur- rent obtains under normal conditions. Hypodermic in- jections are also open to objection. Knies and Ulrich, who experimented in this way, allowed an hour and a half to elapse before enucleating the eye for examination, and this interval is much too long to give satisfactory results. The use of ferrocyanide of potassium has eluci- dated one point, viz., the secretion of the vitreous by the ciliary body. Scholer and Uhthoff made use of fluores- cine, and dissected the eyes of rabbits upon which they had experimented, a variable time after the injection, and learned therefrom that the intra-ocular fluids originate in the ciliary body. Injections of Chinese ink directly into the vitreous have been made by Ulrich, and subse- quently by Gifford, and the latter concluded that the elimination of fluid from the vitreous occurred at the optic papilla. Panas has made a series of experiments on these animals, in search of facts bearing on the nutri- tion of the vitreous, and has concluded from his researches that a nutritive current starts from the papilla, traverses the vitreous, lens, and aqueous, and leaves the eye by Schlemm's canal. These conclusions have not, however, been sufficiently proved. Stilling's hypothesis that the eli- mination of fluid from the vitreous takes place at the papil- la, is the most probable one. Leplat concludes, from some experiments very recently undertaken, that the nutritive fluids of the vitreous are secreted by the ciliary body, but he emphasizes the statement that it is from the ciliary body alone that these fluids come. From this point the current travels backward, and that portion which enters the central canal of the vitreous flows rapidly toward the papilla. Certain clinical facts, however, seem to favor the view that the vitreous is supplied with nutritive fluid by the whole uveal tract. In choroiditis, not involving the ciliary region, opacities are met with in the vitreous. In myopia the posterior layers of the vitreous are some- times liquefied. It is an admitted fact that the rods and cones derive their nourishment from the choroid, but it is difficult to imagine that nutrient fluid should traverse the retina, which has a very different blood-supply, in order to reach the vitreous ; if so, it should contribute to Fia. 4607.-Represents a Ver- tical, Equatorial Section of a Hardened Vitreous. From a dense external cortical layer run a number of radi- ating partitions, which con- verge toward the centre, and end indistinctly in a central mass. A short distance within the outer layer, there is a second, thinner, con- centric layer. These radi- ating septa are doubtless the result of the hardening process. (From the Traitc Complet d'Ophthalmologie, Tome II., 2d fasciculus, by Wecker & Landolt, Paris, 1884.) Fig. 4608.-Various Cell-forms met with in the Normal Vitreous, a and b represent the fusiform or stellate cells described by Iwanoff, and are found principally in the cortex. They are of the most irregular shape with curved outline, and several protoplasmic prolongations with here and there spheroidal swellings. They are usually isolated. The end of the processes is sometimes pointed, a, and sometimes contains a protoplasmic globule, cl. c, e,f, and-g, represent a third form of cells described by Iwanoff, which contain a clear vesicle in the cellular body. Most of these cells are provided with processes, and give the impression of swelling of the cellular substance by imbibition. In some of these cells there are two vesicles connected by a bridge of protoplasm which contains the nucleus, g. (Taken from the article by Schwalbe on the Anatomy of the Vitreous in the Traite Complet d'Ophthalmologie, Tome II., 2d fasciculus, by Wecker & Landoit, Paris, 1884.) the nutrition of the retina, which it clearly does not, as is evidenced by the loss of transparency and function which result from embolism of the central artery. If we suppose that there is a considerable current from the choroid, through the retina to the vitreous, how are we to explain the progressive increase and subsequent de- crease of the quantity of iodine in the vitreous, from be- fore backward, in the experiments in which potassium iodide has been injected. 679 Vitreous Body. Vitreous Body. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Diseases oe the Vitreous Body or Humor. Hyalitis or Inflammation of the Vitreous.-Idiopathic inflammation of the vitreous has long been denied, and it has only been admitted to exist since wre have been able to observe with the ophthalmoscope the changes which take place when a foreign body is introduced into the vitreous humor. The experiments of Pagenstecher, Leber, and others, have proved that the inflammatory irritation may start primarily from the seat of injury of the vitreous body, and radiate in every direction, without being limited to the channel of traumatism. The nature of the inflammation depends on the intensity and duration of the irritation, and, according to Wecker, may be ser- ous, condensed or plastic, and suppurative. Serous hyalitis may be caused by a slight irritation, after starting in the choroid. A more active immigration of cells occurs through the cortex of the vitreous, and these, as they ap- proach the central portion of the vitreous, become in- filtrated with fluid, gradually destroy the delicate frame- work of the vitreous, and cause its liquefaction. This is the simplest variety of inflammation of the vitreous, and is met with principally in chronic choroidal disease. Condensed or plastic hyalitis is always a chronic inflam- mation. There is the same active cellular immigration, but the cells, instead of being destroyed, as in the serous form of inflammation, develop and gradually acquire the properties of the cells of cellular tissue. As a result, more or less extensive opacities are developed in the vitreous, and the latter becomes changed more or less completely into cellular tissue, and subsequently is con- densed by cicatricial contraction. These changes are very often seen to follow the entrance of a foreign body into the vitreous which is not of a very septic nature. Suppurative hyalitis is the most acute and in- tense form of inflammation of the vitreous. The cellular immigration is so immediate and extensive that the tis- sue of the vitreous is rapidly destroyed, and the result is an abscess. This form of hyalitis may be localized and more or less circumscribed ; and if this is the case, the pus may subsequently be absorbed. The walls of the abscess, caused by a surrounding plastic hyalitis, may then collapse, the retina and, possibly, the choroid be- come detached, and partial phthisis bulbi results. If, however, a foreign body has entered the vitreous, the resulting suppuration is much more intense, extends beyond the vitreous to the retina and uveal tract, and panophthalmitis is the result. The symptomatology of hyalitis is, from a clinical stand-point, somewhat dif- ficult to define, especially in the case of suppurative hyalitis, because of the rapid occurrence of suppura- tive choroiditis. The symptoms are best observed in a case where a foreign body has entered the vitreous. The first ophthalmoscopic sign is a delicate opacity, which, following the course of the foreign body, becomes in- tensified immediately around the latter. This opacity is at first diffuse, like fine powder or dust, but this soon becomes circumscribed and condensed, and membranes are developed which obscure the location of the foreign body, and it may eventually become entirely encysted. In such a case the foreign body is attaphed to the point of scleral penetration by a cord of connective tissue, and sometimes by another cord to the point on the interior of the eye which it struck before it rebounded. These cords are the direct cause of the detachment of the retina and choroid, so frequently met with in these cases. If, on the contrary, the foreign body does not become en- cysted, the diffuse opacity in the vitreous extends rapidly toward the lens, so that it soon becomes visible to the eye by oblique illumination, and indicates the presence of an abscess by its yellow color. The microscope has taught us that these ophthalmoscopic signs are due to the presence of great numbers of cells which are in pro- cess of transformation into cellular tissue. The wandering cells may gradually, by their organiza- tion, transform the vitreous into a dense cellular tissue. Vision is, of course, seriously affected very early in the course of a hyalitis, and is rarely, if ever, restored to the normal standard. Purulent infiltration of the vitre- ous sometimes follows operations, such as extraction of ca- taract where there has been prolapse or loss of a portion of the vitreous. In chronic cases of simple optic neuritis or of neuro-retinitis of a low grade, this dusty opacity or infiltration of the vitreous is sometimes seen limited to a narrow posterior zone close to the entrance of the optic nerve. This is probably owing to the proximity of the intervaginal lymph-space around the optic nerve, and to the ease with which migration of leucocytes might oc- cur from this space into the vitreous. As regards the treatment of the various forms of hyalitis, the reader is referred to the article upon the treatment of the various forms of choroiditis, as the therapeutic measures are practically identical. Opacities of the Vitreous, Musca' Volitantes, Myodesopsia. -These are of two kinds, according to their origin, viz.: 1, Opacities arising from the migration and organization of cellular elements ; 2, opacities which result from the detritus of the natural fibrillary and cellular elements of the vitreous body and hyaloid membrane, and the crys- tals of cholesterine and tyrosine found sometimes in a fluid vitreous. Clinically, however, three varieties of vitre- ous opacities may be distinguished : 1. The so-called dust or punctate opacity, occurring in the anterior or posterior zones of the vitreous, and met with in cases of retinitis or chorio retinitis of syphilitic origin. 2. Filamentous, flaky, or globular opacities, the most frequent of all. They are very mobile, floating rapidly with every move- ment of the eyeball, and sinking through the more or less fluid vitreous to the bottom, when the eye is in a state of rest. These opacities are also met with most fre- quently in the anterior or posterior zones of the vitreous, and are sometimes due to idiopathic changes in the vitre- ous, and sometimes to haemorrhages into the vitreous, or to disease of the retina or choroid. When they occur sud- denly, and are of considerable size, they are always due to extravasations of blood, and the haemorrhage comes more frequently from the vessels of the retina or sheath of the optic nerve than from those of the ciliary body and choroid. These haemorrhages have been seen to start from the margin of the optic disk and enter the vitreous in the form of fringed, flake-like opacities, and are not infre- quently met with in patients who are the subjects of diabetes or Bright's disease. All haemorrhages into the vitreous are very slow in disappearing, and the coagula may remain for years without undergoing any apprecia- ble change. When the vitreous is seen to be more or less completely occupied by such a filamentous or floc- culent opacity, we may be certain that the eye has been the seat of repeated extravasations of blood into the vitre- ous, which are often loosely attached to the retina or choroid. The movable opacities are the source of great annoyance to the patient, and cause more or less disturb- ance of vision by the shadows which they cast upon the retina. Real opacities of the vitreous, the products either of inflammatory action or haemorrhage, seriously af- fect the vision. If they are diffuse, they veil more or less completely the entire visual field. 3. Membranous opacities, the least frequent of all, and the result either of a circumscribed or diffuse hyalitis, or of extensive ex- travasations of blood, coming either from the vessels of the sheath of the optic nerve or, in cases of injury, from the choroidal and ciliary vessels. These membranous opacities destroy vision for small objects. They fre- quently become organized, and in the process of con- traction are apt to cause detachment of the vitreous, and not infrequently detachment of the retina and choroid also. The prognosis, of course, varies with the nature and origin of the opacities. When due to extravasation of blood, without any grave lesion of the uveal tract, they may be absorbed, though this is an excessively slow pro- cess. But, usually, vitreous opacities are more or less permanent, inasmuch as there is generally present more or less extensive disease of the uveal tract, or some per- manent disturbance of the general circulation. The treat- ment should, of course, be in accord with the etiological conditions, and should consequently be most frequently that of the accompanying disease of the choroid. If the latter is present the patient should use atropia, wear dark glasses, and be careful to avoid exposure to bright 680 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vitreous Body. Vitreous Body. light, and all errors of diet. The internal administration of potassium iodide, mercurials, and laxatives sometimes does good. Much has been claimed for the subcutane- ous injection of pilocarpine and for the internal adminis- tration of infusions of jaborandi, in inducing diaphoresis, and thus aiding in the promotion of absorption of these vitreous opacities. Some authors also claim good re- sults from repeated paracentesis of the anterior chamber. If the opacities are of long standing, something may perhaps be gained by the application of the constant current in inducing absorption. In the case of opacities due to extravasations of blood, the patient should be kept quietly on his back. Heurteloup's artificial leech should be applied to the temple, and cold compresses applied directly to the closed lids, alternating with the pressure-bandage. Synchysis Simplex and Synchysis Scintillans.-The vitreous body may lose its normal gelatinous consistence, and become more or less fluid. This occurs almost con- a remarkable phenomenon, which consists in the pres- ence of crystals of cholesterine, tyrosine, and the phos- phates in the fluid vitreous. The probable cause is the decomposition of the w'andering cells in the softened vitreous and the precipitation of the elements of decom- position, crystals and fatty particles. The ophthalmo- scopic picture of synchysis scintillans varies in different cases. Sometimes numerous shining particles are seen, which move very rapidly with every motion of the eye- ball, and gradually sink to the bottom of the vitreous when the eye is quiet. Sometimes these shining parti- cles seem fixed in certain layers of the vitreous, on membranes or filamentous opacities. They are seen most frequently in the anterior portion of the vitreous near the posterior surface of the lens. Persistent Hyaloid Canal and Artery.-During intra- uterine life the hyaloid artery crosses the vitreous body through the hyaloid canal, from the optic disk to the hyaloid fossa, and almost always disappears at the end of foetal life. In rare cases, however, it persists through life, and may be seen with the ophthalmoscope as an opaque cord, surrounded by a grayish zone. Zehender has claimed to have seen a red color in this cord, asso- ciated with undulatory movements. Wecker has seen this artery attached to a dislocated lens. Vision in these cases is somewhat impaired. Formation of New Vessels in the Vitreous Body.-Blood- vessels have occasionally been seen in a more or less transparent vitreous, and Wecker claims that what Manz has described as retinitis proliferans is nothing more than the result of organized extravasations of blood in the vitreous, which come from the blood-vessels of the intervaginal space and optic nerve. These are always met with in the posterior and central portions of the vit- reous. Of course, the formation of these new vessels must have been preceded by an inflammatory process. If this view be the true one, neither the retina nor the vitreous has probably had any part in their formation. There are, no doubt, many instances of the development of new vessels in cases of diffuse hyalitis, especially of the plastic type ; but, as such cases do not admit of oph- thalmoscopic diagnosis, they are to be regarded as of purely pathological interest. Foreign Bodies in the Vitreous Humor.-The foreign bodies most frequently met with in the vitreous are particles of metal, grains of lead or powder, and frag- ments of glass, wood, or stone. When such a foreign body has entered the vitreous, and the media of the eye are still clear enough to admit of an ophthalmoscopic ex- amination, it may sometimes be seen, or its presence may be located, by an examination of the field of vision. The degree of force with which the foreign body penetrated the eye, the position of the patient at the time of the ac- cident, and the existence of more or less violent inflam- matory reaction, all, how'ever, modify any diagnosis as to location. If the foreign body become encysted, it may remain for a long period quiescent, without occasioning any disturbance. Still this immunity of the injured eye is never certain, and it may be destroyed long after the injury by violent inflammation. The degree of irritation produced by the entrance of a foreign body may, how- ever, to a certain extent be piedicated, if we know the nature of the foreign particle. Experiments have proved that the simple presence of a foreign body not prone to chemical decomposition, or not containing any germ of an inferior organism, never provokes inflammation in the interior of the eye. Aseptic particles of oxidized metal do not give rise to purulent inflammation, though they may cause grave lesions in the eye, such as acute atrophy and detachment of the retina, with general disintegration of the retinal elements. If, however, germs of inferior organisms have been introduced with the foreign body into the vitreous, suppurative inflammation always en- sues. The inflammation caused by the development of microbes is due to the production of chemical substances by the vital conditions of these microbes, which are pro- vocative of inflammation. Experiments have shown that particles of copper are more likely to set up suppu- ration in the vitreous than particles of steel or iron, if Tig. 4'i()9.-1. Tufts of crystals of tyrosine attached to crystals of cho- lesterine. 2. Spherical masses of tyrosine. 3. Crystals of tyrosine de- posited on cholesterine, with spherical phosphatic masses. 4. Plate of cholesterine with a split or cleft, to which are attached tyrosine needles. 5 and 6. Cellular elements of the vitreous, in one of which the proto- plasm is stuffed with phosphatic crystals. 7. Cells attached to a spheroidal phosphatic mass. 8. Large spheroidal phosphatic mass, in the interior of which are numerous cellular elements. 9. Large spheroidal phosphatic mass, covered with crystal needles. All these figures are taken from a case of synchysis scintillans. (From the article by De Wecker, on Diseases of the Vitreous, in the Traite Complet d'Ophthalmologie, Tome II., 2d fasciculus, by Wecker & Landolt, Paris, 1884.) stantly in chronic inflammation of the vitreous body of considerable extent. This fluidity of the vitreous is met with most frequently in the region of the ciliary body and in the vicinity of the entrance of the optic nerve. The synchysis can be diagnosed with certainty only when opacities of the vitreous are also present, which, by the rapidity and extent of their movements, indicate the de- gree of fluidity of the substance in which they float. It w'as formerly supposed that tremulousness of the iris was a sign of synchysis, but it is now known that this is due simply to the fact that the suspensory ligament of the lens has been stretched or ruptured and the lens dis- located, and thus the iris has lost the support on which it naturally rests. It has also been supposed that softness or hypotonus of the eyeball was a sign of synchysis ; but this excessive softness of the globe, which is the begin- ning of an essential phthisis, rather indicates a condensa- tion of the anterior layers of the vitreous body. Partial fluidity is chiefly met with in cases of sclerotic ectasia, and in the corresponding portion of the vitreous. Gen- eral liquefaction is also observed in staphylomatous eyes, in cases of intraocular effusion, after dislocation of the lens or loss of vitreous, and in cases of choroiditis. It is very common in old persons. Synchysis scintillans is 681 Vitreous Body. Voice. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. they are in contact with the iris, ciliary body, or retina. If these particles are, however, suspended in the vitreous, suppuration is not likely to ensue. One of the great dangers resulting from the presence of a foreign body in the eye is the liability of sympathetic inflammation in the other eye. Hence it is always important, when a foreign body has entered the vitreous, to ascertain whether it can be extracted. If it is still in the lips of the wound, it may be readily extracted. If it can be felt w th the probe in the vicinity of the wound the lat- ter should be enlarged, and the foreign body seized w'ith the forceps and extracted. If the particle has entered the eye and cannot be felt with the probe, a careful ophthalmoscopic examination should be made, if the media are clear, for the purpose of locating it, and at the spot where it is believed the foreign body may be most easily reached a longitudinal incision should be made through the sclerotic and choroid, and an attempt made to seize the object with forceps or hook, previously sterilized. If the foreign body be of iron or steel the extraction should be attempted with the electro-magnet, and it is sometimes necessary to insert the magnet sev- eral times in all possible directions. If this method prove successful, and the foreign body is extracted, the wound in the sclerotic should be closed with sutures. When a traumatic cataract has resulted from the injury, it is per- haps better to extract it and then introduce the pole of the magnet through the corneal wound. If the operation prove unsuccessful in removing the foreign body, it will be necessary to eviscerate the contents of the globe or enucleate the eyeball, in order to prevent possible sym- pathetic inflammation of the fellow-eye. For a success- ful extraction of a foreign body by the magnet three conditions are wellnigh essential: 1, The media must be clear enough to admit of a localization of the foreign body by means of the ophthalmoscope; 2, its position and size must be of such a nature that they do not de- mand too large an incision nor too deep an introduction of the instrument; 3, these attempts at extraction should be made shortly after the injury. Entozoa in the Vitreous Humor.-The entozoon most frequently met with in the human vitreous is the cys- ticercus celluloses. This affection is common in the North of Germany, but rare in most other countries, and al- most unheard of in the United States. The diagnosis of the presence of a cysticercus is not always an easy matter. If an opportunity occurs of observing the development of the entozoon before it enters the vitreous the oph- thalmoscope shows, in the fundus, a bluish-gray opacity situated between the retina and choroid, strongly resem- bling a detachment of the retina. This opacity slowly increases in extent and density, and the retinal vessels gradually grow indistinct. This bluish-gray, transpar- ent vesicle shows at its periphery a clear, slightly reddish reflection. The most pathognomonic symptom of the presence of a cysticercus is the mobility of this grayish vesicle when the eye is kept perfectly still. Occasion- ally the head and neck of the animal are to be seen, as they are projected forward and then retracted into the vesicle. The shape of a perfectly movable cysticercus, after it has entered the vitreous, is spherical, with an ill- defined brilliant reflex at one point of its surface. Care- ful observation of this particular reflex demonstrates a square head and muzzle on the end of a neck of varying length, according to the degree of projection from the vesicular body. When the neck of the animal is fully extended, the head may be seen at times to rotate, and then an excellent view may be obtained of the circle of hook-like processes which surround the mouth. The movements of the neck, head, and processes are some- times incessant. Of course, any detailed observation of these movements demands an absolutely transparent con- dition of the media of the eye. At a later period the diagnosis may be rendered difficult by opacities of the vitreous. These opacities are said to be characteristic, appearing as a system of curtains or veils the folds of which appear under the ophthalmoscope as furrows or deep striae, varying in shape with the movements of the eye. Sometimes strange changes are seen in the fundus of such an eye, such as a large, brilliant white patch, resembling a recent mass of exudation, and which rep- resents the point at which the cysticercus passed through the retina. This patch is usually surrounded by masses of pigment. The usual disturbance at first consists of a well-defined scotoma in the visual field, in the form of a black spot; but, when the later changes have occurred, this disturbance of vision extends all over the field. As these intraocular changes progress the opacities in the vitreous become denser and more numerous, and finally entirely conceal the cysticercus from view, and the vision is usually lost by an extensive detachment of the retina. A chronic irido-choroiditis and cyclitis is then developed, ending in phthisis bulbi, or, more rarely, in purulent panophthalmitis. The course of the disease is always disastrous, and usually somewhat rapid, and an early at- tempt should therefore be made to extract the cysticercus. Of course, such an operation means an extensive incision through the sclerotic and choroid, and the loss of more or less vitreous humor. The best results have been ob- tained by Alfred Graefe, of Halle, who has devised an ophthalmoscope for the special purpose of determining the precise location of the animal. Having located it, he makes a longitudinal incision in the sclerotic as in the operation for detachment of the retina, if the cysticercus is still between the retina and the choroid ; but if the animal is in the vitreous, his incision is carried directly into the vitreous. The conjunctiva is first carefully dis- sected free from the sclerotic, and then an incision, about 8 mm. long, is made slowly through the sclerotic, and, if necessary, directly into the vitreous. Sometimes the cysticercus presents at once in the wound ; if not, it must be searched for and withdrawn with the forceps. The wound is then to be closed with sutures, and antisep- tic dressings applied. Should suppurative inflammation ensue, the eye must be enucleated. Graefe reports six- teen cases of successful extraction of a cysticercus and preservation of the vision, but in all these cases the ani- mal was situated between the retina and choroid, and its localization was perfectly easy. In most of the other cases hitherto reported the results of the operation have been unfavorable. A much more rare entozoon which has in certain cases been met with in the human eye is the filaria spiralis. This worm looks like a delicate thread or filament, about six lines long and a tenth of a line thick, with one end somewhat larger than the other, and has a serpentine motion. This entozoon is met with not infrequently in the vitreous and anterior chamber of the horse. Detachment of the Vitreous Body or Hyaloid Mem- brane.-Detachment of the vitreous humor or of the hy- aloid membrane is of serious danger to the safety of the eye, as it frequently leads to detachment of the retina. It is almost always the consequence of injuries- such as extraction of cataract and other perforating wounds-either through loss of vitreous or from shrink- ing of the degenerated vitreous. It has also been ob- served in connection with high degrees of myopia, in cases of anterior staphyloma, after the occurrence of serous, purulent, or hemorrhagic extravasations within the eye, or as the result of neoplastic growths between the vitreous and retina. Iwanoif considers that there are two varieties of detachment of the vitreous occur- ring after injuries. One variety occurs immediately after the injury, in consequence of the diminution in the con- tents of the eyeball and the vacuum thereby produced. In the other variety the detachment occurs gradually, and depends upon slowly progressive changes in the vitreous. Some authorities think that the suddenly formed uniform opacity in the posterior segment of the vitreous which is often seen in sclerectasia posterior is a detachment of the vitreous. No means have yet been discovered for remedying detachment of the vitreous body. Ossification of the Vitreous Body.-Ossification of the vitreous humor, forming what may be called osteoma cor- poris vitrei, has been described by Wittich and Virchow. The latter speaks of it as of rare occurrence in man, and as being always associated with phthisis bulbi, the re- 682 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Vitreous Body. Voice. suit of a suppurative process or hyalitis. The vitreous humor is subsequently transformed into a solid fibrous mass, which in contracting assumes the form of a solid cord, enlarged at the ends. In the anterior end of the cord, close to the crystalline lens, the osseous tissue, ac- cording to Virchow, is developed. Knapp, on the other hand, denies that osseous formations are ever developed in the vitreous. Charles Stedman Bull. VIVISECTION. There are but three States in which the statutes contain any reference to vivisection. These are New York, New Jersey, and California. The law of New York respecting cruelty to animals runs as follows : "If any person shall torture, torment, deprive of nec- essary sustenance ... or needlessly mutilate or kill, or cause or procure " the same to be done, to " any living creature, every such offender shall for every such offence be guilty of a misdemeanor." Following this section there is a paragraph relating to vivisection : " Nothing in this act contained shall be construed to prohibit, or interfere with, any properly conducted sci- entific experiments or investigations, which experiments shall be performed only under the authority of the fac- ulty of some regularly incorporated medical college or university of the State of New York."1 In California the law is substantially the same.2 Construing these sections together, according to a fa- miliar legal principle, the law in New York and Cali- fornia regarding vivisection may be stated as follows : Vivisection is lawful when performed under the author- ity mentioned and when " properly conducted." If improperly conducted, that is, with the infliction of needless or unjustifiable suffering, the offender would be guilty of a misdemeanor, which is punishable in New York by fine or imprisonment, or both, the maximum penalty being one year in the county jail, including thirty days of solitary confinement, and a fine of two hundred and fifty dollars. In California, also, fine and imprisonment may be imposed for this offence. Vivi- section undertaken without the authority prescribed in the statutes is punishable in like manner. It might be contended that a surgeon who should prac- tise vivisection on his own responsibility, unprovided with the authority mentioned, would not even then be guilty under these statutes, unless it were shown that he inflicted suffering "needlessly" ("cruelly" is the prac- tically synonymous word used in the Californian statute), and that needlessly would mean without a compensating gain to medical science. Under this construction of the statute any surgeon might practise vivisection, subject to the contingency of being adjudged to have inflicted suffering without sufficient excuse. The undertaking would be a dangerous one, however, for a judge or jury might have opinions as to the comparative value of the results obtained which would differ widely from those of the vivisector himself. The better construction is, moreover, that the legislature intended to make unlawful all vivisection not performed under the prescribed au- thority, and that, if any person practises it independent- ly, he is guilty of a misdemeanor. This would be the case even though no suffering were inflicted, for there would be mutilation, and perhaps killing. In New Jersey the law and the penalty are sub- stantially the same, except that the authority under which vivisection may there be performed, if " properly conducted," is that of any " incorporated medical society of the State." 3 In all the other States, with few exceptions-and the exceptions, doubtless, will soon disappear-there are laws against cruelty to dumb animals. In these States, there- fore, vivisection-at least such vivisection as is performed without the use of anaesthetics-might or might not be adjudged to come within the statute. In each case there would be a question whether suffering had been inflicted needlessly or cruelly, and each case would be decided according to its own circumstances and to the views of the particular tribunal before which it came. In the in- terest both of the medical profession and of dumb ani- mals, it is to be hoped that the statute of New York will be copied by all the States, and it would be well if the law were somewhat extended. In Great Britain the buildings in which vivisection may be performed are licensed, and there is an inspector to see that the provi- sions of the statute are carried out. In this way, addi- tional precautions are taken. It is scarcely necessary to point out that such regulations do not hamper the com- petent and conscientious surgeon, and that they tend to make vivisection legally possible everywhere, because they render it free from objection in the view of the peo- ple generally. Henry Childs Merwin. 1 Revised Statutes of New York, vol. iii., p. 2526. 2 Derring's Annotated Codes and Statutes, vol. iv., p. 460. 3 Revision of Statutes of New Jersey, p. 28. VOICE AND SPEECH, PHYSIOLOGY OF. The voice in man is the effect produced upon the auditory nerve by sonorous vibrations originating in the larynx and modified by the resonating cavities above. The primary laryngeal mechanism consists of the inferior or true vocal bands, which are thrown into vibration by the im- pact of a column of air passing upward from the tra- chea, which vibration is modified by the length, tension, and degree of elasticity of the bands. Some further modification results from the changing shape of the su- perior compartment of the larynx. Considered as an apparatus for the production of musical sounds, the larynx may be said to resemble a reed instrument. This class of musical instruments is characterized by partial closure of an orifice, either by a vibrating metallic or wooden tongue, or by the interposition of a membra- nous diaphragm. As the blast of air escapes through the opening, the tongue or membrane, which opposes its exit and thereby produces an increased tension in the column of air, is thrown into vibrations the rapidity of which varies inversely with the length of the vibrating reed or cord, and directly with the square root of its elas- ticity. The sound does not result directly from the vi- brations of the obstructing body, but from the sonorous waves produced in the outcoming aerial column by its alternate condensation and rarefaction. Another factor which directly affects the pitch of the tone is the force with which the air is driven through the obstructed ori- fice. The entire range of the human voice, considered as em- bracing all of its four different qualities-bass, tenor, contralto, and soprano-is about four octaves, extending from E, with eighty vibrations per second, to C", with one thousand and twenty-four vibrations. Exception- ally low bass voices or high sopranos may pass these limits on their respective sides of the scale, but this is about the average. In the production of the voice, or phonation, the vocal bands are drawn inward toward the median line or adducted, narrowing the outlet of the trachea to a slit, which is known technically as the chink of the glottis. Air is then forced upward from the tra- chea by the contraction of the muscles of expiration, and the vocal bands are thrown into sonorous vibration as described above. In different parts of the scale the mechanism varies somewhat, giving rise to an alteration in the quality of the pound or timbre. These different qualities of the voice are designated by singers as the vocal registers. In the male voices, bass and tenor, there are two registers-the lower, and medium or fal- setto ; in the female voice there are three-lower, medium, and upper. The following description of the mechanism of these registers is based upon the researches of Dr. Thomas R. French, of Brooklyn.1 Previous to the appearance of Dr. French's first article upon this subject there was nothing which could be considered as a scientific study of the physiology of the singing voice. The statements of various writers, based upon more or less skilful and desultory observations with the laryngoscope, and with- out accurate means by which the results of these obser- vations could be recorded and compared, are extremely conflicting, there being as many different theories of the production of the registers as there have been writers 683 Voice. Voice. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. upon the subject. Dr. French has employed photog- raphy as the only reliable method at our command for the registration of the phenomena observed in singing through the different notes of the musical scale, and has based his deductions upon the comparison of hundreds of such records, consisting of photographs of the larynx dur- ing the actual emission of every note in the scale, from below upward. While it is not claimed that the study is complete as yet, or that all the points in regard to it are to be considered as fully determined, these results may be accepted as trustworthy so far as they go. In study- ing the vibrations of the vocal bands, it appears to the writer that we should have regard not only to the vary- ing length and tension which they present at different times but also to the fact that, through the alterations in their shape and density which may result from the ac- tion upon them of the muscular fibres by which they are controlled, their elasticity may be changed so that the same vocal band with the same length and degree of tension may have different sonorous qualities conferred upon it by variations in its breadth, its density, and the sharpness of its vibrating edge. These changes are in all probability caused by the combined or independent action of the fasciculi of the internal thyro-arytenoid muscle. This muscle, which arises from the anterior portion of the thyroid cartilage, just external to the an- terior attachment of the vocal band, and is inserted into the anterior border and angle of the arytenoid cartilage, may be fairly considered as forming a part of the vocal band itself. The latter may be described as composed of the thyro-arytenoid muscle, which forms its body and which is covered by the angular projection of the mem- brana elastica laryngis and by the mucous membrane. The membranous portion forms the true vibrating ele- ment of the band, and its tension and elasticity are regu- lated by the contraction and changes of form of its mus- cular body. This is what is understood as the internal tension of the vocal band. The length of the band is fur- ther regulated by the contraction or relaxation of the crico-thyroid muscle, which approximates the anterior portions of the cricoid and thyroid cartilages, and so in- creases the distance between the arytenoid cartilage and the anterior angle of the thyroid, as described in the arti- cle upon the Larynx. This muscle also contributes to the regulation of the tension of the band. As the latter is lengthened.it is necessarily put upon the stretch, and so, pari passu, its tension is increased. The mechanism of the approximation and separation of the vocal bands has been already described in the article upon the Lar- ynx. It may fairly be assumed that, when the parts are arranged for a particular register of the voice, the in- trinsic elasticity of the band is first established through the action of the thyro-arytenoid muscle; then, begin- ning at the lowest note of the register, the band is grad- ually lengthened and stretched as the ascent is made from one tone to another. When the highest tone which can be produced in this way without strain is reached, the adjustment is changed, the band shortens, its internal tension is altered, and then, by gradual lengthening and stretching, the new series of notes is evolved. When this readjustment occurs a sudden break or change in the voice is observed, or, in the phraseology of musicians, the singer strikes another register. The tran- sition from the lower to the middle register takes place at or near F sharp, treble clef, first space. The exact note varies in different individuals. It may be a tone or two above or below F sharp, but the general rule applies to all voices, male as well as female. The second change -namely, from the middle to the upper register-is ob- served at or near F sharp, treble clef, top line. This upper, or head, register is peculiar to the female voice. The observations from which these deductions were ar- rived at were mostly upon untrained voices. No attempt was made by the observer to control the manner of sing- ing, and the change from one register to another was en- tirely involuntary on the part of the subject. With trained singers it would probably be found that there was less diversity in regard to the point at which the passage from one register to the other was accomplished, but this results from the fact that, according to the canons of vo- cal music, the registers should always be changed at the same note. Dr. French is right in maintaining that, from a physiological point of view, observations should be made as far as possible upon natural, untrained voices. In addition to the changes in the vocal bands already described, there is another which is found to occur irreg- ularly in the singing of the upper registers in both sexes. At some point in this register the production of the tone is apparently facilitated by still further shortening of the vocal bands. This is accomplished through what is described as " stop-closure that is to say, by the appo- sition of a portion of the bands the length of the vibrating part is diminished. In the upper or falsetto register of the male this may occur at any point: sometimes pos- teriorly, when the glottis is seen to be open only at its anterior extremity ; sometimes anteriorly, so that only the posterior part is patulous; and occasionally at the centre, leaving two openings-one behind and one in front. Observation of this fact with the laryngoscope has led writers to describe this abbreviation of the vocal chink as the true mechanism of the falsetto or head registers. It is shown, however, by Dr. French, from the compari- son of many series of photographs in which all the notes of the upper register are recorded, that the time of its oc- currence varies very much with different voices. It occurs with some singers in the lower notes of this reg- ister, with some toward the middle, and with some above ; while in the falsetto of the male it sometimes does not occur at all. Some give the "stop-closure " at a certain point in the ascent, and not above, while in others it does not occur at all, the entire vocal aperture remaining open, and the edges of the vocal bands parallel, throughout all the notes of the register. The following concise statement of the position of the cords in the dif- ferent registers of the female voice is taken from a per- sonal communication from Dr. French : " Lower register -loose and short vocal bands, increasing in length with greater tension and closer approximation as the scale is ascended ; middle register-bands again shortened, but with greater tension and closer approximation than in the lower register, with increasing length, greater tension, and closer approximation as the scale is ascended ; upper register-cords again shortened, with still greater ten- sion, the same series of changes as in the other registers, and, in the lower portion of the register there may or may not be stop-closure. If this does not occur in the lower portion of the register it will almost invariably be present in the upper." The differences in the quality of voices are due to the shape of the larynx and of the upper resonating cavities -the nasal cavities, their communicating sinuses, and the mouth. As a rule, bass voices are seen with large larynges and long and broad vocal bands. In tenors the larynx is usually smaller and more delicate. The same relation exists between contraltos and sopranos; the contralto larynx being larger, with longer and broader vocal bands. It may be remarked, in the conclusion of this subject, that the breadth of the vocal bands is only apparent; in other words, they simply look narrower or wider to the laryngoscopist, but whether there is an actual differ- ence in their horizontal dimensions or not we are un- able to say, as apparent narrowing may result from greater overlapping of the ventricular bands. We may further add that the statement, that in singing the me- dium register only the inner edges of the vocal bands are thrown into vibration, has not been established as a fact, and that its actual occurrence during the production of the voice in the living subject is not susceptible of dem- onstration, so far as we know. Speech.-Speech is the communication of ideas from one individual to another by means of modified vocal sounds. In the ordinary speaking voice only three or four tones of the chest-register are used. Syllables and words consist in the use, either singly or in combination, of different sounds and noises, the former of which are 684 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Voice. Voice. called vowels and the latter consonants. A vowel is a sound of a certain fixed quality, made up of a musical note originated in the larynx and modified by the addi- tion of certain overtones communicated to it in the pas- sage of the aerial current through the upper air-passages. The original tone may vary throughout the entire musi- cal scale, but its quality, which results from the position of the palate, tongue, and lips, is always the same. A consonant is a noise which either precedes or terminates a vowel-sound. In the study of this subject the student should always bear in mind that the name of the charac- ter which represents the vowel or consonant in written or printed language is not the speech-element itself, but is, in the case of the consonants, a syllable made up by a vowel and the consonantal modification which is in- tended to be indicated. As the consonants are not really sounds, but simply the interruption or modification of them, they are not generally susceptible of being spoken. FoweZ-sounds are : ah, as in father ; a, as in fate ; e, as in meet ; aw, as in thought; o, as in go ; oo, as in poor ; a, as in that; e, as in met; i, as in pit; o, as in not. The principal diphthongs * are : i. as in ice ; oi, as in joy ; ow, as in now ; u, as in jute ; wi, as in wide. The consonants are produced by changes in the shape of the buccal cavity and pharynx. They are divided by Briicke2 into explosives, aspirates, resonants, and vibra- tory sounds. Explosives.-These are produced by suddenly open- ing or closing the passage at one of the points men- tioned f during the expulsion of air : a, Without the aid of the voice, P, T, K ; b, with the aid of the voice, B, D, G (hard). Opening of the passage is necessary for the formation of one of these consonants when it begins a syl- lable ; closure, when it ends one (e.c/., pa, ap). As P, T, and K are distinguishable from B, D, and G, respectively, only by the absence or presence of the voice, no sharp distinction is possible between them during whispering. 2. Aspirates.-The passage is constricted to a small slit, through which the current of expired (or inspired) air can rush. Hence arise the following consonants : a, Without the aid of voice F, S (sharp), Ch (guttural) ; b, with the aid of voice, V, Z, J (as in the German " ja," etc.). At the constriction between the tongue and the palate a second aspirate may be formed, in addition to the sharp S, viz., L, by completely closing the passage in front and allowing the air to escape only at the sides between the molar teeth. By forcing air through two narrow spaces situated one behind the other-viz., that between the tip of the tongue and the hard palate and that be- tween the two rows of teeth-two other sounds may be produced : a, Without the aid of the voice, Sh ; b, with the aid of the voice, Zh. If a space be left between the tip of the tongue and both rows of teeth the following consonant-sounds are produced : a, Without the aid of the voice, Th (hard), as in thunder; b, with the aid of the voice, Th (soft), as in than. The guttural Ch may be produced near the front of the mouth as in the German word " ich " ; or near the back, as in " ach." F and V, etc., are distinguished in the same way as P and B, etc. 3. Resonants.-The current of air no longer passes through the usual opening, which is closed, but through the nose, which is left open by the depending soft pal- ate. The aid of the voice is necessary. The consonants thus produced are M, N. 4. Vibratory Sounds.-There are three varieties of the vibratory R which differ in their place of origin. The first is the labial R, produced by the vibration of the lips, which does not occur as an articulate sound in any European language ; the second is that produced by the vibration of the tip of the tongue in the constricted por- tion of the buccal cavity formed by the tongue and the teeth ; and the third is the guttural R. In order to pro- duce them, the pharyngo-buccal cavity is constricted at the necessary point, but not firmly ; and the margins are then set vibrating by the expiration of air. ^he vibra- tions are, however, too slow to give forth a definite note. The consonants may therefore be grouped in the follow- ing manner : Labials. Dentals. Gutturals. 1. Explosives: a. Without voice.. P T K b. With voice B D G 2. Aspirates: a. Without voice.. F S (hard), L, Sh, Th (hard) Ch (in ich & <.■ ii b. With voice V Z, L, Zh, Th (soft) J (in ja) 3. Resonants M N N (nasal) 4. Vibratory sounds. .Labial R Lingual R Guttural R H is the sound produced in the larynx by the quick rushing of the current of air through the widely opened glottis. Compound consonants are produced by suddenly open- ing the air-passage, previously closed, for the utterance of P, T, or K, as the case might be, and allowing the current of air to rush through the second of the before- mentioned places of constriction narrowed as if for the utterance of S (hard); thus are produced Ps (Greek Psi), Ts (German Z), and Ks (X). Other compound consonants are formed by the " rapid transition from the position of mouth necessary to produce one consonant to that necessary to produce the other." A syllable is formed either by a simple vowel-sound, as the article a, or by the introduction or termination, or both, of a vowel-sound by one or more consonants. Words consist either of single syllables or of several syllables combined spoken together. In speaking, a slight interval of time is allowed to elapse between the different groups of syllables, in order to indicate partic- ularwords. • The nervous mechanism of speech is motor and sen- sory. The motor nerves are those which control the res- piratory acts and the muscles of the larynx, pharynx, soft palate, lips, tongue, jaws, and cheeks. It results from this that the mechanism of speech is very compli- cated. The sensory apparatus includes the auditory nerve, through which the memory of sounds and w^ords, and their meaning, are acquired, as well as centres for the memory of the forms and qualities of objects, the memory of ideas, and the memory requisite for the proper combina- tion of the muscular movements of the vocal apparatus for the production of speech-sounds. With this may be included the motor apparatus employed in writing, and the ganglionic centres concerned in the memory of the forms of written characters and their combinations. Disorders of Speech. 1. Aphasia.-The interrup- tions of these various nervous functions is the basis of the different forms of aphasia. The four varieties of aphasia are: 1. The memory of the sound of the word is lost, and the sound cannot be recognized when heard. 2. The visual image cannot be recalled, and the patient is unable to read or write spontaneously. 3. Loss of memory of the muscular combinations necessary to pronounce a word ; in this case the muscles of articulation are not weakened, articulation itself is lost. 4. A loss of the memory of the muscular movements necessary for writ- ing. This is known as agraphia. The centres concerned in these acts are Broca's convolution and some por- tions of the island of Reil. In addition to these, a motor centre for the movements of the larynx has been located in the district supplied by the middle cerebral artery, in * Compound vowels or diphthongs are the result of a glide from one vowel-sound to another ; e. g., i is the combined sound of ah and e. + The " articulation-positions" of Brucke : viz., 1. Between both lips, or lips and teeth ; 2, between the tongue and hard palate or upper teeth ; 3, between the tongue and soft palate ; 4, between the true vocal bands. 685 Voice. Volition. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the vicinity of the island of Reil and the third frontal convolution.3 Besides these affections of speech, due to disease or injury of the cerebral centres, there are other morbid conditions, such as local paralyses and mechanical de- fects from malformations or injuries of certain parts of the speech-apparatus. 2. Aphonia.-Aphonia is the inability to produce au- dible vocal sounds. The patient speaks with a whispering voice. The fundamental note normally produced in the larynx is absent, and there is loss of power to alter the pitch of the voice. This is due to mechanical interfer- ence with the vibrations of the vocal bands, from either injury or the presence of inflammatory swelling or infil- tration of the vocal bands themselves, or of the contiguous parts ; to the presence of morbid growths ; to disease of the articulations of the cartilages of the larynx, or to paralyses or spasms of the muscles of phonation. Hys- terical aphonia is a psychical disturbance in which the patient is possessed of the erroneous idea that he or she is unable to speak. Some of these have been the subjects of supposed faith-healers, psycho-therapeutists, et hoc genus omne. 3. Lisping.-This results from the inability to properly form those aspirates in the production of which the tongue is placed against the upper teeth or the hard palate at their base. It results from the loss of teeth, from mal- formation of the jaws, or from faulty education. 4. The defects resulting from inability to interrupt the passage of air from the pharynx into the nasal cavities. This occurs in cleft palate ; in paralysis of the muscles of the soft palate, usually diphtheritic in origin ; from loss of portions of the soft palate through disease or injury ; and from various inflammatory and catarrhal affections in which the swollen condition of the mucous and sub- mucous layers either prevents the close and regular ap- position of the velum to the posterior pharyngeal wall, or interferes with the action of the muscles in this region. In these cases the escape of air through the nose pre- vents the proper formation of all those consonantal sounds in which the opening is partially or completely closed, and in the case of cleft palate interferes with the production of most of the aspirates. Vowel-sounds may also be impure, because of the malformation of the res- onating cavities. In addition to the improper articula- tion, the air can be heard rushing through the nose during vocalization. 5. The obstruction of the nares by inflammatory swell- ing or morbid growths may partly or completely prevent the escape of air through the nose in speaking, and so interfere with the formation of the resonant consonants. M and N are usually replaced by P and B. 6. Stammering and stuttering are spasmodic affections of speech due, probably, to an abnormal action of the cortical motor centres. While, in many instances, the distinction between these two functional disturbances is well marked and easily recognized, they are sometimes combined. If we divide speech into vocalization and articulation, the cause of stammering will be found to lie in an error of the former; that of stuttering, in the later. In stammering there is a spasm of the muscles of inspiration, particularly the diaphragm. On attempting to speak, the victim of this unfortunate malady is seized with a spasm which, for the time, prevents expiration and vocalization. When this remits he is able to go on until a few words or sentences are enunciated, when a fresh paroxysm interrupts him, and he is compelled to struggle anew for breath and phonatory power. He can articulate distinctly, but lacks the power to regulate his breathing. Sometimes, during a violent paroxysm, there may also be a spasm of the laryngeal muscles. In stuttering, on the other hand, the difficulty is with the muscles of the tongue, lips, and face generally. Spasmodic contractions of these muscles, aggravated by the victim's painful consciousness of his ridiculous ap- pearance, prevent the adjustment necessary for the pro- duction of articulate sounds, and the repeated efforts result in that " damnable iteration" so characteristic of the affliction. By proceeding slowly, accompanying the enunciation by a rhythmical motion of the finger, or fol- lowing the measure of a musical composition, the dif- ficulty may be overcome, so that stutterers are usually able to sing and, frequently, to declaim. Not so the stam- merer. The latter gets little or no assistance from these aids. He must study to regulate his breathing by sys- tematic exercises, and by taking a deep, steady inhalation and commencing the expiration and getting it well under way before attempting to vocalize. Diseases and deformities of the mouth and upper air- passages, which have sometimes been assigned as causes of stammering and stuttering, are simply coincident con- ditions which may add to the embarrassment of the suf- ferer, and require treatment for that reason. Nervine tonics, sedatives, and antispasmodics, may be useful ad- juvants to the treatment. The latter should be hygienic and gymnastic in character. Stammering and stuttering, like other functional ner- vous diseases, are frequently hereditary, and may, also, be either originated or aggravated by imitation. Chil- dren, particularly those who inherit the tendency, should, therefore, never be allowed to remain long in the society of those who are already the victims of these speech defects. Benjamin F. Westbrook. 1 On a Perfected Method of Photographing the Larynx, N. Y. Medical Journal, December 13, 1884. Photographing the Larynx : an essay' read before the College of Phy- sicians of Philadelphia, April 1, 1885, and printed in their transactions, Third Series, vol. viii. Also a paper on the same subject read before the American Laryngo- logical Association, September 20, 1888. 2 Hermann : Elements of Human Physiology, London, 1875, p. 315. 3 Ueber die Localisation des corticalen motorischen Centrum des Larynx. D. Bryson Delavan, New York, 1887, contribution to the 8th International Med. Congress. VOLITION, DISORDERS OF. A discussion of dis- orders of volition would be quite unintelligible without giving at first some description of the normal psychology of volition. This is particularly the case for the reason that the terms used by metaphysical and psychological writers vary much in accordance with the school, and even the individual. The present writer follows in gen- eral the views of the modern physio-psychological teach- ers. The Psychology of Volition.-In a simple mental act, which begins with a sensory impression and results in a voluntary movement, we find by analysis the following steps : 1, Sensation ; 2, perception and apperception ; 3, ideation and feeling ; 4, judgment or choice ; 5, will and volition ; 6, muscular movement. Let us take an example. One sees an orange before him. The simple consciousness of a round yellowr ob- ject before the eyes is all that (1) sensation gives him. This sensation is immediately correlated with previous experiences with oranges, which have stored up visual, tactile, muscular, and gustatory memories. The process by which these past memories are associated with the present sensation of the yellow sphere is called (2) per- ception. Perception is a process, then, of associating past memory, or sensation-clusters, as they have been called, with the present simple and new sensation. The result is the (3) concept or idea of the orange.* With the production of this concept there is a mental activity called by Wundt apperception, which is the act of con- centration of the attention upon the special object that has excited the senses. Apperception is a form of voluntary attention, and contains an element of volition. With the concept of the orange, to return, there is asso- ciated (4) a feeling of, perhaps, an agreeable character, which suggests another feeling of desire for the orange. Now thought and reason come in, and the person com- pares and associates ideas. Finally he (5) judges or concludes that he will take the orange. But though he has concluded to take it, he has not done it, and may not. Will and volition have not yet come in. Eventually he decides and acts. * Some writers call the concept of a real thing a " perception," and give the term "concept" to a product of abstract reasoning or imagi- nation. There has resulted much confusion caused from thus calling perception sometimes a process, sometimes a result. 686 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Voice, Volition. In such decision with action there has been generated a positive psychic or nervous force. This is the will. The resulting innervation of the motor areas of the brain is volition. Will is a highly complex nervous discharge ; it is a form of energy, a force. Volition is the result ; it is the conscious flow of the energy to the motor areas. It cannot be too strongly insisted that the will represents the generation of a psychic influence or force, that voli- tion is its expression. Will is the cell, volition the trans- mitting force that causes movement. It is not easy to represent complex mental processes by a diagram, but in the present instance one may serve our purpose, it being understood that it by no means repre- sents a complete psychological analysis. In the diagram a simple reflex act is represented by the lines 1, 2', 7, 8, 8'. An instinctive act such as the quick, angry blow in return for an injury, or the sudden conscious movements that follow the sight of danger, is represented by 1, 2, 3 and 4, 7, 8. A voluntary act following an excitation of sense is in- dicated by the lines 1, 2, 3 and 4, 5, the lines connecting 3 to 5 with 6, 7, 8. The voluntary acts following a pro- cess of reasoning or the development of a feeling, are rep- resented by the lines connecting 5 or 9 with 6, and 7, 8, or 6'. The 8' repre- sents inhibition or re- pression of movement, for volition, it is not necessary to say, has for its effect inhibition, quite as much as exci- tation of motor activ- ity. It will be seen from the diagram that voli- tion is also a highly complex, reflex act. Only the reflecting force or energizing will has a most extraordi- narily complex origin, and may possibly in- volve a subtler element than pure physical en- ergy. The will is not an entity or a faculty of the mind, nor is it a spe- cific power enthroned within us. It is a de- termining force which is itself the complex result of in- herited and acquired experiences. It is the energizing power of the character. Its expression in volition rep- resents the reaction of the individual to the environ- ment. A man's volitions depend, therefore, upon the imprints and character of his brain as determined by heredity, education, and environment-plus, perhaps, something else. Modern psychology does not, to be sure, recognize anything as determining volition but the first three factors mentioned. Yet it is not impossible or unscientific to assume that some finer spiritual essence may also act in connection with these other factors. The noble scorn of the psychologists, who assert that the fac- tors known are all the factors, sometimes carries one away from the true scientific position, which is : to be positive about things known, and not to set limits on what may yet be known. With modern psychology such a thing as free will in the older sense is, of course, impossible. We react to our environment in accordance with the material make- up of our organism. The introduction of a spiritual ele- ment into the mechanism of volition might make a less gross fatalism, but upon this subject I have not space to dwell. The Disorders of Volition.-The mechanism that I have described may be disordered in various ways : I. The energizing force, which represents the "char- acter " or will-power, may be impaired so that the stim- uli sent up from 3, or 5, or 9, i.e., from thoughts, emotions, and desires, cannot arouse it at all or only feebly. This is called aboulia. II. The maze of centres and association tracts, repre- sented by the will, may be so highly sensitive that it re- ceives and inclines to react to every slight stimulus, and a world of confusing and antagonizing attempts at voli- tion occur. Or it is overloaded with stimuli from a brain crowded with ideas, or turbulent with conflicting feel- ings. III. On the other hand, the efferent tract from the will, 6, to the motor areas, 7, may have its functions suspended. Desire exists, resolution is formed, but no action, or only feeble action, follows. This would also be a form of aboulia. IV. Again, the will may energize too actively and violently, as in cases of acute mania, or perhaps in per- sons of abnormally positive and dictatorial character. This is called hyperboulia. Aboulic states are far the most frequent. V. There are also forms of volitional disorder in which a person wishes to do one thing, but immediately does another. It seems as though the association-tracts were mixed up, and impulses intended for one kind of conduct or one group of muscles go to another. This state may be termed paraboulia. We have therefore : 1. Aboulia, from tor- por of the will. 2. Aboulia, from an- tagonistic or over-nu- merous excitations of the will, or from an over-sensitiveness of the volitional mechan- ism to stimuli. 3. Aboulia, from im- pairment of the con- ducting tracts of voli- tion. 4. Hyperboulia, from excessive activity of the will. 5. Paraboulia, from misdirection of voli- tional impulses. These different dis- orders are best illus- trated by citing certain cases which have been reported by alienists : I. Take, for example, the first form, that of aboulia in which there is an atony or anaesthesia of the centres re- presenting 6, i.e., will. Illustrations of this condition occur in the early stages of melancholia and dementia. But, besides this, instances are cited in which the voli- tional torpor seems almost the only mental defect. Billed relates the case of a young Italian woman " of brilliant education," who became insane from having been crossed in love ; she recovered, but afterward fell into a profound apathy. " She reasons soundly on every subject, but no longer has any power of will or of love ; no consciousness of what happens to her, of what she feels, or of what she does. She says she is as one that is neither dead nor alive ; like one living in continual sleep, to whom objects appear as though wrapt in a cloud, to 'whom persons seem to move like shadows, and words to come from a world far away." Esquirol quotes the description given by a patient who was cured of aboulia : " My lack of activity," said the patient, " was owing to the fact that my sensations were too faint to exert any influence on my will." The same author, adds Ribot, has also noted the profound change such patients experience in their general sense of exist- ence (coenaesthesia). " My existence is incomplete," writes a patient to him. " The functions, the power of performing the ordinary acts of life, remain with me ; but, in the performance of them, there is always some- thing wanting, to wit, the sensation proper to each and the pleasure that follows them. Each one of my senses, Fig. 4610. 687 Volition. Volition. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. each part of myself is, so to speak, separated from me, nor can it now procure for me any sensation." In these cases the patients do not feel keenly enough to act, and the trouble might be said to be affective as well as volitional. Yet the paralysis of the will is the most striking phenomenon. In hysteria there is always some disturbance of volition. The trouble here seems to be a deficiency or torpor in the highest and energizing centre. The centres are anaesthetic. This is shown by the fact that such patients do not and cannot strongly re- solve ; while, on the other hand, powerful emotions some- times rouse up the dormant will and produce effective results. Hysterical aboulia belongs, therefore, in the main, to this first class. II. The condition known as folie du doute or grubel- sucht, the " doubting mania," well illustrates that form of volitional disorder in which the reflexive mechanism of the will is over-irritable and reacts to slight stimuli, producing a constant succession of contradictory, absurd, or useless acts. Examples of this kind of disorder are not rare ; I have reported a typical one in the Alienist and Neurologist, July, 1884. The patient was a gentleman, thirty years of age, who came to my office one morning complaining of head- pressure, buzzing in the ears, constipation, seminal loss at stool, feelings of weight and constriction in the ab- domen, sweating about the anus and buttocks, mental irritability, dislike to society, etc. He had been treated for these and other symptoms for ten years by a quack. He was then extremely anxious to get well, believing that his business future depended upon his rapid and complete recovery. I considered it a case of hypochondriasis, and laid out a plan of moral and medicinal treatment. I soon found that I was obliged to give him the most explicit details as to every act of his daily life. When, he asked, should he wash ? should he use cold or warm water, and at what exact temperature 'I and should he use soap and water or clear water ? should he wipe himself dry with a towel, and should he rub hard, and how long ? when should he shave ? and how many times a week ? should he take his pill with water ? etc. I was obliged to tell him exactly how much to walk and when ; to enumerate every article of diet, and to prescribe the exact limits of sexual indulgence. He had scarcely been gone from my office ten minutes when he returned, saying that Iliad forgotten to tell him whether he was to wash his hands in soap and water or clear water. Several other details he inquired after. In subsequent visits he rarely failed, after leaving my office, to come back again to inquire about some triv- ial matter. At the end of my consultations with him, which I could never make less than half an hour, he would insist on going over every detail of the treatment, diet, and mode of life laid down. He admitted that he was a nuisance and a " crank," and recognized his pecu- liarities in a measure. His constant desire was to get well, and he for a long time lived in the expectation that the next month or next spring he would suddenly get over his troubles and act like other people. He was book- keeper in a large banking house and held a responsible position, doing the duties satisfactorily. He was married to a sensible wife, who recognized his infirmities, and as- sisted, as much as possible, in judicious moral treatment. Another very good case is reported by M. Cabade {UEncephale, October, 1882). The patient, a man thirty-four years of age, was of a neurotic family, and had suffered from an attack of acute rheumatism with certain cerebral complications. The progress of the disease toward recovery was slow and painful, but eventually he seemed to have quite re- covered. Hardly, however, was convalescence estab- lished when he began to experience symptoms of the affection called "mysophobia." Then came troubles of volition. He could not make up his mind to pass through a door; before succeeding, he made many fruitless attempts, and often members of his family were obliged to encourage him by words, and even to aid him with their own hands to accomplish the act. From this time on he could not perform the most simple acts of life without difficulty and hesitation, and, when he had at last succeeded, he repeated them many times. For instance, if he were seated and wished to change his place, he w'ould rise, then sit down, then rise again, and so on, ten, fifteen, or twenty times, before he could decide.to take a step toward the point he desired to reach. If he were walking, and encountered a tree or a rock, he stopped before it, then retraced his steps, then resumed his original direction, stopped again, went back, returned, and so on, ten or twenty times, before he was able to pass the imaginary obstacle. Often, in order to pass the tree or stone which he came to in his walks, he was obliged to run. Often, after having suc- ceeded, he would retrace his steps, and then the whole series of hesitations was gone over again. Thus, one day, entering the consulting-room of M. Ball, he went out again quickly, then returned, saying, " I was afraid I had come in badly." A disorder similar to folie du doute has been described by Dr. Hammond under the name of " mysophobia," or fear of contamination. A case of this kind was reported by me in the Alienist and Neurologist, loc. cit. The patient, a young woman twenty-eight years of age, though in fair physical health, was kept in bed by her aboulia. She could walk, but would not, because it annoyed her so to dress and to touch anything. And if she walked out, the sight of anything, to her mind out of order, would upset her completely. She never dressed herself for fear of touch- ing something. Her mother dressed her, and if in that operation anything went wrong, she had to w'ash her and then start over again. For some time she bad been in the habit of washing her own hands and face, whenever the least particle of dust or anything else touched her. This kept her at the washbowl nearly all day, till her hands became wrinkled like a washwoman's. Finally the water was taken from the room. During my visit, she burst into tears, but did not dare to wipe them* away ; so she held her face up to her mother, who applied a handkerchief and dried the eyes. At one time, she had her mother make her a pair of cotton mittens to prevent her hands from getting soiled. She was equally particu- lar about the arrangement of things in her room. When the doctor came in he had to sit in a particular chair, placed in a particular position, and he was not allowed to step on particular parts of the carpet. The cases in which morbid fears produce paralysis of the will are in part volitional disorders, though not en- tirely such. In these cases the person is prevented from doing certain things by a sudden access of fear, produced without reasonable cause. Depressing emotions always depress volition, but in those suffering from morbid fear, emotion, in itself unreasonable, also unreasonably depresses the will. Beard has described many forms of morbid fears, and they are not infrequent in neurological practice. A patient of my own, a young man twenty-two years of age, suffered from agoraphobia and could with the greatest difficulty cross a street or open place. He came up to my office only by walking along the most crowded avenue, every now' and then darting into a shop when his fear became excessive. Many neurasthenic women become morbidly afraid of going out on the street alone, or even in company. Westphal (Archie fur Psych., vol. iii.) describes a good type of this disorder. " A traveller of strong constitu- tion, perfectly sound of mind, and presenting no disor- der of the motor faculty, is suddenly seized with a feeling of alarm at the sight of an open space-as a public square -of some little size. If he must cross one of the great squares of Berlin, he fancies the distance to be several miles and despairs of ever reaching the other side. This feeling grows less or disappears if he goes around the square, following the line of houses, also if he has some person with him, or even if he supports himself on a walking-cane." Carpenter quotes from Bennett a case of " paralysis of the will" which belongs to the class un- der discussion. " If, when walking in the street, this 688 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Volition. Volition. individual came to a gap in the line of houses, his will suddenly became inoperative and he could not proceed. An unbuilt-on space in the street was sure to stop him. Crossing a street also was very difficult, and on going in or out of a door he was always arrested for some min- utes." In this category belong also, for the most part, the dis- orders of volition that result from exuberant emotional states, or excess in purely intellectual pursuits. Persons with excitable emotions often lack volitional power, not because the mechanism of volition is defective, but be- cause it is injudiciously stimulated. On the other hand, persons who engage too exclusively in purely intellectual work, are accumulating knowledge and collating it, feel eventually an impairment of volition in most directions from actual disuse, or perhaps their will works badly be- cause it is stimulated by an excess of ideas and feelings. The mind is too full, reason too predominant, motives are in excess. Goethe expressed this when he said: " Action narrows but strengthens, thought broadens but weakens." . III. Cases of aboulia in which the defect seems to be rather in the associating or volitional tract than in the higher centres, are reported. Esquirol describes the fol- lowing case: "A magistrate," he writes, "highly dis- tinguished for his learning and his power as a speaker, was seized with an attack of monomania, in consequence of certain troubles of mind. He regained entirely his reason, but he would not go into the world again, though he acknowledged himself to be in the wrong in not doing so ; neither would he attend to his business, though he well knew that it suffered in consequence of this whim. His conversation was both rational and sprightly. When advised to travel or to attend to his affairs-' I know,' he would answer, * that I ought to do so, but I am unable. Your advice is very good ; I wish I could follow it; I am convinced ; but only enable me to will, with the will that determines and executes. . . . It is certain,' said he one day to me, ' that I have no will save not to will, for I have my reason unimpaired, and I know what I ought to do, but strength fails me when I ought to act.' " Dr. J. H. Bennett (Carpenter's " Mental Physiology," p. 385) records the case of " a gentleman who frequently could not carry out what he wished to perform." Often, on endeavoring to undress he was two hours before he could get off his coat, all his mental faculties, volition excepted, being perfect. On one occasion, having ordered a glass of water, it was presented to him on a tray, but he could not take it, though anxious to do so ; and he kept the servant standing before him half an hour, when the obstruction was overcome." He described his feelings to be " as if another person had taken possession of his will." To this class of impaired volitions belong the cases of opium habit and inebriety. However strong the resolu- tion mentally made, when temptation comes, there is absolutely no ability to resist, and the victim follows blindly the dictates of the morbid desire. The will is good, the intellect noble, the character naturally admir- able, but volition fails, and morbid instincts dominate. In the classes I. and II., the mind is usually not strong, but in this class are numbered some of the brightest in- tellects and most engaging personalities. There is char- acter, but it cannot assert itself. Besides these aboulic types, the volitional mechanism is suspended entirely in the condition known as hypnot- ism, and in the allied states of "ecstasy," (vide articles " Sleep," " Ecstasy "). Here we have total extinction of the will. The person is a thinking, feeling automaton. The whole volitional mechanism ceases to act. Of classes IV. and V., of hyperboulia and paraboulia, I shall say little, because they rarely occur as isolated dis- orders. Under the head of volitional disorders (class IV., hyper- boulia) some writers describe forms of insanity charac- terized by morbid impulses, instinctive mania, homicidal mania, etc. This, it seems to me, is hardly just. In the case of sudden violent impulses causing persons to commit ab- surd or criminal acts, the will simply has no share. There is rather a sudden discharge from emotive or ideational centres upon the motor areas (from 9 or 5.5 to 7, ride diagram). The disorder is an affective rather than a volitional one. I have spoken only of volition and its disorders as rep- resented by outward acts or conduct. But the will is also brought into play in conducting the operations of the mind, more particularly in centralizing and directing it in the phenomena of attention. The same kinds of disorder, however, may affect this, the highest phase of the volitional mechanism ; and, indeed, the disorders of the two parts generally go together. The impairment of voluntary attention is seen in luna- tics and in persons of feeble or unstable minds ; but, like other forms of aboulia, it may occur in the most gifted, as in the case of Coleridge ; or it may be acquired by bad educational methods, or by the use of drugs which de- grade the volitional powers generally. Voluntary atten- tion upon intellectual processes for a prolonged period is the most difficult form of mental work, and is only seen in its highest development in men of genius, like Newton. This latter, indeed, ascribed all his success to this power. Inability to control the thoughts, to fix the attention, is a condition often brought to the attention of physicians and educators. It is characteristic of feeble-mindedness and the hysterical temperament. It occurs whenever the brain is weary, and becomes chronic in chronic neuras- thenic states. It is not incompatible with very acute powers of observation. Anatomical Seat of Volition.-Since the will-energy is mainly or entirely the reflex of the individual character, it can have no special centre. Its activity depends upon that of the whole brain. But there is probably one por- tion of the cerebrum in which volitional work is espe- cially performed, viz., the frontal lobes. These lobes are large in man as compared with lower animals ; they are smaller relatively in women, children, and sometimes in imbeciles, in whom volitional power is less highly marked. Ferrier, Horsley, and Schaefer have observed a hebetude, or partial dementia, in mon- keys whose frontal lobes were removed. Goltz has found that, by washing away the frontal lobes in dogs, decided changes in character are produced. Lesions of the frontal lobes in man may be latent, but more often produce changes in character. The passions are the same, but intellect and volition are feeble, and the person's condition is one of irritable imbecility with silly ideas and delusions. Such a state is termed by German writers moria. Ferrier thinks that degeneration of the frontal lobes impairs chiefly the faculty of voluntary attention, a fac- ulty which is, of course, part of the volitional mechan- ism. In studying the relation of focal brain lesions to types of insanity, Jastrowitz ("Beitrage zur Lehre ueber die Localization, im Gehirn.," p. 33, Leipzig, 1888) reached only one conclusion, viz., that tumors of the frontal lobes were associated with a condition of dementia, with a peculiar foolish excitability. He has seen half a dozen such cases. Altogether, therefore, the evidence shows that the frontal or prsefrontal lobes are closely connected with Volition. Pathology.-Leaving out of consideration cases of disordered volition due to insanity, idiocy, brain inju- ries, and gross diseases, and including only quite pure volitional disorders, we shall find no pathological anat- omy underlying the condition. Volitional disorders such as I have described, usually, however, occur in persons with a degenerated nervous system, and aboulia may be regarded as a degenerative disease. Naturally, in the process of devolution the highest centres are first attacked and first show signs of decay. Some exciting cause, such as sexual excesses, al- coholic habits, or emotional strain may exist to precipi- tate the appearance of the trouble. Treatment.-The treatment of disorders of volition 689 Volition. V ulva. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. must depend upon its form and cause. In most cases complications exist that require a special adaptation of remedial measures. Practically, it is only those cases in which there is ir- resolute character and feeble will, or defect of volun- tary attention, that come to the general practitioner and educator for help. In the treatment of such troubles it must be borne in mind,/rsi, that the will is strengthened by strengthening the body and the nervous functions generally. Hence, hygienic and roborant measures are indicated. Second, the education of the will consists in adapting to each individual a system of rewards and punishments. Volition is most closely correlated with affective states, and is best controlled by controlling these states. Reasoning processes have little effect on the unstable will. Bibliography. Billod : Des Maladies de la Volonte. Annals of Medical Psychology, 1847. Ribot: Diseases of the Will. Hammond : A Treatise on Insanity. Carpenter: Mental Physiology. See also the works of Wundt, Lewes' Problems of Life and Mind, Mauds- ley's Physiology of the Mind, and Various Treatises on Insanity. Charles Loomis Dana. VULVA, DISEASES OF THE. By the term vulva is meant those portions of the female organs of generation which lie outside the hymen, and which are usually spoken of as the external organs of generation. Anatomy.-Before considering the diseases which commonly affect this part of the body, we must have some idea of the gross and minute anatomy of the region. The vulva is made up of the mons veneris, labia ma- jora and minora-the latter not infrequently called nym- phae-the vestibule, clitoris, meatus urinarius, fourchette, fossa navicularis, hymen or the remains of the hymen, the carunculae myrtiformes, and, lastly, the perinaeum. The mons veneris is a rounded eminence in front of the symphysis pubis, formed by an accumulation of very dense connective tissue and fat; from the time of pu- berty this eminence is covered with hair, and is the seat of many of the diseases of this region which the physi- cian is called upon to treat. The labia majora are two lateral folds of integument on each side of the entrance of the vagina, forming the boundary of the vulva, extending from the mons veneris in front, where they form the anterior commissure, to the perinaeum behind, wfliere they form the fourchette and posterior commissure. The fourchette is simply the thinned-out labia majora, that is, the labia majora destitute of connective tissue and fat. Between these labia is the rima vulvae or in- troitus vaginae. The labia majora, as well as minora, presently to be described, are formed by folds of the integument, and contain sebaceous glands. In infancy the labia are sepa- rated, exposing the underlying structures, but in adult life, in women who have not had children, they lie in close apposition (vulva connivens). In women who have borne children, and who have suffered a laceration of the perinaeum, the vulva gapes widely (vulva hians). In old age the labia atrophy and the vulva approaches somewhat the condition seen in infancy. The labia minora, or nymphae, are two folds of mu- cous membrane, beginning at the clitoris above, and running down on each side on the inner surface of the labia majora. Some authorities consider the nymphae as folds of mucous membrane, others as folds of muco- cutaneous tissue, while still others look upon them as folds of true skin. No doubt change in the appearance of the integument takes place when they have been long exposed'by the separation of the labia majora, or have become hyper- trophied. The folds of the labia minora which surround the clitoris are called prepuce and frenum, according to their location ; the anterior the prepuce, the posterior fold the frenum clitoridis. The clitoris lies in the anterior commissure, concealed by the folds of the nymphae. It is a small, elongated body, corresponding in structure to the penis in the male, but differing from it in having no corpus spongio- sum or urethra. The body of the clitoris is fully an inch in length, and is surmounted by a true glans. The greater part of the body is covered by mucous mem- brane. The triangular space in the anterior part of the vulvar orifice, bounded by the nymphae, clitoris, and vagina, is called the vestibule, and on the middle point of the base of the triangle is the meatus urinarius-not a perpendicular slit as in the penis, but rounded and puckered. The urethra is an inch and a half in length, and passes along the anterior wall of the vagina. The direction which the canal takes varies in the pregnant and non- pregnant state. The space between the fourchette and the posterior commissure is called the fossa navicularis, but is of no particular interest. The hymen is a thin fold of mucous membrane, and forms a kind of diaphragm with an opening of varying shape. Histological research shows that the hymen is nothing more than the anterior extremity of the vagina, covered outside by the mucous membrane of the vulva. The hymen is subject to individual variations ; it is not infrequently absent in front, in which case it takes the form of a semilunar fold, with the concavity looking forward. The membrane may be perforated by more than one aperture (cribriform hymen), or it may be a mere fringe. In rare cases it is stronger than usual, and completely closes the vagina, giving rise to a condition known as imperforate hymen. The hymen is nearly always ruptured by sexual inter- course, and at the birth of the first child becomes oblit- erated or forms small fleshy projections called carun- culae myrtiformes. These carunculae are considered by some to be reduplications of the vaginal mucous mem- brane which existed prior to the rupture of the hymen ; by others, to be the result of injury inflicted by the pas- sage of the child's head during parturition. The perinaeum is a triangular mass composed of areola, adipose, and fibrous tissue, situated between the lowyer portion of the posterior wall of the vagina and the lower part of the anterior wall of the rectum. The base of the triangle is the integument lying between the posterior commissure and the anus. The apex of the triangle is directed upward, between the vagina and rectum. This triangular mass is important on account of its supposed function in supporting the pelvic viscera. There must be some other element than the perinaeum which keeps the pelvic organs in place, for we see about as many cases of prolapse with the perinaeum in perfect condition as without it; in fact, numerous cases are seen every year, of complete prolapse, and yet the women have never had children and the perinaeum is in excel- lent condition. The vascular supply of the vulva. The internal pudic artery gives off the following branches : a. The super- ficial perineal ; b, the artery of the bulb ; c, the artery of the corpus cavernosum ; d, the artery of the clitoris. The internal iliac gives off vaginal branches. The femoral gives origin to the superficial and deep external pudic. The veins correspond with the arteries, and, in addition, we have the bulbs of the vestibule and the pars intermedia. The bulbs consist of a cluster of dilated veins, one inch in length, situated on each side of the vulva ; they form an erectile mass. The pars intermedia is a double row of veins between the clitoris and the bulbs of the vestibule. The glands of the vulva are : a, Sebaceous glands, found on the mons veneris, labia majora and minora ; b, mucous glands, on the inner surface of the labia minora and about the clitoris and meatus urinarius; c, vulvo- vaginal glands, situated on each side of the vulva : they are racemose in structure, and open into the vulva just outside the hymen. Besides these glands there are certain ducts, called after Gartner and Skene, which are frequently the cause 690 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Volition. Vulva. of trouble. These ducts correspond to the vas deferens in the male. They pass down the anterior wall of the vagina, parallel to the urethra, and when distended with fluid they give rise to vaginal cysts. The nerves supplying the vulva are : a, Genito-crural of the lumbar plexus ; b, pudic from the sacral plexus ; c, inferior pudendal from the small sciatic. Diseases of the' Vulva may, for convenience, be classified as follows: Deformities and injuries of the vulva ; skin diseases of the vulva ; herniae, varicose veins, and haematoma of the vulva ; oedema of the vulva ; ulcers and fissures of the vulva; diseases of the vulvo-vaginal glands ; hydrocele of the vulva ; hyperaesthesia of the vulva; vulvitis-simple and chronic, diphtheritic, gon- orrhoeal, follicular, phlegmonous; furunculosis. Deformities of the External Genitals.-There may be an entire absence of the external genitals, due to an arrested development. The conditions known as epi- and hypo-spadias may exist in the female as well as in the male, and are used to describe corresponding deform- ities. In the first, the opening is in the anterior urethral wall; in the second, the opening is in the posterior. The clitoris may be absent, cleft, rudimentary, or hy- pertrophied. The labia minora may be wanting on one or both sides, or they may be hypertrophied, and then go by the name of the Hottentot apron. Hermaphrodism.-The malformations of the sexual or- gans which constitute this condition are of very varying degree. In most cases there is no difficulty in determin- ing the sex of the child, but in some the distinction is very difficult. They are classified as follows : A, Spurious hermaph- rodism : 1, Epi- and hypo-spadias ; 2, hypertrophied clitoris ; 3, atresia of vulva. B, True hermaphrodism : 1, Lateral hermaphrodism, testicle on one side and ovary on the other ; 2, double hermaphrodism, testicle and ovary on same side ; 3, transverse, when the internal organs are male and the external are female. Most often the female genitals simulate the male ; the clitoris will be hypertrophied, and the glans clitoridis may be perforated by a canal. There may be atresia of the vagina and vulva at the vulvar opening. The labia may be united in such a manner as to closely resemble the scrotum, and at the same time the ovaries may be prolapsed into the labia. Fat in the labia majora may tend to increase the deformity. Injuries of the vulva may be due to external violence, to coitus, or to parturition. The most common causes of external violence are blows, falls, or some penetrating wound. Women are frequently injured in this way by the breaking of cham- ber-pots upon which they are sitting, or by falling upon the back of a chair, or the edge of a trunk or box. If the skin is not broken there is simply pain, swelling, and ecchymosis of the parts, and, later, if there is much in- jury to the tissues, there may be sloughing. If the ex- travasation of blood is very great, we have an haematoma of the vulva. An incision or lacerated wound of the vulva will give rise to severe haemorrhage. Injuries due to coitus are not common, and are proba- bly the result of extreme violence, as it is hard to realize how such an accident can happen in any other way. The symptoms are only those of pain and haemorrhage. Injury due to parturition is the result of the stretching of the perinaeum over the child's head. Tears in the per- rineum rarely give rise to alarming haemorrhage, but those which run out laterally into the region of the bulbs of the vestibule or pars intermedia often cause a profuse haemorrhage, which can be controlled only by very active measures. Treatment of injuries of the vulva : Contused wounds are treated with cold compresses of lead and opium. Haemorrhage from slight lacerated or incised wounds can easily be controlled by pressure with aT-bandage. In deeper and more extensive wounds, which give rise to free haemorrhage, particularly if the injury is in the re- gion of the clitoris or vestibule, the suture should be made use of, as nothing is so sure to control the bleed- ing. Slight lacerations of the perinaeum call for no interfer- ence, but deeper ones should be brought together with heavy catgut or silver sutures. The diseases which are commonly met with about the vulva are such as are found in other parts of the body. The mens veneris and labia majora are often the seat of pediculi, eczema, herpes, acne, ulcers, warts, condylo- mata, haematoma, adipose hypertrophy, and pityriasis. Pityriasis is a harmless eruption, but, on account of its marked discoloration, it may give rise to much anxiety on the part of the patient. It gives a brownish appear- ance to the skin and occurs in patches of various shapes and sizes. These patches are rarely confined to the geni- tals, but spread symmetrically over the groins and abdo- men. The eruption is slightly raised-not scaly-and when scraped away and treated with a solution of potassa and examined under the microscope it is seen to consist of a vegetable growth which has thread-like processes, called mycelia, surmounted by spores. This eruption rarely gives rise to any symptoms, and may be unnoticed if the patient is careless about her toilet. The treatment consists in cleanliness and keeping the parts dry after washing them with soap and water. When the mons veneris and labia are clean one of the following lotions will be found useful: 1). Sol. sod. hyposulphitis 3 iij.-O j. I?. Sol. sod. bicarb 3 iij.-O j. I£. Sol. hydrargyri bichlor 1-1,000. As a dusting-powder there is nothing better than bo- racic acid. Eczema of the mons veneris is usually secondary to a similar eruption on the labia, and has the same character- istics as eczema in any other part of the body. It is the most common form of skin disease met with on the gen- itals of women, and is certainly the most persistent, re- sulting in a chronic eczema which makes the patient utterly wretched. Eczema of the genitals does not often attack women before the prime of life, and is most common at or about the menopause. Patients with eczema of the vulva usually present themselves for treatment after the acute stage is passed, and the parts are then red, hard, and swollen. There is considerable pain and a sero-purulent discharge is pres- ent. The patient's distress is often increased by the warmth of the bed, and under such circumstances she can obtain sleep only in the sitting position, with the genitals exposed to the air. Together with eczema, there may be painful fissures about the groins and anus. Eczema of the vulva may be caused by : 1. The pres- ence of parasites ; 2, the presence of some irritating dis- charge from the bladder, uterus, or vagina; 3, diabetic urine ; 4, incontinence of urine ; 5, functional disturbance of the liver ; 6, functional disturbance of the stomach or intestines ; 7, the gouty diathesis ; 8, pregnancy. Parasites are best removed by cutting the hair as short as possible, washing the parts thoroughly with a solu- tion of bichloride (1 to 1,000), and smearing the mons and labia with the ointment or oleate of mercury, or with balsam of Peru, which seems as efficient as anything, and is certainly much more agreeable than the prepara- tions of mercury. Discharges from the bladder and vagina should be prevented from coming in contact with the inflamed surface. The vulva may be smeared with vaseline or the ointment of boracic acid before the patient urinates, or she can urinate while seated in a tub of warm water. Frequent vaginal douches of hot water are very grate- ful to the patient. To the douche there may be added boracic acid (3 ij. to O j.) or liquor plumbi subacetatis ( 3 j- to O j.). A teaspoonful or two of powdered boracic acid should be left in the vagina, together with a firm tampon. If eczema occurs in elderly women, and is the expres- 691 V ulva. Vulva. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. sion of a gouty diathesis, the patient should be put upon colchicum and the iodide of potassium. Local applications of a solution of carbolic acid, five per cent., followed by painting the eruption once or twice a day with the lotions given below, will relieve the pruritus and hasten the cure. Zinci oxidi, Zinci carbonatis 5a 3 ij. Glycerinse 3 iss. Aquae rosarum ad | iv. M. 3- Acidi tannici 3ij. Glycerinae, Alcoholis aa § ss. Aquae § iv. M. Glycerine is itself an irritant to the skin of some pa- tients, and this point should not be forgotten whenever we have occasion to use the substance in any prescrip- tions for the cure of skin diseases. To relieve the pruritus and induce sleep, the vulva should be covered with lint, soaked in a solution of lead and opium. Herpes of the Vulva.-The form of herpes found about the vulva is usually that of herpes zoster or shingles, characterized by groups of small blisters scattered along the course of the superficial nerves. Eczema and herpes may occur together about the vulva. The first is more diffuse, the latter is grouped in clusters of small vesicles with only a superficial redness. In eczema the true skin, as well as the epidermis, is involved, there being swelling with the redness. In herpes the deeper parts are rarely affected. In herpes there is acute pain over the course of the nerve, which may last some time after the eruption has entirely disappeared. Treatment consists in the use of frequent baths, rest in bed, and the local application of the lead and opium solution. In severe cases we are compelled to resort to the use of hypodermic injections of morphine, which will certainly relieve the patient for the time being, and in some cases effects a permanent cure. Acne, pure and simple, is a very common eruption on the external genitals, but it soon becomes complicated by the pruritus which causes the patient to scratch the parts, so that in a very short time the eruption cannot be differentiated from furunculus or eczema. Chronic acne is most commonly met with in women at the climac- teric, who are or have been suffering from a chronic discharge from the vagina or uterus. The patients also have some gastric or intestinal disturbance. So far as a local cause for the disease is concerned, lack of clean- liness is the most common. The acne-pustule may be of small size, or as large as an ordinary boil or furuncle. The treatment of acne of the vulva is the same as that of the disease in other parts. The cause, if possible, should be found and removed, strict cleanliness should be insisted on, and the patient's general condition must be improved by tonics. Furunculosis occurs as the result of poisoning of the parts by an acrid vaginal discharge. The poison gains access to the system through the follicle from which a hair has been pulled. The hair on the labia becomes matted together by the purulent vaginal discharge, and as the hairs are pulled out the follicles become infected and are the starting-points for small abscesses. The hair about the vulva must be kept short whenever a patient has an irritating discharge from the vagina, and this, with absolute cleanliness, will cure the disease. The boils should be opened early when fully formed, and a poultice should be applied. A general tonic treat- ment is usually necessary. Venereal Warts, Pointed Condylomata, or Specific Vegeta- tions.-Warts may be congenital, but such cases are rare. They are almost always due to venereal taint, either syphilitic or gonorrhoeal. They consist of a delicate connective-tissue framework, with large blood-vessels, and are covered with a thickened layer of epidermis. It is supposed that discharges which give rise to these warts in the female are the source of a virulent type of gonorrhoea in the male, so that warts on the genitals of public women demand the most active treatment. They are divided into a soft and a hard variety, a difference chiefly due to the amount of moisture to which they are subjected. During pregnancy they grow rapidly and spread far up into the vagina. When these warts are neglected they tend to divide at their summits, become feathery, and form fissures at their bases, which become the seat of infective discharges. The w'arts will recur after removal unless the irritating discharge is cured. The treatment consists in removing the growths with the scissors or cautery, if they are of large size. If they are small and if treatment is begun early, it will be suffi- cient to insure cleanliness by means of frequent douches of bichloride of mercury, 1 to 5,000, and by washing the external genitals with a solution of 1 to 1,000. The parts should be kept dry with equal parts of calomel and alum. After the douche the vagina should be washed out with a solution of nitrate of silver ( 3 ss. to 5 j.). If the gonorrhoea occurs during pregnancy, every effort should be made to cure the vaginitis before labor comes on, for by so doing we may prevent a serious at- tack of ophthalmia in the child. Condylomata are of syphilitic origin and are sometimes called gummatous or mucous tubercles or patches. They are of the same nature, essentially, as venereal w'arts, but have less connective tissue in their structure ; they are due to specific infection and consist of inflamed and hypertrophied papillae. They are not, strictly speak- ing, primary in their nature, but may give rise to a pri- mary sore in the male. The patient with condylomata has a chronic vaginal discharge and is uncleanly in her habits. Few women who pay the least attention to cleanliness are troubled with condylomata. Experiments have shown that vaseline or some other simple ointment renders the specific virus comparatively inert. Condylomata appear first on the inner surfaces of the labia, the vaginitis having infected some abrasion in the vaginal mucous membrane. Treatment consists in cleanliness both in the vagina and about the vulva-frequent douches of bichloride of mercury (1 to 5,000) or liquor plumbi subacetatis (3 j. to O j.). Externally the bichloride (1 to 1,000) should be used, and the parts dusted and kept dry with equal parts of alum and calomel. The patient should also be put upon the ordinary specific treatment. Under this plan of treatment the patches should disappear at the end of a week or two, but, so long as the patient is in the second stage of the constitutional disease the mucous patches will return if she is at all careless about her toilet. Lupus of the vulva is rare, but is occasionally seen on the labia majora of young and poorly nourished women. The disease begins as a pimple, is slow in its growth, and has a depressed centre which contains a soft, pulpy mate- rial. The tissue about the ulcers is infiltrated, and it heals very slowly, leaving behind a depressed and glist- ening scar. There is no specific treatment. Tonics are generally indicated, and, locally, a solution of bichloride, 1 to 1,000. Excision of the ulcer is probably the best treatment. Pruritus vulvas, or itching of the vulva, occurs in many of the diseases of the external genitals. The following are the most common causes : An irritating discharge from the bladder, vagina, or uterus ; neurosis ; parasites (pediculus pubis, acarus scabiei, ascarides); certain dis- eases of the vulva ; and want of cleanliness. It is necessary to find, if possible, the cause of the trouble, and then to remove it. Vaginal discharges can be controlled by frequent douches and tampons. The parts should be kept covered with a mild ointment or the patient should urinate while sitting in water. In neuro- tic patients tonics and the bromides, with cleanliness, will usually control the itching; weak solutions of ni- trate of silver will also frequently relieve the itching. The mucous surfaces may be washed w'ith a four per cent, solution of cocaine. Parasites, such as the crab- louse and itch-mite can be quickly removed by cutting 692 Vulva. Vulva. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the hair, washing the parts with bichloride solution, 1 to 1,000, and applying the oleate or ointment of mercury, balsam of Peru, or sulphur-ointment. Injections of the in- fusion of quassia will remove ascarides from the rectum. Vascular Degeneration on the Nymphoe.-As described by Tait, this disease consists of a progressive atrophy of the mucous membrane on the inner surface of the nymphae. The only thing found on inspection is a slight circumscribed redness, with extreme sensitiveness. In this condition we find atrophy of the connective tissue and exposure of the nerve-filaments and capillaries. The disease occurs at or about the menopause and runs a chronic course. Pain is the only symptom. The treatment consists in local applications of weak solutions of nitrate of silver, or carbolic acid, cocaine, or the lead and opium solution on lint may be placed be- tween the labia. Vaginismus is a painful spasm of the constrictor va- ginae muscle, due to fissures, ulcers, urethral caruncle, or inflamed hymen. Pain on intercourse and sterility are the only symptoms. When the patient is examined by the vagina, the extreme sensitiveness and spasm are appreciated. The treatment should be directed to removing all sources of irritation in or about the vulva or urethra. Fissures and ulcers should be treated with nitrate of silver ; urethral caruncles should be removed. The os- tium vaginae must be enlarged by gradual or forcible dilatation and a glass dilator should be worn for a short time at night on going to bed. Forcible dilatation is performed while the patient is under ether by stretching the sphincter by the hands, or dividing it with an ordinary scalpel on each side of the fourchette. Hyperasthesia of the vulva is a condition with symp- toms like those given under Vaginismus and Urethral Caruncle, excepting the spasm, and consists of an in- creased sensibility of the mucous membrane of the vulva. There is no inflammation and nothing seems to effect a cure. A four per cent, solution of cocaine sprayed on the parts will afford relief. Urethral caruncle is a vascular excrescence in the ure- thra. It is seen as a red tumor, sensitive to the touch, and very vascular, which is the seat of pain on micturi- tion and on intercourse. The treatment consists in its removal with the scissors or cautery and tamponing the vagina. Prolapse of the mucous membrane of the urethra may be remedied by applications of nitrate of silver or by the button-hole operation through the urethra. The incision is made into the anterior vaginal wall down to the mu- cous membrane of the urethra, which is pulled out of the incision and removed, and the edges of the wound are then stitched together. Herniai about the vulva are divided into inguinal, vaginal, and pudendal. tn inguinal hernia portions of the abdominal contents come down the canal of Nuck into the labia majora. The symptoms and treatment are the same as those of hernia in the same location in the male. Vaginal hernia consists in the protrusion of a portion of the abdominal contents through the vulva-the walls of the vagina, the peritoneum, and vaginal mucous mem- brane remaining intact. The condition is due usually to violence, parturition, straining, or lifting. Vaginal hernia is named from the wall which is protruded and the contents of the sac. When the bladder is prolapsed with the anterior vaginal wall it is called a cystocele, and when the rectum is prolapsed, bringing with it the pos- terior vaginal wall, it is called a rectocele. Vaginal herniae are treated with pessaries and other supports, with a truss, or T-bandage. The treatment of inguinal hernia is the same as that of hernia in the male. An operation to constrict the calibre of the vagina will keep the parts in place for a time. Hydrocele, or cyst of the round ligament, is simply a collection of fluid in the canal of Nuck. This fluid is usually serum, and it may contain blood and pus. The symptoms consist of a painless swelling in one groin, which grows slowly and gives little annoyance. In- tercourse may be interfered with, and sterility result. Walking is usually rendered difficult, and if the swelling increases greatly in size the patient can move about only with great discomfort. The treatment consists either in evacuating the sac and injecting it with a few drops of carbolic acid or tincture of iodine, or in laying open the sac and packing it with iodoform gauze. Should it be possible to press back the fluid into the abdominal cavity, it may be done, and the sac prevented from refilling by making the patient wear a well-fitting truss. Ulcers about the vulva are due to venereal disease, to laceration of the perinaeum, to injury during coitus, or to malnutrition of the patient. They are divided into spe- cific and non-specific ulcers. The specific ulcers, hard and soft chancres, are found commonly at the posterior commissure or on the inner surface of the labia minora. The treatment is the same as when the ulcers are found in other parts of the body, and consists in the observance of cleanliness and the application of iodoform or calomel, or the ulcers may be touched with a solution of nitrate of silver ( 3 ss. to § j.), or with the solid stick. Hematoma of the vulva is a swelling due to the ac- cumulation of blood under the skin from the rupture of a blood-vessel beneath the surface. The causes of such an extravasation of blood are blows, falls, kicks, and varicose veins about the vulva. The symptoms are pain, swelling, and discoloration of the parts. Cold, in the form of an ice-bag or ice-coil, is to be ap- plied, and, should suppuration seem probable, it is best to open early, remove all the clots, stuff the wound with iodoform gauze, and allow it to heal from below. The haemorrhage can be controlled by hot applications, hot water, and the use of pressure by means of a firm T- bandage. CHdema of the vulva may be due to injury, and then it usually results in the formation of an abscess, or it may be simply the symptom of some organic disease of the liver, heart, or kidneys. The symptoms are pain and swelling of the parts and inability to walk. The treatment consists in finding the cause, and reliev- ing that if possible. If the oedema is the result of injury, every effort should be made to prevent suppuration by the use of evaporating lotions, such as lead and opium, or by punctures. A firm T-bandage should be applied and worn constantly. Varicose veins of the vulva are very common, particu- larly in women who have borne children. These veins, if dilated at all before pregnancy, are very much in- creased in size during that period, and if any are ruptured during labor they give rise to alarming haemorrhage, which can only be controlled by sutures. Causes are: Pregnancy ; tumor of the abdomen ; constipation ; lifting heavy weights ; long standing ; dis- ease of the veins. There may be no symptoms at all. In some patients there is only pruritus ; in others, a burning sensation, with a slight amount of pain. There is no special treatment for this condition. The cause of the trouble should be removed, the bowels are to be kept open, and hot baths and astringent applications may be ordered. Should rupture take place, the haemor- rhage may be stopped by pressure upon the pelvic bone until a suture can be passed under the bleeding vessel. A firm T-bandage is sufficient to control slight bleeding. Inflammation of the Vulvo-vaginal Gland.-The in- flammation may be confined to the ducts, or to the gland itself. There may be one cyst, or multiple cysts. These cysts contain a thick, clear mucus, and sometimes the mu- cus has a brownish tinge. Suppuration may result, and then an abscess forms. This condition is most often the result of a specific vaginitis. The symptoms are pain, which is felt on walking, and dyspareunia. The contents of the cysts should be evacuated, and a portion or the whole of the cyst-wall should be removed. The cavity is then to be packed with iodoform gauze and 693 Vulva. Warm Springs. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the wound allowed to granulate up from the bottom. Hart and Barbour recommend the use of the cautery for opening and treating the inner wall of the cysts. Vulvitis may occur in children or in adults, and may be classified as follows : 1, Simple (catarrhal) ; 2, specific (gonorrhoeal); 3, follicular ; 4, diphtheritic ; 5, phleg- monous ; and, 6, chronic. The causes of simple or catarrhal vaginitis are old age, foreign bodies, want of cleanliness, discharges, injury or onanism, worms, irritants, and excessive venery. Vulvitis in Children.-In catarrhal vulvitis the pain and redness of the mucous membrane are slight and there is little swelling of the parts ; the chief distress is from the itching and heat in the vagina and vulva, ac- companied, at first, by a mucous discharge which soon becomes muco-purulent. The condition known as ca- tarrhal vulvitis is most frequently seen in young girls, and is soon cured by cleanliness and the use of a mild astringent douche of alum or tannin, 3 j. to the pint. In young children the disease is not uncommon, and may give rise to the suspicion that the child has been vio- lated. It is sometimes very difficult to make a diagno- sis between a catarrhal vulvitis and that of specific ori- gin. The cause for such a vulvitis in young children is to be found in want of cleanliness, irritation from the urine, or in the strumous diathesis. Sir J. Y. Simpson asserts that it often assumes an epidemic form in chil- dren of a family or district. Symptoms of catarrhal vulvitis in children. The little patient does not feel well, has for several days a moderate amount of fever, and cries when the urine is passed. The vulva is of a bright-red color, the hymen is congested, and there is a discharge of a clear, glairy mucus, which is rarely purulent. The discharge is acid, bloody at times, and irritates the surface over which it passes. Such irritation may lead to excoriation of the vulvar mucous membrane, leaving bleeding spots. Frequent baths, to insure cleanliness, and the passing of the urine while sitting in warm waler will ease the pain. The labia should be separated by lint soaked in the solution of lead and opium. Gonorrhoeal infection in children may be due either to direct or to indirect means. The carrying of gonor- rhoeal pus on the hands or diapers is not uncommon. The symptoms of gonorrhoeal vulvitis in children are the same as those of the catarrhal form, but are much more severe. The invasion and course are more virulent. The child may have considerable fever, and even convul- sions, and will shriek with pain when passing water. The vulva is usually very oedematous, and of a deep fiery- red color. There may be gonorrhoeal warts, buboes, and arthritic complications. Gonococci may or may not be present. If the vulvitis in children is chronic it may be referred to some local irritation, such as ascarides from the rectum. In chronic cases itching is a marked symptom, espe- cially after the patient is wrarm in bed. In such cases the child becomes very nervous and even almost choreic. The child should be kept quiet in bed, and every six hours should take a full bath, with some soothing sub- stance added. While in the bath a stream of warm water should be directed against the inflamed parts. Lint soaked with the lead and opium solution may be used in the intervals, the labia being kept separated as in simple vulvitis. In a few days the patient will be better, and then use can be made of puff powders after the bath, such as bismuth, starch, lycopodium, or a mixture of bismuth and glycerine. This is a very soothing applica- tion and stops the excessive secretion. For the gonor- rhoeal vulvitis in children, bichloride of mercury solution (1 to 5,000) should be used after thoroughly cleaning the parts. It is always best, in every case of vulvitis in children, to exclude the possibility of thread-worms by injecting into the rectum an infusion of quassia (3 ss. to O j.). In young children about two ounces of this solution may be injected at a time. Chronic vulvitis in children be- gins as strumous or infantile leucorrhoea. Phlegmonous vulvitis in children is an inflammation affecting the connective tissue of the labia. It may fol- low as the result of catarrhal vulvitis or may be due to gonorrhoeal infection. It not infrequently occurs as a complication of the exanthemata. Traumatism may also be a cause. Usually the patient has a furuncular diathesis. Bottle-fed children seem to be more disposed to this form of vulvitis than those who are nursed. At some point in the vulva we have the evidences of inflammation, redness, pain, and swelling. The child is restless, cries a great deal, and seems very sick. The temperature is usually very high. The treatment should be both constitutional and local. The former is the more important and consists in the use of iron, lime, and soda. The sirup of the hypophos- phites is excellent. Local treatment consists in the application of hot lead and opium poultices or stupes, to hasten pointing. The abscess must be opened early, as it may point in some disadvantageous place. Diphtheritic Vulvitis.-Diphtheria of the genitals alone in children is rare, but it occurs as a complication or se- quela of diphtheria elsewhere in the body. Cases in which diphtheria of the external genitals does occur generally prove fatal. The membrane may form about the geni- tals before it is visible in the pharynx. The patches are ash-colored, membranous, and resemble a thin layer of chamois-skin. Around the membranous patches is a red areola. The surface bleeds easily when the membrane is removed. In women, during the puerperal period, the same condition may be found, particularly during epidemics of puerperal fever, and is a dangerous compli- cation. Gangrenous vulvitis is usually the result of gonorrhoea, measles, or scarlet fever, and in adults it may occur as the result of injury during parturition. The gangrene spreads rapidly, and converts the tissue into a stinking slough. The prognosis is bad. The treatment must consist in supporting the patient's strength and keeping the parts clean. Vulvitis in Adults.-The causes of catarrhal vulvitis in adults are much the same as those given for a similar condition in children, viz.: injuries; chemical irritants ; worms ; discharges from the uterus or vagina ; strong soaps , masturbation ; too frequent intercourse ; vaginis- mus ; pruritus ; irritation of the urine. At first there are no constitutional symptoms-the pa- tient is conscious of only a slight amount of heat and itching about the vulva. Later on, the parts look red, are tender, and micturition is painful. There is little or no swelling of the vulva, and the secretion at first is rather scanty, but later becomes more profuse, is acid in reaction, and quite irritating. If the disease is more se- vere the mucous membrane for the first day or two is hot and dry, then the discharge becomes suddenly purulent, is profuse, and produces some excoriations which, if ex- tensive and there is much oedema of the parts, may give rise to the suspicion of gonorrhoeal infection. The disease may infect the vulvo-vaginal glands, hair- sacs, or sebaceous glands about the labia majora, and may also cause urethritis. Gonorrhoeal Vulvitis.-In nine out of ten cases of acute vulvitis in adults the cause may be found in gonorrhoeal infection. The onset of the attack may be sudden, and constitutional symptoms may be very pronounced. The local symptoms are heat and pain in the vulva. (Edema and redness are, as a rule, present to a marked degree in all cases of specific vulvitis. The urethra and vagina are generally invaded by the disease, and in severe and protracted cases the uterus, Fallopian tubes, and perito- neum may be involved. The oedema and redness do not exist to such an extent in any other form of vulvitis. If the urethra is involved there will be pain on mictu- rition, and a purulent discharge from the canal. To get pus from the urethra it is necessary, first, to clean the parts thoroughly, then pass the index-finger into the va- gina, and draw it firmly along the anterior wall in the region of the urethra. The pus will be forced out to the meatus, and may be collected on a slide and examined for gonococci, which will be found if the case is one of 694 V ulva. Warm Springs. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. gonorrhoeal vulvitis. Patients are liable also to have attacks of gonorrhoeal rheumatism as a complication. If the symptoms are severe the patient must be put to bed, and kept on a light diet. She should take one or two sitz-baths a day, and irrigate the parts frequently with hot water, or hot water with 3 j. or 3 ij. of the tincture of opium and lead-water to the pint. Pond's Extract is also useful in relieving the distress occasioned by the inflammation. It is very important that the labia should be kept apart with iodoform gauze. If the inflammation has involved the urethra, it is to be treated as in the male. The urethra may be injected with cocaine to relieve the pain, and irrigated with warm water, or with a very weak so- lution of bichloride of mercury, 1 to 2,000. After the acute stage is over stronger injections may be used. The citrate or acetate of potash, gr. xx., t.i.d., should be given from the beginning. Follicular Vulvitis. - The inflammation is generally confined to the sebaceous glands, rarely to the mucous. In adults the disease may be due to the same causes as catarrhal vulvitis, but is usually due to pregnancy, dur- ing which period glandular hypera3mia is most marked. Senile leucorrhoea is also a frequent cause. Great pain and discomfort in moving about, dyspareu- nia, and vaginismus are the chief symptoms. The dis- charge may be scanty, but it is very irritating and may cause an erythema or a true dermatitis. The swelling of the sebaceous glands may be so great as to give the appearance of acne or even furunculosis. The largest swellings occur on the inner surface of the labia majora. The pruritus maybe so severe as to cause small abrasions of the skin by scratching. The vulva must be kept clean by frequent baths and douches of hot water, and the inner surfaces of the labia should be washed with a solution of nitrate of silver, from ten to twenty grains to the ounce, or with crude pyro- ligneous acid. The parts are to be kept dry with finely powdered boracic acid. If the patient is pregnant she will not be cured of the disease until pregnancy is over. Chronic vulvitis is usually follicular or phlegmonous, like that of children. The most active causes are, pregnancy or the puerperal state, local injury, or friction due to masturbation, pru- ritus vulvae, irritating discharges, or parasites. The symptoms are the same as those of other forms of vulvitis. The treatment consists in cleanliness and the use of the solution of nitrate of silver, from ten to twenty grains to the ounce, every other day. Cocaine solution, four per cent., will relieve pain and discomfort due to the in- flammation. Charles Ware. WAHOO (Euonymus, U. S. Ph. ; Spindle-tree, Burn- ing Bush, etc.). The bark of Euonymus atropurpureus Jacquin : order Celastracea. A graceful shrub ten or twelve feet high, with opposite, oval-oblong, pointed, ser- rate leaves, and small, regular, dark purple flowers in axillary cymes. Sepals, petals, and stamens usually four; the latter inserted on a disk w'hich extends over the ovary; pistil one; ovary 3- to 5-lobed and 3- to 5-celled, with several ovules in each cell; pods deeply lobed, smooth, bright crimson, drooping on long slender pe- duncles. It is a native of the Middle and Western States, and is frequently cultivated for its beauty. Euonymus appears to have been first, and is still per- haps mostly, employed in the Western States. It was introduced into Philadelphia, some twenty-five years ago, by Dr. Geo. W. Carpenter (U. S. Dispensatory). The officinal dried bark is " in quilled or curved pieces, about one-twelfth of an inch (2 millimetres) thick ; outer surface ash-gray, with blackish patches, detached in thin and small scales; inner surface whitish or slightly tawny, smooth; fracture smooth, whitish, the inner layers tangentially striate ; nearly inodorous ; taste sweet- ish, somewhat bitter and acrid." The bark of E. Ameri- canus is sometimes mixed with the above. The composition of Wahoo is not very well made out. Several resins, oil, wax, and numerous more ordinary substances have been obtained from it, as well as a gluco- side named Euonymin; indeed, several " euonymins," of somewhat different characters, have been separated by as many chemists. From all of these, again, is to be dis- tinguished the resinoid "Euonymin" obtained by pre- cipitating the tincture. Uses.-Wahoo is a not very certain, usually gentle, but sometimes griping laxative, with a reputation as a cholagogue. It may be given in chronic constipation, or perhaps better in occasional attacks of constipation with dyspepsia, heaviness, and symptoms of diminished he- patic action. Dose of the Extract (Extractum Euonymi, U. S. Ph.), one or two decigrams (gr. j. ad iij.) in pill form once or twice a day. Allied Plants.-Several other Euonmyi of similar properties grow in this country and Europe. Allied Drugs.-See Buckthorn. W. P. Bolles. WAH-WAH-SUM MAGNETIC SPRING. Location and Post-office.-St. Louis, Gratiot County, Mich. Access.-By the Detroit, Lansing & Northern, the Toledo, Ann Arbor & North Michigan, or the Saginaw Valley & St. Louis Railroads. Analysis (Professor S. P. Duffield).-One gallon con- tains : Grains. Sulphate of lime 66.50 Silicate of lime 6.72 Chloride of lime trace Bicarbonate of soda 106.40 Bicarbonate of lime 69.40 Bicarbonate of magnesia 17.50 Bicarbonate of iron 1.20 Silica, free 2.88 Organic matter and loss 2.00 Total 272.60 Cubic inches. Carbonic-acid gas 6.21 Sulphuretted hydrogen gas trace Therapeutic Properties.-A strong alkaline cathar- tic water. Its magnetic properties are asserted on good authority, but what therapeutic value this quality would offer, besides amusement, we do not know. This spring or, more properly, well is situated in about the centre of the lower peninsula of the State of Michi- gan. It was discovered in boring for salt water, at a depth of two hundred feet. After a short time it was accidentally found that the iron tubing of the well had become magnetized, attracting and holding pieces of metal. By immersion in the water for a day or two articles became magnetized ; hence the name of Magnetic Water. St. Louis is situated in the pine-forest region of Michigan, near the Pine River. There are several hotels at the springs, and a large bath-house with facilities for all descriptions of baths. The flow of the well is two hundred and eighty gallons per minute, at a constant temperature of 50° F. George B. Fowler. WARMBRUNN is a German spa situated in the Hirsch- berg Valley, Prussia, lying at an elevation of 1,100 feet above the sea. The climate is cool, and even in mid- summer unpleasantly warm days are said to be rare. There are four thermal springs in the place, the temper- ature of which varies between 97° and 108° F. in the several springs. The waters are not rich in mineral con- stituents, containing only about 0.6 Gr., principally sodium sulphate and carbonate, to the litre. Warm- brunn is visited chiefly by those suffering from certain forms of paralysis, chronic rheumatism, and joint affec- tions. The wraters are occasionally drank and used in the form of spray-inhalations, but their principal employ- ment is as baths of various kinds. The season is from the first of May to the end of September. Many of the foreign visitors are Russians, among whom Warmbrunn has gained quite a reputation in the treatment of rheu- matic affections. T. L. S. WARM SPRINGS, GA. Location and Post-office. - Warm Springs, Meriwether County, Ga. Access.-By the Columbus & Rome Railroad to Stin- son's ; thence by stage five miles to the springs. 695 Warm Springs. Water. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Analysis.-One pint contains : Grains. Carbonate of iron 3.29 Oxide of calcium 4.64 Oxide of magnesium 11.68 Total 19.61 Hydro-sulphuric acid a large quantity Cubic inch. Carbonic-acid gas 1.11 Temperature, 90° F.; specific gravity, 998. Therapeutic Properties.-This water is chiefly used as baths, and as such is very popular. Its mild thermal and alkaline character is sufficient to establish its use as a valuable bath. These springs are situated in the western part of Geor- gia, on a spur 'of the Pine Mountains, at an altitude of eighteen hundred feet, in a country of great natural beauty. The flow is fourteen hundred gallons per min- ute, at a temperature of 90° F., affording an ample and continuous supply of water for the bathing-pools. There is also a fine chalybeate spring on the grounds. The hotel furnishes amusements for its guests in the way of billiards, ten-pins, music, etc., and a well-supplied stable affords facilities for pleasure-driving and riding through the beautiful surrounding country. G. B. F. WARM SPRINGS, N. C. Location and Post-office.- Warm Springs, Madison County, N. C. Access.-By the North Carolina Division of the East Tennessee, Virginia & Georgia, or the Western North Carolina Railroads, direct to the springs. Analysis (E. Adelmarth, M.D.).-One pint contains : Therapeutic Properties.-Thermic-sulphur water. The springs are situated on the western border of North Carolina, ,on the bank of the French Broad Biver, where it cuts its way through the Bald Mountains. They are at an elevation of seventeen hundred feet, and surrounded by pine-covered mountains. The climate is bracing, se- vere heat being unknown, and the scenery is grand. G. B. F. - WARM SPRINGS, VA. Location and Post-office.- Bath Court House, Bath County, Va. Access.-From the East by the Chesapeake & Ohio Railway to Millborough Station, thence fifteen miles by stage ; and from the West by the same railroad to Cov- ington, thence twenty-two miles by stage. Analysis (A. H. Hayes, M.D.).-One pint contains : Grains. Carbonate of lime 0.653 Sulphate of lime 1.816 Sulphate of potassa 0.171 Sulphate of ammonia 0.046 Crenate of iron 0.312 Silicates of magnesia and alumina 0.216 Total 3.214 Gases : Cub. in. Carbonic acid 1.80 Sulphuretted hydrogen 0.04 Nitrogen.... 0.41 Temperature, 98° F. Therapeutic Properties.-A limpid, slightly styp- tic (lime) water, used chiefly for bathing. These springs are situated amid the grand mountain- ous scenery of the western portion of Virginia. The flow of water forms a stream sufficient to turn a mill- wheel, and is estimated at six thousand gallons per min- ute. G. B. F. WASHINGTON. The accompanying chart, represent- ing the climate of the City of Washington, D. C., and obtained from the U. S. Chief Signal Office, is here intro- duced for convenience of reference. A detailed descrip- tion of this, and of the other like charts published in the Handbook, together with directions as to the best meth- od of using them, has been given in the article entitled Climate in Vol. II., pp. 189-191. II. II. Chloride of potassium.... Chloride of sodium Bathing Springs. 102° F. Grains. 0.039 0.114 Drinking Springs. 97° F. Grains. 0.063 0.137 Chloride of magnesium... 0.027 0.046 Chloride of calcium 1.263 1.118 Sulphate of potassa 0.045 0.059 Sulphate of soda 1.128 1.113 Sulphate of magnesia .... 0.168 1.016 Sulphate of lime 5.110 5.067 Soluble silicates 1.121 1.192 Totals 9.015 9.811 Gases: Cub. in. Cub. in. Carbonic acid 1.37 1.34 Sulphuretted hydrogen... 0.22 0.31 Climate of Washington, D. C.-Latitude 38° 54', Longitude 77° 2'.-Period of Observations, November 1, 1870, to De- cember 31, 1883.-Elevation of Place of Observation above the Sea-level, 61 feet. Spring Summer.... Autumn.... Winter Year 29.7 31.7 37.2 47.9 59.8 70.1 74.4 70.8 63.1 51.9 39.8 32.0 7 A.M. Degrees. Mean ten at 37.9 42.0 48.2 59.9 72.1 80.7 85.2 81.8 75.1 64.8 49.8 40.1 | 3 P.M. Degrees. fl? ® g gf 3? > : : : : ; 32.1 34.6 40.5 50.3 61.2 70.3 74.8 71.8 64.6 54.5 42.3 34.7 | 11 P.M. Degrees. if months of I 52.9 75.5 56.1 34.9 54.9 © © © © CO H^'w^COH to De- grees. Average mean temperature de- duced from Column A. 56.7 78.5 62.5 41.3 | 56.0 41.9 40.8 49.4 1 58.3 70.5 77.5 81.4 79.0 77.0 65.5 47.5 41.8 Highest. Degrees. Mean temperature for peril >d of ob- servation. Ed 50.2 73.9 53.7 29.8 52.2 27.6 28.8 35.4 47.6 59.2 69.1 74.0 71.6 62.3 50.7 40.2 26.5 Lowest. Degrees. 1 I 39.3 1 46.0 51.6 1 62.6 74.9 I 82.7 87.7 84.5 78.0 69.0 53.6 44.4 £ Average maximum temperature for period. ' * * I * a 1 w «'© r ' © - J O t! Average minimum temperature for period. i 3 a sssslsisssss © © co co o © bi © © © © © Highest. Degrees. Absolute tempera period. H o © © © © © o © © © © © Lowest. Degrees. naximum .ture for 15.5 20.8 34.0 42.5 46.0 61.0 64.0 61.0 59.8 43.5 29.0 21.2 Highest. Degrees. Absolute minimum temperature for period. : : : : : -14.0 -1.5 4.0 22.5 33.5 46.5 57.0 50.0 38.0 26.0 12.5 -13.0 Lowest. Degrees. Greatest number of days in any single month on which the tem- perature was below the mean monthly minimum temperature. 20 19 25 18 25 21 21 24 28 25 21 22 0 Greatest number of days in any single month on which the tem- perature was aliove the mean 1 monthly maximum temperature. । CO© ©©WWi©©^©^© 696 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Warm Spring*. Water. • 2 = SgOa- : • • ~h 85.0 79.5 75.0 67.5 62.5 56.0 45.0 51.0 66.3 66.3 67.5 86.0 92.0 56.0 91.8 92.0 118.3 Range of temper- ature for period. Cm 73.4 68.3 64.8 62.6 63.5 66.7 66.8 72.2 73.3 71.9 70.6 71.9 63.6 68.6 71.9 71.2 68.8 Mean relative hu- midity. T 31 11.8 11.8 12.7 12.0 11.8 15 7 14.2 13.1 10.5 11.1 12.6 12.9 36.5 43.0 34.2 36.5 150.2 Average number of fair days. 6.0 6.8 7.3 8.1 10.8 7.8 9.1 9.3 10.8 11.5 8.4 7.9 26.2 26.2 30.7 20.7 103.8 Average number of clear days. 2 17.8 18.6 20.0 20.1 22.6 23.5 23.3 22.4 21.3 22.6 21.0 20.8 62.7 69.2 64.9 57.2 254.0 Average number of fair and clear days. O 1 K Inches. 3.16 2.85 4.04 3.07 2.98 4.23 4.08 4.97 4.42 3.00 2.84 2.92 10.09 13.28 10.26 8.93 42.56 Average rainfall. Prevailing direc- tion of wind. 6.4 7.1 8.6 8.0 6.5 5.9 5.5 4.8 5.3 5.4 6.2 6.5 7.7 5.4 5.6 6.7 6.4 Average velocity of wind, in miles, per hour. was, in all cases, of itself sufficient to warrant a positive opinion as to purity, and still less as to wholesomeness or unwholesomeness. In view of these differences of opin- ion the writer, before entering on an extended series of analyses in connection with the yellow-fever epidemics of 1878-79, decided that an official opinion ought not to be given on the quality of the water-supply without a care- ful consideration of all the evidence procurable, and that the sanitary analysis of a water ought to consist not of one process, but of 1. A determination of the total solids, for the purpose of ascertaining whether the sample comes within the limits of potability, with incidental observations on the general character of the inorganic salts, 2. The loss suffered by the total solids on ignition, as affording a view of the organic matter in toto, and pos- sibly a further insight into the character of the saline constituents. 3. An estimation of the quantity of oxygen necessary to oxidize the oxidizable matters present in the water, as af- fording a view, when taken in connection with other ex- periments, of the organic matter on its carbonaceous side. 4. An estimation of the amount of ammonia which may be obtained as the last stage of the destruction of the or- ganic matter present, as giving a view of the said organic matter from its nitrogenous side. 5, 6, and 7. Determinations of the ammonia, nitrous and nitric acids, as indicating the amount of organic matter which may have been present in the w'ater at a period more or less remote, and defining the period, when viewed in conjunction with other considerations. 8. A determination of the chlorine present, as bearing on sewage-contamination. 9. The examination of the sediment by the microscope, as yielding corroborative evidence as to grade and kind of impurity. 10. A study of the source and surroundings of the uater- supply in connection with the results of the investigations above enumerated, to furnish a proper appraisement of the value of the said results. There are, in addition, some preliminary points which require attention, such as the characters presented by the water to the senses of sight, taste, and smell. The sam- ple may be turbid from a variety of suspended matters, and such a water is always an impure water, but not necessarily an unwholesome one. The words pure and wholesome are occasionally used without discrimination. The first is of chemical application, and implies absence of all substances foreign to the substance in question. The second is of sanitary application, and implies the in- ability of any of the substances in the substance in ques- tion to produce evil effects on the human system. A pure water may not be as wholesome as one that is chemically impure. Distilled or condensed water dis- agrees with many people on account of its flat taste and the feeling of oppression which it causes in the stomach. On the other hand, a spring-water which is notably impure from the presence of certain inorganic salts, may be unob- jectionable on the score of wholesomeness. A water, although it may be transparent and colorless, is not of necessity either a pure or a wholesome water, for it may contain saline, earthy, or organic substances which are harmful. Graveyard-waters, which are noted for their clear and sparkling appearance, are largely charged with nitrates, and may not be free from suspicion of evil effects. Turbidity may be owing to minute parti- cles of inorganic matter, as sand, clay, soot, etc., to the debris of animal or vegetable matter, or to the presence of microscopic forms ; it varies from simple loss of lustre through all degrees of haziness and cloudiness to well- defined turbidity from particles visible to the unaided eye. Occasionally the question arises as to the propriety of permitting a turbid water to settle before examining it. This should not be done in ordinary analyses. The water-sample furnished for examination should repre- sent the supply as used, and should be examined without any preliminary purification by sedimentation. The presence of minute particles of suspended matter WATER. Analysis.-When a water is concentrated by evaporation and tested by chemical reagents the inorganic substances dissolved in it give notable and well-known reactions. Formerly these mineral matters were separated one from the other and weighed ; and the report of the analysis gave a tabular view of their quantity and supposed constitution when the various bases and acids were recombined on paper in accordance with known chemical laws. This constituted the for- mal or scientific analysis of the water. The sanitary analysis of this period consisted of an endeavor to find out, by some ready method, the general character and approximate quantity of the dissolved solids. The or- ganic matter present was known only by its odor, by the color which it gave to the residue after evaporation, the blackening and loss of weight which the residue suf- fered on ignition, and by some liquid reactions, as the decoloration of permanganate solution, so indefinite in their indications as to be in reality little more than inter- esting laboratory experiments. But as the progress of sanitary medicine developed the importance of the ob- scure organic matter in the causation of disease, the time which was formerly spent in formal analyses of the min- eral ingredients became devoted to inquiries into the or- ganic constitution of the water. The weight lost by the residue on ignition was investigated, and the error caused by the dissipation of carbonic acid was recognized and eliminated. The residue was submitted to combustion by processes which revealed with more or less accuracy the quantities of carbon, hydrogen, nitrogen, and oxygen contained in it. Easier methods of approximating to the quantity of one or other of these elements were suggested and perfected by patient work in the laboratory. Such, for instance, were the approximation to the quantity of nitrogen by the estimation of the ammonia produced from it, and the view presented of the whole of the elements by the amount of permanganate of potash required to oxidize them. In a word, the analysis of a potable water became the analysis of its organic constituents, while the mineral matters, which received so much attention at the hands of former analysts, came to be considered only in so far as they gave information concerning these less known and more dangerous organic substances. A good deal of feeling was displayed by the authors and advocates of some of these processes, each contend- ing that his favorite method was superior, and all that was needful to enable the operator to give an opinion on the quality of an examined water. Certain arbitrary limits of organic impurity were assigned within which waters were assumed to be wholesome or allowable, and beyond which they were condemned as unwholesome or dangerous. But since it was asserted that instances had occurred where waters which were approved as pure by one mode of analysis had been reported by another mode as of doubtful or even dangerous quality, there was ground for suspecting that not one of these processes 697 Water, Water. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. oftentimes gives a color to a really colorless water. Thus rain-waters may be darkened by minute carbon particles. But color may be due to matters in solution. Dissolved vegetable matters frequently give a yellow or dark tint to the water. Some observers determine the color by looking down at a well-lighted white surface through a long tube filled with the water. Pure waters are gener- ally bluish. Odor, if faintly present, may be detected by shaking a bottle half-filled with the water and testing by the sense of smell the air which has been thus washed with the water. Some well-waters which have lain in contact with a stratum of clay have an unpleasant odor and taste, due to a decomposition of sulphides, but no injuri- ous effects have been attributed to their use ; and if the well is so frequently used that the water is not permitted to stagnate, the odor ceases to taint the supply. The total solids in water are obtained by evaporating 100 c.c. to perfect dryness in a platinum dish. The weight in milligrams, less the weight of the dish, gives expression to the solids in parts per 100,000 of the water. Sanitary analysts generally express their results in this way to facilitate comparisons between the results of dif- ferent analyses. Some, however, use the litre as a stand- ard, and calculate the figures obtained by experiment into parts per million, i.e., milligrams per litre. But these technical ratios are sometimes rendered into grains per gallon for the popular comprehension. The appear- ance of the residue often indicates its characters. It may be more or less discolored from the presence of organic matter. It may consist of a scarcely visible pellicle, if from a pure rain-water ; or of a dense whitish crust, as in some well-waters. Lime carbonate coats the whole of the concavity of the dish from the original water-level. Lime sulphate gives a dense coating near the bottom, and with it present there will be no alkaline carbonates. Soluble salts deposited from the last drops of the evapo- rating liquid are chlorides, sulphates, or nitrates. On gently igniting the capsule the organic matter be- comes decomposed, leaving its carbon to darken the mineral residue. If the quantity present is small, the coloration is faint and evanescent. A continuance of the heat dissipates the carbon by oxidation. If the organic matter is in larger quantity, concentric lines or patches of blackening may be formed and be slow to disappear. With foul waters a thick black eschar will line the capsule, showing points of ignited carbon, and yielding fumes which may be recognized as vegetable (peaty), animal (burning feathers, etc.), or nitrous. If nitrates are present, even in small quantity, they may be detected by their odor in the fumes ; if in large quan- tity, the energy with which the oxidation of the carbon film is effected will also discover them. But other changes take place during the ignition of the residue. Salts which contained water of crystalliza- tion, become crisped and effloresced. Lime sulphate be- comes anhydrous, and in part reduced to sulphide, by the carbon of the organic matter. Ammoniacal salts are volatilized. Magnesium chloride parts with its chlorine and becomes represented by the oxide, and lime carbon- ate may likewise be reduced. The loss of weight suf- fered by the residue during ignition may thus be due to many causes besides the destruction and dissipation of organic matter. By adding a few drops of a solution of ammonium carbonate, and heating gently to drive off the water and volatile alkali, the lost carbonic acid may be replaced, but there are no means of knowing the other losses of the inorganic matter from decomposition and volatilization. The loss of weight on ignition is there- fore no measure of the inorganic matter present in the water. Some residues, which are comparatively free from organic matter but contain a large proportion of nitrates, will lose much weight. Even when there are no salts subject to decomposition by heat, as in the resi- dues of rain-waters, variations in the weight lost do not indicate corresponding variations in the quantity of or- ganic matter. In a series of cistern-waters examined by the writer, the weight lost was from two to five parts per 100,000 ; but the organic matter, as represented by more accurate experiments subsequently performed, was not in every instance proportioned to the loss. Hygroscopic water, which is dissipated with difficulty, is a prominent source of error in these experiments as ordinarily con- ducted. Hence analytical results, expressed as so many grains of organic matter per gallon of water, assume a knowledge on the part of the analyst which he does not possess. But while the loss by weight is of relatively small importance, the observations made during the pro- cess of ignition not infrequently convey all that may be revealed by an exhaustive analysis of the specimen. Ready methods of determining the quality of a water are in great request. A reagent which will strike a brill- iant color in an unwholesome water, while it leaves a wholesome water clear and colorless, forms one of the unrealized dreams of the amateur sanitarian. Hopes of this kind originated in the decoloration of perman- ganate solutions by organic matter. The ready methods appear from time to time in sanitary and family journals, but none of them has the scientific value which attaches to the easily performed experiment of evaporating a small quantity of the water in a porcelain or platinum capsule and igniting the residue. If there are no fumes nor odor, and the slight darkening of the color of the film is immediately dissipated, the water may be ap- proved as wholesome with as much assurance as after a thorough investigation by all the processes. On the other hand, if fumes are evolved, and especially if these are nitrous or manifestly of animal origin, while the carbon film is thick and oxidized with difficulty, the water may be condemned as likely to prove unwhole- some, for certainly a more extended examination will only give further demonstration of its undesirable quali- ties. But between these extremes, comparative organic purity on the one hand and great organic impurity on the other, instances constantly occur where all the light which the processes of organic analysis are capable of throwing upon the quantity and quality of the organic matter is needful to the formation of an authoritative opinion. In such cases, instead of igniting the organic residue in this primitive manner, its combustion is effected with all the precautions which experience has suggested for the avoidance of error, and the carbonic acid, nitrogen, and nitric oxide evolved are collected and measured for the quantitative determination of the carbon and nitrogen respectively. This constitutes the process of Frankland and Armstrong. In it a certain quantity of the water, depending on the probable amount of impurity present, is evaporated to dryness. To prevent contamination by atmospheric dust during the continuance of the slow evaporation, the capsule containing the water is covered by a bell-glass which rests in a gutter, to convey away the condensed moisture ; provision is made for the auto- matic feeding of the capsule until the whole charge of water has been evaporated. The ammonia present in the water is fixed, and nitrogen-salts are destroyed by the addition of sulphurous acid. But as there is, nevertheless, a loss of ammonia proportioned to its total amount, its quantity has to be determined by a previous experiment, that the necessary correction for this loss may be ap- plied when the process is finished ; and any errors in the determination of the ammonia will be felt in the deter- mination of the organic nitrogen in the residue. The dry residue is mixed with oxide of copper, and trans- ferred to a combustion-tube which is attached by an air-tight joint to a Sprengel pump. After the air has been exhausted from the tube heat is applied, and the gases evolved are withdrawn by the pump and collected over mercury. They are then transferred to an accu- rately graduated measuring apparatus, where the loss of volume, after the introduction of a little potassic hy- drate, indicates quantitatively the carbonic acid yielded by the carbon of the organic "matter. Pyrogallic acid is then added to absorb any oxygen which may have been liberated from the copper oxide. If oxygen was present, the residual gas is nitrogen. But in the absence of oxy- gen a few bubbles of this gas are introduced to peroxi- dize any nitric oxide present, the resulting peroxide be- 698 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Water. Water. ing removed by the pyrogallate of potash ; after which the nitrogen is measured. This nitrogen represents the nitrogen of the organic matter and of the ammonia present in the water, minus that of the ammonia lost during the evaporation and plus that of organic matter adventitiously introduced during the experiment. To determine this latter error, the operator has to make several experiments on distilled water. In Frankland's laboratory the control experiment on one litre of pure water gives .05 milligram of nitrogen, or .005 part per 100,000 of the water. The precautions taken in this process to prevent at- mospheric contact during the evaporation is an acknowd- edgment of the liability to errors from this cause. It is claimed by some that the evaporation of a water to dry- ness, without loss of the organic elements, is an impossi- bility, especially in the presence of sulphuric acid oxi- dized from the sulphurous by the destruction of nitrates. Many instances have occurred, to the knowledge of the writer, in w'hich volatile organic matter is present in the water,-in such cases the analysis of the residue is of no value ; they will be more definitely specified in discuss- ing the albuminoid-ammonia process. The corrections applied to the nitrogen in this com- bustion-process may in some instances be greater than the total of the organic nitrogen present. Thus, in the first analysis given in Dr. Frankland's book, where the nitrogen amounts to .007 part and the ammonia to .029 part, the correction for loss of the latter during the evaporation is equal to .006 part of nitrogen, while that for nitrogen adventitiously introduced is .005 part, mak- ing .013 part of correction for error in dealing w'ith .007 part of material. Dr. Mallet concludes, w'ith regard to this process as conducted by Frankland, that it cannot be considered as determining the carbon and nitrogen of organic matter in water in a sense to justify the claim of absolute value for its results. It is but a method of ap- proximation involving sundry errors, and in part a bal- ance of errors. But even allowing that it gives absolute- ly accurate results, the information conveyed concerning the organic matter is of the most general character, con- sisting only of the amounts of carbon and of nitrogen contained in it. Of course, if a larger quantity of each of these elements is obtained from the residue, the water which it represents must have been polluted with a larger quantity of organic matter, while a specimen which yields low' results may generally be accepted as correspondingly pure. Dr. Frankland gives the following classification of waters, based upon the results of the combustion-pro- cess. They are divided into two sections, because the or- ganic matter of the upland surface-water is usually of a less dangerous nature than that of other waters which are more liable to be infected by the zymotic poisons. Section I. Upland Surface-water. - Class I. Water of great organic purity, containing a proportion of organic elements (organic carbon and organic nitrogen) not exceeding 0.2 part in 100,000 parts of water. Class II. Water of medium purity, containing from 0.2 to 0.4 part of organic elements in 100,000. Class III. Water of doubtful purity, containing from 0.4 to 0.6 part of organic elements in 100,000. Class IV. Impure water, containing more than 0.6 part of organic elements in 100,000. Section IL Water other than Upland Sur- face.-Class I. Water of great organic purity, contain- ing a proportion of organic elements not exceeding 0.1 part in 100,000. Class II. Water of medium purity, containing from 0.1 to 0.2 part of organic elements in 100,000. Class III. Water of doubtful purity, containing from 0.2 to 0.4 part of organic elements in 100,000. Class IV. Impure water, containing upw'ard of 0.4 part of organic elements in 100,000. But there is nothing certain in this formal classifica- tion. The determination of the organic elements en- ables the analyst only to indicate the position of a given water on a scale of impurity arbitrarily based on the quantities of these elements,-nothing is discovered as to the quality of the organic matter. The analytical results may be similar, whether the organic substances are harmless or hurtful. Inasmuch, however, as animal matters are conceded to be more dangerous than vege- table substances, on account of their greater liability to be associated with the germs or poisons of specific dis- eases, it is claimed that a consideration of the ratio of carbon to nitrogen will intimate the origin of the organic matter, and in this way convey some idea of its possible qualities. The nitrogenous proximate principles of ani- mal life do not differ in composition materially from those of the vegetable kingdom, but the latter are usually associated with carbonaceous substances which modify the results obtained by the combustion. Frankland says that if the ratio of carbon to nitrogen be as low as 3 : 1 the organic matter is of animal origin, while if it be as high as 8 : 1 it is chiefly, if not exclusively, of vegetable origin. But in the majority of potable w'aters the ratio falls between these extremes, and its value as an indica- tion of origin is lost. There are perhaps few natural w'aters polluted solely by animal matters ; and the changes W'hich take place in decomposing animal or vegetable matters by which the elements are converted into car- bonic acid and ammonia may alter their ratio. The care, time, manipulative tact, and constant prac- tice needful to secure trustworthy results by this method have led analysts to seek for less difficult processes which will indicate the relative position of waters on a scale of organic impurity. One of these, known as the perman- ganate process, has been strongly advocated by Dr. Tidy. The organic matter as it exists in the water is oxidized by the permanganate, which thereby loses its brilliant color, and the quantity of this salt thus discolored gives a knowledge of the amount of oxygen required for the oxidation of the organic and other oxidizable matters present in the water. Tidy's process consists in acidu- lating two given measures of the water-sample with sul- phuric acid, adding an excess of the permanganate solu- tion and permitting the oxidation to go on w'ithout the application of artificial heat, in one of the measures for one hour, and in the other measure for three hours. At the expiration of the proper period in each case, potassi- um iodide is added to the specimen. The permanganate which has remained undecomposed by the organic mat- ter liberates a proportionate quantity of iodine from the iodide, the amount of w'hich is determined by a solu- tion of sodium hyposulphite and the starch-test for free iodine. A blank experiment on distilled water must be conducted at the same time to ascertain the strength of the hyposulphite solution. The sodium salt indicates the iodine, the iodine the excess of permanganate, and when this is deducted from the total of the permanganate solution originally added to the water, the oxygen given up by that portion of it w'hich has been discharged by the organic matter may be calculated. Dr. Tidy assumes that practically the whole of the organic matter of the water will be oxidized in the experiment which is con- tinued for three hours, while the result of that w'hich is concluded at the end of one hour w'ill give information of value in determining the nature of the organic matter, inasmuch as animal matters and those which are of a pu- trescent character are conceived to be more readily acted upon than vegetable or non-putrescent substances. But Professor Mallet has shown that the largest amount of oxygen consumed in three hours by the organic matter of a series of waters examined with reference to this point was only seventy-five per cent, of that which was con- sumed by a more continued action, and that the average amount used in the three hours constituted but fifty-seven per cent. His experiments also indicate that while there is little difference in the rapidity of the oxidation whether the organic matters are of animal or vegetable origin, putrescent or non-putrescent, the proportionate consump- tion of oxygen within the first hour is rather greater for waters containing vegetable than for those containing animal matters. But although the combustion effected by the permanaganate is usually imperfect and the oxy- gen only an approximate measure of the organic sub- stances, waters containing the same kind of organic 699 Water. Water. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. matter may be as accurately graded by the use of this process as by the less readily applicable method of com- bustion. Dr. Frankland, in making periodical examina- tions of water from the same source, found a remarkable agreement between the results of the two processes ; and, in conjunction with Dr. Tidy, adopted the following scale of classification as parallel to that formed for the results of the combustion process. Upland Surface-water.-Class I. Water of great organic purity, absorbing from permanganate of potash not more than 0.1 part of oxygen per 100,000 parts of water. Class II. Water of medium purity, absorbing from 0.1 to 0.3 of oxygen per 100,000 parts of w'ater. Class III. Water of doubtful purity, absorbing from 0.3 to 0.4 part per 100,000. Class IV. Impure water, absorbing more than 0.4 part per 100,000. Water other than Upland Surface.-Class I. Water of great organic purity, absorbing from perman- ganate of potash not more than 0.05 part of oxygen per 100,000 parts of water. Class II. Water of medium purity, absorbing from 0.05 to 0.15 part of oxygen per 100,000. Class III. Water of doubtful purity, absorbing from 0.15 to 0.2 part of oxygen per 100,000. Class IV. Impure water, absorbing more than 0.2 part of oxygen per 100,000, ■ The process used by the writer is that of Kubel, in which the oxidation is conducted at the boiling temper- ature and the excess of permanganate ascertained by the aid of an oxalic-acid solution. The oxidation is carried further by this method than by the action at ordinary temperatures ; but if volatile organic matter is present the results are not reliable. There is required a per- manganate solution containing 0.1 milligram of avail- able oxygen in each cubic centimetre. Were the salt always chemically pure the required solution would be obtained by dissolving .395 gram in a litre of water ; but as it is not reliable in this respect, it is better to dissolve a few centigrams more than the theoretical weight, deter- mine the exact strength by means of metallic iron in sul- phuric-acid solution, and dilute to the required strength. The oxalic-acid solution, when containing .790 gram of acid per litre, will decompose the permanganate solution volume for volume; but it is not needful that the two shall correspond exactly, as a blank experiment on per- fectly pure water has to be performed to determine the relation between them. To insure purity on the part of the water used in this standardizing experiment distill- ed water should be treated with permanganate and re- distilled. Two hundred cubic centimetres of this pure water are put in a flask capable of holding nearly double the quantity, to which ten cubic centimetres of a 1 : 3 di- lution of sulphuric acid and four, five, or six cubic centi- metres of the permanganate test-liquid are added. The contents of the flask are then boiled for ten minutes, dur- ing which the brilliant color remains unaffected. The flask is removed from the gas-flame and ten centimetres of the oxalic solution are added. Some effervescence takes place, and the color of the liquid is discharged. Permanganate is then dropped from a burette until a faint rose-tinge pervades the liquid. The quantity of permanganate destroyed is a measure of all the decom- posing influences of the experiment as performed on a water wThich is itself passive. The oxalic acid is the principal of these influences, but there may be others, as impurities in the sulphuric acid, the effects of the boil- ing, etc. If, therefore, the relation between the solu- tions is expressed as 10 c.c. oxalic = 10.5 c.c. permanga- nate, it is understood that all decolorizing causes, as well as the drop or two necessary to give the tinge of color indicative of the conclusion of the experiment, are included in the expenditure of 10.5 c.c. If the experi- ment is repeated on an impure water, while all the con- ditions remain as before, saving the different character of the water, any increase in the quantity of permangan- ate required to produce a permanent tinge of color after the boiling will be due to the intruded influence of the impurity. If the impure water decolorize 16.5 c.c. of permanganate when experimented on in this way, and 10 c.c. oxalic = 10.5 permanganate, 4 c.c. of the test-solu- tion will have been destroyed by the organic matter of the water ; or, in other words, .4 milligram of oxygen will have been necessary to its oxidation. But potable waters submitted to examination by this test sometimes contain other matters which act upon the permanganate, as nitrous acid, iron, and hydrogen sul- phide. If these be present their quantity must be ascer- tained and allowance made for their influence, or, as suggested by De Chaumont, they may be dissipated or oxidized by boiling for twenty minutes with sulphuric acid, which treatment does not affect the organic matter of the water. The quantity of oxygen which the organic impurity of a water requires for its destruction by this method gives no intimation as to the character of the organic matter. In- deed there are some substances, as urea, which are not affected by the permanganate. An impure water may, therefore, by this test be pronounced pure, while, on the other hand, a water containing harmless carbon-particles, the product of fuel-combustion, may stand high on the scale of impurity. It is only when the permanganate re- sults are considered in connection with other testimony that their value can be determined. Practically, the amount of permanganate destroyed is proportioned to the blackening of the residue on igni- tion. Varying quantities of oxygen may be regarded as giving expression to varying shades of blackening during combustion. A high result indicates impurity ; but if there is performed at the same time on the water-sample an experiment which will give an approximative viewr of the nitrogen contained in it, and if this nitrogen is small as compared with the oxygen results, the organic matter may be considered as of vegetable origin as surely as if an 8 : 1 result by Frankland's process had authorized the opinion ; while, if the nitrogen is relatively large, an an- imal derivation for the matter is as certainly indicated. The process by which the nitrogen is generally esti- mated is that known as Wanklyn's, or the albuminoid-am- monia process. In it the organic matter of the water is de- composed at the boiling temperature by permanganate in the presence of an alkali, and its nitrogen, evolved as am- monia, the so-called organic or albuminoid ammonia, is collected and estimated. Most natural waters contain minute quantities of free ammonia which must be.re- moved from them by boiling before this experiment on the organic nitrogen is performed ; but as the free am- monia, originating usually in the putrefactive destruction of nitrogenous organic matter, gives in many instances important testimony concerning the quality of a water, its quantity is always determined in the process of pre- paring the water for the experiment on its organic matter. Half a litre of the water is placed in a retort capable of holding as much again. A few cubic centi- metres of a solution of recently ignited sodium carbon- ate is added to the water, which is then distilled. The condenser, attached to the retort by clean black-rubber connections, should be large and supplied with a con- stant current of tap-water. The distillate is collected in cylindrical glasses about 18 centimetres (7 inches) in height and 2.3 centimetres (.9 inch) in diameter. They contain about 70 cubic centimetres and have a mark at the fifty cubic centimetre level. When the distillate reaches this level the glass is replaced by a second, and while the distillation proceeds the ammonia which may be present in the first glass is estimated by the Nessler reagent. This is made by dissolving 35 grams of potas- sium iodide and 16 grams of mercuric chloride, each in a small quantity of water, adding the mercuric solution to that of the iodide until a permanent scarlet tinge shows the presence of a slight excess. A solution of 160 grams of potassium hydrate (or of 120 grams of sodium hydrate, the alkalinity of which is relatively greater) in 800 cubic centimetres of water is added to the mixture, which is then made up to one litre by the ad- dition of water. A few drops of a cold saturated solu- tion of mercuric chloride is shaken up with the prepared 700 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Water. Water. liquid, which, after becoming clear by sedimentation, is ready for use. A small quantity of this reagent dropped into water containing ammonia causes a coloration, the shade of which is proportioned to the amount of am- monia present : .0025 milligram of ammonia in 50 cubic centimetres of water gives a recognizable coloration, and 0.1 milligram a deep sherry-brown color, while notably larger amounts occasion a turbidity. But to estimate accurately the quantity of ammonia present in the 50 cubic centimetres of the distillate, the color produced in it by adding two cubic centimetres of the Nessler reagent is compared with the color produced by the same means in similar glasses containing known quantities of ammonia. Thus the color of the ammoniacal distillate may be pre- sented for comparison with a series of test-glasses con- taining .01, .03, .05, .07, .09 milligram of ammonia, each in 50 cubic centimetres of ammonia-free water, and if no perfect agreement is found with any of these standard tubes a fresh standard may be prepared containing the quantity of ammonia which this first comparison has in- dicated as likely to be present. By the time this com- parison is made the second fifty-cubic-centimetre measure, or Nessler glass, has been filled by the progress of the distillation and is ready for estimation in like manner. The distillation is continued until a measure of 50 cubic centimetres is obtained which shows perfect freedom from ammonia by giving no coloration with the reagent; and when this occurs the residual water in the retort, representing the original half-litre, may be considered free from preformed ammonia and ready for the experi- ment on its organic matter. The first measure of the distillate contains the largest quantity of ammonia, and it is a judicious precaution, lest it be so strongly ammon- iated as to cause a turbidity with the Nessler solution, which would spoil the experiment by rendering color- comparisons impossible, to wajt for the second or third measure, and decide from the quantity found in one or other of these whether the first measure should be treated as a whole or definitely diluted before attempting the colorimetric estimation. The color struck by the Ness- ler reagent in ammoniacal waters requires from three to five minutes for its full development. After this it remains unchanged for many hours. The amounts of free ammonia found in each of the measures distilled are added together and divided by 5, to express the results in parts of 100,000 of the water, or multiplied by 2 to express parts per million. The permanganate solution for the destruction of the organic matter must be prepared with care to insure its freedom from ammonia, which would vitiate the experi- mental results. To three-quarters of a litre of distilled water, which gives no ammoniacal coloration with the Nessler reagent in a test-glass, there are added one hun- dred grams of caustic potash and four grams of perman- ganate, and the liquid is distilled from a retort until re- duced to one-half litre; the last fifty cubic centimetres of the distillate will be free from ammonia, and will thereby indicate the freedom of the alkaline solution from ammoniacal taint. It has been objected to Wank- lyn's process that the permanganate solution may con- tain traces of ammonia, but if it does so the fault lies with the operator, not with the process. To the residual water in the retort, from which the free ammonia has been distilled and estimated, a measure of fifty cubic centimetres of this alkaline permanganate solution is added, and the distillation is continued as before, the distillate being collected in the fifty-cubic- centimetre Nessler glasses, and the ammonia therein es- timated by colorimetry, testing the second or third meas- ure of the distillate, in the first instance, in the case of an unknown or suspicious water, lest the ammonia in the first measure should be so great as to occasion a tur- bidity with the Nessler reagent. The process is con- tinued until a measure is obtained which is free from ammonia, or until no more can be distilled without dan- ger of fracturing the retort. The action of the permanganate in this process is allowed by Wanklyn to be imperfect. The whole of the nitrogen of the organic matter is not converted into am- monia ; but he claims that as the albuminoids in water are of similar constitution, and yield up a definite quan- tity of their nitrogen, the results of the process in differ- ent instances are susceptible of comparison, and enable the operator to rate a water on an arbitrary scale of ni- trogenous impurity. This scale he formulates thus : " Drinking-w'ater falls into three classes, according to the degree of organic purity, as follows: " Class I.-Water of extraordinary organic purity, yielding from .00 up to .05 part of albuminoid am- monia per million. This class comprises the most care- fully prepared distilled water and highly filtered waters, both natural {i.e., deep-spring waters) and artificial {i.e., such water as has passed through a silicated-carbon filter in good working order). Occasionally a river-water, in its unfiltered condition, falls into this class. Water of this class cannot be objected to organically. " Class II.-Comprehends the general drinking-waters of this country. It gives from .05 to .10 part of albu- minoid ammonia per million. I believe that any water falling into this class is safe organically. " Class III.-Comprehends the dirty waters, and is characterized by yielding more than 0.10 part of albu- minoid ammonia per million." But when the albuminoid ammonia amounts to .05 part per million, he brings in the free ammonia as an element in the determination of quality, and is " in- clined to regard with some suspicion a water yielding a considerable quantity of free ammonia along with more than 0.5 part of albuminoid ammonia per million. Free ammonia, however, being absent or very small, a water should not be condemned unless the albuminoid am- monia reaches something like 0.10 per million. Albu- minoid ammonia above 0.10 per million begins to be a very suspicious sign ; and over 0.15, it ought to condemn a water absolutely." Most rain-waters in the United States, collected in clean dishes as they fall from the clouds, would be con- demned by Wanklyn's dictum. Most of our river-waters which are in daily use would be condemned on similar grounds. In the experience of the writer, while Wank- lyn's limit of allowable impurity may be accepted in the case of wells where the danger of infiltration from privies is great, it should be extended to 0.20 in the case of our river and other surface waters, as it is not until the albuminoid ammonia reaches or exceeds this quantity that a taint becomes developed in the water during warm weather, and that diarrhoea, dysentery, or febrile condi- tions are connected with its use. But while the total amount of nitrogen obtained from the organic matter of a water is the main object of the experiment, a certain value attaches to the manner in which the ammonia is evolved. Wanklyn observed that vegetable matter gave up its nitrogen as ammonia slowly. The writer found, by examining his laboratory notes with reference to this point, that in many instances where the organic matter was undoubtedly of vegetable origin the albuminoid ammonia diminished by one-half in succes- sive distillates of 50 c.c. Thus water from the swamps near New Orleans yielded, in the first measure distilled, .24 milligr. ; in the second, .12 milligr. ; in the third, .06 milligr. ; and in the fourth, .03 milligr., equalling a total of .45 milligr. in the 500 c.c. of the swamp-water dis- tilled, or .90 part per million. But, from many experi- ments on pure animal and vegetable albuminoids, it was found that their tendency to change, or putrescent char- acter, rather than their derivation, influenced the manner of the evolution. A gradual disengagement, as in the case of the swamp-water given above, indicates the presence of organic matter, whether animal or vegetable, in a fresh, or comparatively fresh, condition, while a more rapid evolution indicates that the organic matter is in a putres- cent or decomposing condition. It has been suggested, as an objection to the albumi- noid-ammonia process, that after the distillation has been concluded by the withdrawal of a measure which shows freedom from ammonia, more ammonia may be obtained from the contents of the retort on again resuming the distillation after some hours. Many experiments were 701 Water. Water. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. made by the writer, not only on natural waters the ni- trogen of which is usually readily given up, but on arti- ficial solutions of organic matter, and in no instance was ammonia recovered from the retort, even after the lapse of days, when the original experiment had been carried far enough to show that the disengagement of ammonia had ceased. The permanganate acts slowly on some organic matters, and under the conditions of Wank- lyn's experiment, with only a certain quantity of liquid in the retort, it may be impossible to carry the pro- cess far enough to show the cessation of the evolution. The experiment may have to be concluded by the ex- haustion of the water in the retort before all the or- ganic matter has been decomposed, as in the swamp- water above mentioned, and in such a case a renewal of the distillation, with an addition of ammonia-free water, would necessarily result in the evolution of more am- monia. In such cases the time which is occupied in the distillation affects the results obtained. Slow boiling with a lowered flame will give more ammonia than a rapid ebullition, which brings the experiment to a speedy termination by the exhaustion of the water in the retort. In view of these facts, Professor Mallet, in summing up the results of an experimental investigation into the comparative merits of the various processes by which the organic matter of a water may be estimated, says of the albuminoid process, that the value of its results de- pends more upon watching the progress and rate of evo- lution of the ammonia than upon determining its total amount. But he found a good deal of general similarity between the figures for albuminoid ammonia and those for organic nitrogen (by Frankland's process), although there were frequent discrepancies of varying extent, such as prevent the one being taken as an accurate measure of the other. In conducting these ammonia-distillations there is always a notable loss from imperfect condensation of the ammonia evolved. In a series of experiments on waters containing a known quantity of ammonia the amount thus lost averaged a little over seven per cent, of the to- tal. During these experiments the distillation was gen- erally effected as recommended by Wanklyn, with the gas-jet playing freely on the bottom of the retort, so as to cause vigorous ebullition. The time occupied in the distillation of a Nessler measure of 50 c.c. was ten or twelve minutes, and a free and constant stream of water at summer temperature passed through the condenser. When the operation was conducted with a smaller flame, and especially when the condensing water was at its win- ter temperature, the loss from imperfect condensation was reduced to two or three per cent. Some nitrogenous substances are not decomposed by the alkaline permanganate solution used in this process ; such are the ferro- and ferri-cyanide of potassium, nitro- mannite, nitrotoluene, and azobenzene. But the water- analyst is more particularly interested in the anomalous behavior of urea when subjected to the process which has been described. Professor Wanklyn is very positive in his assertion that it is not affected by being boiled with the alkaline permanganate solution. He says: " Except in the instance of nitro-compounds, urea, and ferrocyanide of potassium, we have not met with any unequivocal instance of failure of an organic nitroge- nous substance to evolve ammonia on being heated to 100° C. with a strongly alkaline solution of permanga- nate." And again : "In presence of permanganate and excess of potash urea is doubtless decomposed, but it yields no ammonia, which is a very extraordinary and noteworthy fact." "On inquiring into the other pecu- liarities of structure which prevent alkaline permanga- nate evolving nitrogen of a given organic compound in the form of ammonia, our attention is arrested by the example of urea, which evolves none of its nitrogen as ammonia when so treated." On the contrary, urea, whether from urine or ammonium cyanate, yields about twenty-two per cent, of its nitrogen as ammonia when treated as Wanklyn treated the alkaloids and other or- ganic substances in determining the amount of the nitro- gen evolved as ammonia ; and if the conditions of the experiment are arranged to permit of a longer contin- uance of the action of the permanganate on the urea, the whole of its nitrogen will be accounted for, provided due allowance is made for the loss which occurs from imperfect condensation. When urea is dissolved in water the presence of a small percentage of free ammonia may be detected in the solution by the Nessler reagent. If the urea solution is added to an ammonia-free water and half a litre of the dilution is distilled with or without sodium carbonate, as in Wanklyn's process for the separation and estima- tion of free ammonia, the first and second measures of the distillate will contain a comparatively large propor- tion of the preformed ammonia; but the third, fourth, and succeeding measures will show a persistent and equable evolution, indicating that under the influence of the boiling temperature urea is being decomposed stead- ily and gradually into ammonia. If a similar quantity of the ureal solution, made up to the half-litre with pure water, is distilled with a charge of the alkaline perman- ganate, the first and second measures of the distillate will contain a comparatively large proportion of the pre- formed ammonia, but the third, fourth, and succeeding measures will show a persistent and equable evolution which will be as much again as in the corresponding measures of the previous experiment, indicating that the alkaline permanganate exercises as strong an influence on the decomposition of the urea as that exerted by the boiling. Thus, while the persistent equable evolution of ammonia from 1 milligram of urea treated with or with- out sodium carbonate under the ordinary conditions of the Wanklyn process is .01 milligram in each measure, .02 milligram is obtained in the presence of the alkaline permanganate. A number of experiments on the decomposition of urea showed that while tjie amount of the ammonia col- lected in the later measures of the distillate might be made to vary by raising or lowering the gas-flame and so altering the time occupied in the distillation of the measure, it was a constant quantity where the rate of ebullition did not vary, and under similar conditions the quantity given by the alkaline permanganate was always as large again as that obtained by simple distillation. Di- lutions of fresh and decomposing urine in tap-water gave similar results. This peculiarity in the behavior of urea is of importance, as by it not only may the presence of this substance in the water be diagnosticated, but an ap- proximate estimate may be made of its quantity. Labo- ratory notes giving the details of the evolution of ammonia from organic chemicals and composite organic solutions, the waste-products of manufactories, etc., were examined, but not one was found presenting reactions by which it could be confounded with urea. Thus, while some gave a persistent and equable evolution of albuminoid ammo- nia, no free ammonia was liberated. Among those act- ing in this way were potassium cyanide, potassium and silver cyanide, sodium nitroprusside, alloxan, and some of the alkaloids. In several instances factory-drainings gave a persisting evolution of both free and albuminoid ammonia, but not in the ratio 1 : 2, as furnished by the decomposition of urea. The details of the analysis of a large number of waters were examined with reference to this point, and in all cases where the evolution had oc- curred in the manner stated urea was known to have been present, or its presence was probable in view of the known origin of the sample. The writer is therefore of the opinion that where this peculiarity is found in treat- ing a water-sample by the Wanklyn process, the presence of liquid sewage amounts to more than a probability. It is true, in some of the analytical notes examined, the evo- lution was not recorded as having taken place in this pe- culiar manner, although sewage was probably, or, indeed, known to be, present ; but as in these instances many days had elapsed between the collection of the sample and its analysis, urea might have disappeared in the meantime by the natural fermentative process. Moreover, the process is approximatively quantitative ; for, since 1 milligram of urea in 500 c.c. of water gives a persisting and equable evolution of .01 milligram of am- 702 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Water. Water. monia when distilled alone or with sodium carbonate, and an evolution of .02 milligram when subsequently treated with the alkaline permanganate, a water-sample which gives such results must have contained urine equiv- alent to at least 1 milligram of urea in each half-litre. The urea in urine is, of course, a variable quantity ; but experiments on a number of samples of fresh urine, |, f, i, and 1 c.c. in the half-litre, gave an average evolution of .01 milligram of free ammonia in the third and fourth measures of the distillate, and of .02 milligram of albu- minoid ammonia when the water contained 1 part of urine in 15,000 parts of water. For example, one-half cubic centimetre of urine in 500 c.c. of water, equalling 1 part in 1,000, gave .47, .25, .15, and .15 of free ammo- nia, respectively, in the four measures of 50 c.c. each, and .54, .34, .32, and .32 of albuminoid ammonia in the four measures distilled from the alkaline permanganate. This method of detecting the presence of sewage in water was put to practical use in an examination of the wells and cisterns of Nahant. One of these, known to the writer only by its number in a series, showed black rings and islets, with sooty fumes and foul odors on ig- nition, and gave .19 part of free and .53 part of albumi- noid ammonia per million. This of necessity condemned it as an organically foul water, but as the ammonias were evolved in the manner indicated as peculiar to urea, and as, moreover, the water, known from its gen- eral characters to be a cistern-water, contained a larger proportion of chlorine than is normal to cistern-waters, the writer had no hesitation in reporting it as contaminated with a certain proportion of urinous admixture. One month later another of the Nahant series of w'aters, known to the analyst only by its number, was reported on an- alysis as a satisfactory cistern-wrater. Thereupon the following history was communicated: Typhoid fever had appeared in a cottage built by a gentleman as a sum- mer residence on the seashore. The water was suspected as having to do with the causation, and a sample ana- lyzed by Professor E. S. Wood, of Harvard, was pro- nounced unfit for use. The proprietor, dissatisfied with this report, sent a specimen to another chemist, who returned a similar verdict. A physician inspected the premises and suggested that sewer-gases might have been condensed on the roof from the ventilating pipe of the water-closet. Thereupon means were adopted to remedy the evil; and the cistern was pumped out, cleaned, relined with cement, and put in what was con- ceived to be perfect condition. When filled, the sample was collected which on examination was reported as pol- luted with urine. This naturally shocked the proprietor, after all his efforts to obtain a pure rain-water, and he felt more inclined to deny credit to water-analysis than to pronounce his cistern guilty. But Mr. Bowditch, of Bos- ton, who was conducting the sanitary survey of Nahant, conceived that further investigation was imperatively demanded. There was a possibility of leakage into the cistern from certain drains which carried off kitchen- waste, but this would not account for the urea unless the servants were in the habit of putting this system to an unauthorized use, and the proprietor, though willing to concede that some servants might act in this manner, would not allow that his could be guilty of such a prac- tice. However, it appears that the drains had no con- nection with the cistern. But Mr. Bowditch, in his ex- amination, discovered that there were three apertures into the cistern while only two conductors from the roof entered it. It was then remembered that two years before, in adding a wing to the building, a conductor had been disused, but what had been done with it was not known. The old conductor was then uncovered by Mr. Bowditch, and its distal end was found open under the sur- face near the piazza where grew some vines which were sometimes nourished with chamber-slops. It was further found to be the custom of the house to collect all such slops in pails, which were emptied through a water-closet on the first floor and then placed on the roof of the pi- azza to air. The old conductor was removed and its cistern-aperture sealed, and the connection was cut be- tween the cistern and the roof of the piazza, the roof of the house thus becoming the only contributing surface. When the cistern was again filled after these changes the analysis authorized a favorable opinion on the con- tained water. This appears to be a satisfactory illustra- tion of the value of attending to the manner in which the ammonias come over during the distillations of the Wanklyn process. Another point in connection with the albuminoid pro- cess is worthy of consideration. It has been stated above that weak ammoniacal solutions, -when Nesslerized, yield a tint varying from a pale straw-color to a dark sherry- brown, in proportion to the amount of the ammonia present. But it sometimes happens in testing the distil- late, especially those measures containing the free am- monia in Wanklyn's water-process, that a green colora- tion masks the brown of the ammonia and prevents the accurate estimation of the latter by the colorimetric method. If there be but a trace of ammonia present the color may be olive-green or even citron-green, with or without a faint tendency to the formation of a haziness in the liquid. This color-interference has no doubt been noticed by many analysts, but the writer is unaware that any explanation has been furnished, although some years ago a reference was made to it at a meeting of the Eng- lish Society of Public Analysts. Wanklyn does not even mention its occurrence. As the bilge-water of a sugar ship from Cardenas, Cuba, was found to give this peculiar coloration, it was supposed to be due to an ethylic compound. The hy- drochlorate of triethylamine when tested gave a whitish precipitate with a yellow tinge in strong solutions, and in weak solutions some whitish streaks were developed which immediately became dissolved to a hazy citron- green color. Methylamine gave a somewhat similar reaction, and amylamine a white solid color. These substances, when distilled with excess of alkaline per- manganate, yielded the true ammonia-color. But the unknown volatile organic matter which gives the citron- green color in w'ater-distillations was found by careful experiments in many instances to contain no nitrogen. Ethylic ether and alcohol, when added to water and Nesslerized, gave reactions similar to that produced by the triethylamine. The coloration most resembling that found occasion- ally in water-analysis -was yielded by the distillate from solutions of glucose. The organic matter in this distil- late contained no nitrogen, but required a large amount of oxygen for its oxidation by the Tidy or Kubel meth- od. Cane-sugar and starch, when so treated as to cause partial conversion into glucose, gave similar results. Tannin also gave this coloration when distilled with car- bonate of soda. It was further noticed that the solutions of glucose and tannin became of a deep yellow color on the addition of sodium carbonate, and that this yellow coloration was also struck by the alkaline carbonate in those waters which were found afterward to give the in- terference with the ammonia-reaction. The citron-green color, when produced by the Nessler reagent, was there- fore considered to indicate the presence in the water of non-nitrogenous vegetable substances in the progress of fermentative change. During these experiments on this volatile organic sub- stance a water was prepared which furnished a distilled water requiring, measure for measure, considerably more oxygen from permanganate than the residue in the retort. Such a water, tested by Frankland's combustion-process, would give fallacious results, and by the Kubel method would require less oxygen than by Tidy's process-thus explaining some of the discrepancies which have been found in the use of these processes. The information which may be gathered concerning the character of a water by a comparison of the results of the Wanklyn and Kubel processes may be formulated as follows : A water yielding up the nitrogen of its organic con- stituents slowly as albuminoid ammonia contains recent organic matter; Of animal derivation, if a small quantity of oxygen be required to oxidize it by the Kubel or Tidy process ; 703 Water. W'ater. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Of vegetable derivation, if a large quantity of oxygen be required. A water yielding up the nitrogen of its organic con- stituents more rapidly contains decomposing organic mat- ter ; Of animal derivation, if a small quantity of oxygen be required to oxidize it, and if there be no interference with the development of the true ammonia-coloration during Nesslerization; Of vegetable derivation, if a large quantity of oxygen be required, and if a yellow coloration be developed in the water on the addition of sodium carbonate and a greenish color interfere with the estimation, particularly of the free ammonia, by Nessler's method. The nitrates in a water are of much importance, as be- ing the inorganic or skeletal remains of formerly exist- ing nitrogenous organic matter. In themselves they are harmless ; but the water which contains them must at one time have been contaminated with organic sub- stances. The production of nitrates from organic nitro- gen was an unexplained fact considered due to some ob- scure process of oxidation until the observations of Schloesing, Muntz, and Warington demonstrated in it the action of a living ferment. The traces of nitrites and nitrates sometimes found in rain-water, especially after thunder-storms, are due to electric action on the inorganic nitrogen of the atmosphere ; but the nitrates of waters which have been in contact with the soil are formed from the ammonia which the waters contain. The self-purification of water-that is, the disappearance of its free ammonia and organic matter-is effected by this process of nitrification. Repeated experiments were conducted by the writer, at intervals of ten days, on a series of thirty-one samples of natural waters and organic solutions, furnished by Professor Mallet as part of the material for his investigation into the accuracy and value of the processes of water-analysis. The re- sults showed the conversion of organic matter into free ammonia, and the gradual disappearance of the am- monia, while traces of nitrous acid occasionally sug- gested that the nitrogen of the lost ammonia might be found in newly formed nitric acid. At the time these experiments were performed no opportunity was af- forded of following up the lost ammonia ; but in recent investigations it was accounted for by the nitrogen of the newly developed nitric acid. Since, then, nitrogenous organic matter, in its progress to a stable inorganic con- dition, passes through an ammoniacaland a nitrous stage, the presence of ammonia, nitrites, or nitrates in a w'ater indicates a progressive degree of remoteness from the source of organic pollution. Ammonia and nitrites tes- tify to the proximity of this source, especially if accom- panied by a large proportion of unaltered organic matter ; and in such instances the nitrates also must be viewed as recently formed. But if nitrates are unaccom- panied by the transition-products, they have, theoreti- cally, no bearing on the quality of the water other than by augmenting the quantity of the inorganic solids, for they may even be of geological formation, organic once, but as thoroughly dissociated from their former organic con- ditions as is the chlorine of the sodium salt in sea-water. Hence R. A. Smith was inclined to believe that the pres- ence of nitrates showed that the most dangerous state of the organic matter was past. Wanklyn says that the nitrates offer no data of any value in judging of the or- ganic quality of a water. But as the nitrates are always derived from organic matter, and very generally from recent matter, Frankland gives greater weight to their presence, and makes them, w'ith the nitrites and am- monia, the basis of a calculation showing what he calls the previous sewage-contamination of the water. Ekin goes further, and claims, from an experience which has found nitrates in waters which had undoubtedly caused typhoid fever and yet were free from any unusual amount of recent organic matter, that nitrates in excess of 0.5 or 0.6 part in 100,000 point significantly to dangerous pol- lution. This is an extreme view. A water which con- tains the nitrified remains of organic matter should have its surroundings minutely inspected, and if there is a possibility that the nitrates are derived from any neigh- boring polluting source liable to infection with typhoid excreta, suspicion as to the wholesomeness of the water may be entertained, for some change in the circulation of the percolating current may at any time bring unoxi- dized organic matter into the water, and, moreover, there is great probability that the specific fever-poison may persist notwithstanding a filtration which destroys ordinary or non-specific sewage. The mode of detecting and estimating the free am- monia has been already stated. Nitrites are detected by Greiss's method. A small quantity of sulphanilic acid is added to the water, and immediately afterward a similar quantity of a solution of naphthylamine hydrochlorate, when, if nitrites are present, a beautiful rose-color is developed in the liquid. The color deepens gradually for about twenty minutes, when it attains its maximum. This test is exceedingly delicate; according to Warrington it will indicate the presence of one part of nitrogen as nitrous acid in one thousand million parts of water. The sul- phanilic acid is prepared by adding guttatim 30 grams of aniline to 60 grams of fuming sulphuric acid con- tained in a porcelain capsule and carefully heating the liquid until it becomes dark and thick and ceases to evolve sulphurous fumes. When cold, the mass is poured into half a litre of cold water and permitted to stand for some hours, when the water is removed and the residue treated with half a litre of hot water, which, when cold, is also decanted. The mass, which has been thus washed in cold and hot water, is then macerated for twenty-four hours in one litre of hot water. This, which forms the sulphanilic-acid solution, is filtered, treated with animal charcoal, and again filtered, after which it is made up to 1,500 c.c. with pure water. It becomes pink on keeping, but a little charcoal in the bottom of the bot- tle prevents this color-change. For the naphthylamine solution one gram of the salt is dissolved in 100 c.c. of water. The cylindrical Nessler glasses may be used in testing the water ; and colorimetric comparisons with glasses containing known quantities of nitrous acid, in the form of pure potassium nitrite, will give accurate determina- tions of the quantity present. Nitrates are conveniently detected by means of Spreng- el's solution, which consists of one part of carbolic acid dissolved in four parts of sulphuric acid, and subse- quently diluted with two parts of water. It forms a faintly reddish solution when seen in mass, but is almost colorless when dropped on a white porcelain surface. The water to be tested is evaporated to dryness in a por- celain capsule. A few drops of the test-liquid are per- mitted to fall on the residue and are trailed over its sur- face by tilting the capsule. If nitrates are present in notable quantity a dark blood-red color is developed on the trail of the test-drops. If traces only are present the color is fainter-so faint, perhaps, that it may be difficult to decide if the original color of the drops has been really deepened. Besides this, the darkening produced in some organic residues by the acid of the test obscures the re- action with minute traces of nitrates, but, nevertheless, the test is of value. If 50 c.c. of the water have been evaporated and the Sprengel drops give no reaction, or doubtful indications, nitrates may be present to the amount of 0.2 milligram or 0.4 part per 100,000 of the water; but if the quantity present is in excess of this, it is indicated with certainty. Thus the nitrates which Ekin considers should cause the condemnation of a water are shown by the test, while, if the amount is below his limit of 0.5 or 0.6 per 100,000, the reaction may be uncer- tain or absent. If an accurate estimation of the nitrates is desired, their reduction by means of aluminium in al- kaline solution affords a ready method of effecting it. A measured quantity of water is distilled from a retort, as in the albuminoid-ammonia process, to remove the free ammonia, after which the residual water is treated with a solution of caustic soda and some pieces of aluminium foil. The caustic soda must be free from ammonia, to insure which its preparation from the metal is needful. 704 Water. Water. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. After a few hours the nitrates are destroyed, and their nitrogen converted into ammonia, which may be distilled and estimated by the color-method with Nessler's reagent. Repeated experiments have shown that the nitrogen of organic matter is not affected by this treatment. Frankland has called the nitrates the skeleton of sew age ; but these salts may have their origin in the nitro- gen of vegetable organic matter as well as in that of ani- mal matter. If any one salt is especially characteristic of animal life it is sodium, chloride. It is an essential component of the animal tissues, and is therefore present in the excretions. Chlorine in a water associates the sample with a pre-existing animal matter. If ammonia is present in unusual quantity the proximity of the pol- luting source whence the chlorine was derived may be considered certain. If nitrates, and especially nitrites, are present, the chlorine may also be referred to a recent pollution. These various substances, found on analysis, support each other's testimony and give greater value to the analytical results. Rain-water contains minute traces of chlorine, especially in showers falling near the sea-coast. Cistern-waters collected from foul roofs may contain a fraction of a part per million. River-waters usually contain up to five parts per million, and well- and spring-waters more than this. The more extensive the contact with the soil the greater usually is the amount of chlorides present. Chlorine is detected by the action of silver nitrate on its solutions. This test should be applied to a few cubic centimetres of a water undei1 examination, not to mani- fest the presence of the chlorine, for that may be taken for granted, but to give a rough estimate of its quantity, that the analyst may know what volume of water will be convenient or necessary for the exact determination of quantity. When a dense cloud or curdy precipitate ap- pears in this preliminary experiment, the chlorine may be estimated in the unconcentrated water ; but when the silver salt gives only a faint haze, it will be advisable to evaporate 100 c.c. to a small bulk for the quantitative ex- periment ; and, if the silver gives little or no reaction, as much as 400 c.c. may be required. •When a water containing chlorides is colored slightly with neutral potassium chromate, and is afterward treated drop by drop with a silver solution, the chloride of silver falls as a white precipitate, and the liquid under treat- ment retains its yellow color so long as any chlorine remains unprecipitated. But as soon as the last of the chlorine has been thrown down, the silver chromate, which is then at liberty to be formed, flushes the liquid with a reddish color. The silver solution, in the circum- stances, is a quantitative test for the chlorine. It may be made by dissolving 5.250 grains of silver nitrate in one litre of water. This will give a solution each cubic cen- timetre of which is equivalent to a little more than one milligram of chlorine. Its exact strength must be de- termined by means of a weighed quantity of pure sodium chloride, after which it may be diluted so that one cubic centimetre shall precipitate exactly one milligram of chlorine. The potassium chromate used to indicate the end of the chlorine precipitation should be perfectly neutral, and free from traces of chlorine. In analyzing cistern- waters which have but a minute quantity of chlorides, absolute purity on the part of the chromate is impera- tive, although in well-waters largely charged with chlo- rine the error introduced by a slight impurity in the chromate would be of no consequence. Where the amount of organic matter is large, and especially if urine is present, the ending of the reaction with the chromate as indicator is somewhat indefinite ; but in these instances the method recommended by Sal- kowski gives accurate results. An excess of the silver solution is added to the foul chlorinated water, which, after being boiled, is filtered from the precipitated chlo- ride. A measured portion of the filtered liquid is then treated with ferric sulphate ; and ammonium sulpho- cyanate of a strength equivalent to the silver test already used-one cubic centimetre of the one precipitating one cubic centimetre of the other-is dropped in from a bu- rette until the appearance of a blood-rod tinge indicates that the measurement of the excess of silver in the liquid has been accomplished. The estimation of the chlorine is in some instances all that is needful to show the character of a given water or series of waters. The writer, when in Memphis, Tenn., in 1879, made an exhaustive analysis of the un- derground cistern-waters which were first presented to him. On reviewing these analyses, after a number of them had been tabulated, it became manifest that the amount of chlorine might be made the test of soundness or leakage of the cisterns. At first sight it would seem as if the total amount of dissolved solids would be the best criterion, as rain-water properly stored contains such a small proportion of these matters, but in many instances the residue contained lime in comparatively large quan- tities, without that corresponding increase in the chlo- rides which would be expected if the lime-salts siped in from the soil. The inference was that the lining of the cistern was undergoing solution by the water-an im- portant fact, as bearing on the permanence of the cistern in its sound condition, but rendering the total solids as determined by evaporation and weighing of no value as a test of leakage. But, on the other hand, since from a sound cistern the water could not gather any increase of chlorides, the presence of chlorine in excess of the quan- tity normal to roof-caught rain-water became an indica- tion of siping or leakage from the soil into the cistern which furnished the sample. On reaching this conclu- sion an examination was made of a large number of cis- terns by means of the chlorine determinations. Many ■were found so strongly charged by this contribution from the soil that a large supply of water was obtained from the cisterns in question for more detailed investigation into the quality of the matter accompanying such amounts of chlorine leakage. Many rain-waters which were collected directly from the roof contained as much as .075 part chlorine in 100,000 of the water. Evidently, therefore, a cistern-water which did not contain more than this might be considered free from soil-pollution, for the finished analyses showed the Mem- phis soil to be so charged with chlorides that the slight- est leakage or siping gave a marked increase to the chlorine figure. A small excess over the normal might exist and the cistern be sound, the increase being due to an unusual foulness of the roof. As much as .15 part of chlorine (per 100,000 parts of water) was shown to be consistent with soundness; but as the amount increased beyond this figure the probability of leakage became proportionally greater. In reporting"the results of this examination at Memphis, those waters which contained less than .075 part chlorine were re- garded as from undoubtedly sound cisterns, the supply itself being in all probability of good quality. When the quantity lay between .075 and .15 part, the cisterns were regarded as probably sound, and the increase as due to vegetable contamination and foulness of the shed- ding surfaces, although in a small proportion of the cases it might be owing to a slight siping from the soil ; and in these instances the water was of necessity re- garded as of doubtful quality. When the chlorine figure lay between .15 and .30 part, the cistern was reported as probably siping, the increase coming from the soil, and being in all likelihood a sewage-accompaniment, al- though in rare cases probably due to a large organic im- purity without leakage on the part of the cistern ; and in either of these cases the water was probably bad. Last- ly, where the amount exceeded .30 part the cistern was viewed as undoubtedly leaky, and as containing an im- pure water-supply. The estimation of the chlorine concludes the organic analysis of clear waters, but it is always advisable to sup- plement the chemical methods by microscopic examina- tion and bacterioscopic investigations, as they may fur- nish points of information bearing on the character of the organic matter. Although the sediment to the un- aided eye may appear as nil, or as the merest film upon the bottom of the containing vessel, the microscope may reveal in it an infinite variety of vitalized forms, few of 705 Water. Water. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. which, however, have been associated with injurious qualities of the water. Thus the symmetrical forms of the desmids and diatoms are found in the sediment of almost every natural water. Their presence is there- fore deprived of any special sanitary value, except where it constitutes the characteristic of the microscopic field, as in cases of pure well- or spring-waters. Impu- rity in the water develops other forms of life which with- draw the attention of the observer from the occasional diatoms. The filamentous oscillatoriacese and nostocs, with their transverse markings and constrictions, and the other confervoid genera in which the colored endochrome becomes converted into motile zoospores, as in zygnema, spirogyra, zygogonium, conferva, oedogonium, and chce- tophora, are so generally found in water that it is only when they become prominent as a sediment that excess of organic impurity may be suspected. Of the animals, rotifer and hydatina among the rotifers, cypris, cyclops, and daphnia among the entomostraca, and macrobiotus and hydrachna among the arachnids, occur frequently in waters which analysis has shown to be pure, and expe- rience to be destitute of any unwholesome qualities ; while the tentacled infusoria, such as euglena and pera- nema, and the ciliated acomia, enchelys, and alyscum are also to be found in w'aters which give good results chem- ically. Pure waters have generally but little sediment. Impure waters, although frequently depositing a sedi- ment which swarms with vital forms, may give a micro- scopical field which is as devoid of living forms as that furnished by a pure spring-water. This result may be obtained after water has been thoroughly sedimented in the well or cistern whence it has been withdrawn for ex- amination. But if the sedimentation has been less per- fect, so that some particles of vegetable debris are left floating in the water, these particles will be seen to swarm with living forms if the water is impure ; while, if it is pure, any vegetable debris thus accidentally pres- ent will not be found to be the centre of a vital settle- ment. In some instances an organically impure water has presented a perfectly dead field when the amount of saline matter in solution was large. The bacterial fecundity of such waters may be deter- mined by the method suggested and used by Dr. Burdon Sanderson in his " Researches into the Ultimate Pathology of Contagion," the report of which was published by the medical officers of the Privy Council, 1871. Dr. Sander- son found, in his investigations into the origin and growth of bacteria, that waters which show freedom from or- ganic germs, not only under the microscope but when viewed by the electric beam, are nevertheless capable of determining bacterial growth when added to a proper nutritive liquid. Pasteur's solution, which consists of 10 parts of sugar, 0.5 of tartrate of ammonia, 0.1 of yeast ash, and 100 of water, was used in the experiment. This liquid, when boiled in a flask which has been sterilized or exposed to a heat of 200° C. (392° F.) in a hot-air oven, will remain clear indefinitely, provided it is protected from atmospheric dust by a plug of cotton-wool; but if a few drops of water are added to the solution by means of a sterilized pipette a turbidity will occur in the course of a few days from the development and growth of in- numerable bacteria and fungi. The length of time the test-liquid remains clear, and the density of its subse- quent cloudiness, were proposed as a means of determin- ing the relative zymotic properties of drinking-waters. This process is destitute of value as an indicator of the quantity of organic matter. There are few waters that will not yield positive results when so treated ; dis- tilled water will determine the growth, unless it has been recently boiled. But no claim of this kind was advanced on its behalf. It was merely a method of determining the relative bacterial fecundity of two or more waters ; and when the ordinary chemical examination failed to in- dicate a difference between samples that had been sub- mitted for comparison, this test was useful in determining a preference. It is now, however, set aside by new bio- logical methods. The discovery of the comma bacillus by Koch, with the expectation of further developments from his methods of biological research, has for some time past made the sanitary analysts feel as if there would speedily be no more use for their chemical knowledge and experience of the constitution of water-supplies. The medical pro- fession, and even the general public, became fascinated with the views and possibilities opened up by the Ger- man method of growing invisible germs on solid gelatine plates until the colonies of each reached a magnitude that brought them within the ken even of the naked eye. The original germinal spots could be counted, to demon- strate the number of individuals that had existed in the water under examination. Differences could be observed in the appearance of the various colonies. Transplanta- tion could be effected and pure cultivations of each could be obtained for further microscopic and biologic study. It seemed as if the end had been reached, and that the question of the wholesomeness or unwholesomeness of a water was at last susceptible of solution by laboratory methods. But the progress of experimental work is slow. The anticipations of the enthusiasts, onlookers chiefly, may be reached ultimately ; but in the meantime it may be safely asserted that the new method has only succeeded in developing the difficulties by which it is surrounded and in casting doubt on its own results as a gauge of the quality of a water-supply. In Koch's method a given quantity of the water is mixed with a sterile peptonized meat-jelly, which is then distributed evenly on a glass plate, where it solidities. The plate is placed in a moist and properly protected apparatus and kept at a temperature of about 20° C., which is that most favorable to germination and growth. After a few days the colonies appear. They vary in size and shape, some minute, some larger and spreading, some round or oval, smooth, fibrillated or tuberculated, and some liquefying the jelly which is their nidus. The peptonized meat-juice usually contains about ten per cent, of gelatine, which keeps it solid up to about 25° C. It is prepared by digesting one pound of fresh meat in a litre of distilled water for twenty-four hours in a refrigerator ; after which it is strained and pressed, and the resultant liquor made up to one litre. It is now boiled to coagulate the albuminoids, and clarified by adding the white and shells of two or three eggs, boiling vigorously, removing the scum, and afterward straining through flannel. The other ingredients are then added ; 10 to 30 grams of peptone, 5 grams of chloride of sodium, and 100 grams of gelatine; after which the whole is passed through a hot filtering apparatus. Any acidity that may have developed in the preparation is neutralized by the cautious addition of sodic carbonate. It is then transferred to test-tubes for use, each tube receiving about 10 c.c. The charged tubes are sterilized by an exposure of ten or fifteen minutes in a steaming vessel on each of three succeeding days, and after this, if the jelly remain free from developments for several days, it may be re- garded as fit for use. When a water is to be examined a tube is selected and its contents liquefied ; and of course in this, as in all other manipulations, every care must be taken to guard against the intrusion of aerial or other germs. The water-sample is received into the tube from a small-noz- zled pipette which delivers a drop of known size. The quantity used depends upon the character of the wrater. If it be poor in germs, one-half of a cubic centimetre may be added ; if rich, it may be needful to dilute the sample with distilled water previous to using the pipette : if its character is unknown, several tubes must be used, each to have added to it a suitable dilution. The tube is agitated to mix the water thoroughly with the liquefied jelly, which is then transferred to a level glass plate, usually about six by four inches, having an ice-chamber beneath it to promote the rapid congelation of the gela- tine film. The plate, reposing in a moist glass chamber, is then set aside at the proper temperature for the cul- tivation of such germs as may be present. Among the first of the facts demonstrated by this new method of study was the universality of bacterial germs in water. It was difficult to find a water which would not yield a few colonies ; even distilled water from the 706 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Water. Water. laboratory of the chemist was sometimes charged with them. The question arose, Does the number of colonies developed from a water have any bearing on wholesome- ness irrespective of the character of the individual colo- nies ? To this Bischof (" Trans. Soc. Medical Officers of Health," 1885-86, p. 110) has given a decided reply. It was recognized that a water which, when freshly drawn, gave rise to but few colonies, would yield very different results after storage for a few days, on account of the rapid multiplication of germs in the stored water; and it was also recognized that this multiplication depended less on the number of bacteria originally present or the organic pabulum at their disposal than on such accidents as temperature and exposure to, or deprivation of, light, oxygen, etc. But notwithstanding the development of these germs a wholesome water does not become un- wholesome, as is well authenticated by the use of such stored waters. A sample of New River water, concern- ing the purity of which there could be no question, as it yielded only fifty-three colonies per cubic centimetre, was found after a storage of six days to yield no less than seven hundred and seventy thousand colonies, a number seventeen times in excess of that derived from the Thames water at London Bridge ; yet there was not the slightest evidence to show that the water in which this immense number had been developed was not a wholesome water. A water might be as free from bac- teria as that of Loch Katrine, or it might contain as many as this stored sample of New River water, without aspersion on its wholesomeness. Of what value, then, the intermediate hundreds or thousands-particularly as these numbers may be obtained from the same water on one day or another ? If seven hundred and seventy thou- sand be consistent with wholesomeness, where is the line to be drawn ? We know by experience that sewage or animal excretions constitute a dangerous element in water-supplies, but the number of colonies throws no light upon this element, for Bischof added sewage to a sample of the New River water, and after storing it for six days, as in the parallel experiment with the pure water from the river, he found that the bacteria in the latter exceeded those in the tainted sample almost twenty times. But supposing the number of the colonies to be an in- dication of value, several important objections are urged against the accuracy of the results yielded by the gela- tine method. Zoogloea masses and chains are not broken up by the agitation in the tube, so that a mass may give origin merely to a simple colony. From analogy, as well as direct experiment, we know that different kinds of bacteria require different kinds of food. The addi- tion of a little phosphate of soda to an ordinary water will greatly increase the colonies in the gelatine. Some organisms that do not flourish on the meat-jelly will do so on potatoes, Iceland moss, bread-paste, and other vegetable nutrient substances. The water-supply of Antwerp, which was stated by a commission of experts to be completely sterile to Koch's test, gave evidence of abundant life when potato was used as the field of cul- tivation. Remembering these defects in the gelatine process, and recalling the fact that number means noth- ing, what remains to be done ? To study the colonies- to transfer to gelatine, blood-serum, potatoes, etc., in order to obtain pure cultivations. To examine these microscopically and study their characters, which are simple enough, yet complex in their simplicity. The bacteria are thick or thin, straight or curved, oval, round, or square-cut at their ends, long and filamentous, or so short as to merge into the torula or coccus, the cocci pre- senting every form of aggregation from single to zoog- Icea, and the whole perhaps mixed with mycelial threads, shreds of mucor, spores, etc. Every water has a variety of forms, though in some the cocci, in others the bac- teria, may predominate. Which are harmless ? Which are harmful ? Nobody knows. In fact, the difficulties of the microscopic field are so great that few observers have attempted to state the number of different kinds of organisms present, and fewer still to isolate by pure cult- ures and investigate by subsequent experimentation. The gelatine culture-test is valuable only for its prom- ise of the future. At present it gives little information, and that little is assailed on all sides by interrogation points. Chemical analysis gives a definite statement of the quantity of the organic matter present and throws light upon its character, but the results of the culture- field vary for the same water according as it is examined on one day or another. But to return from these culture-tests to the ordinary course of sanitary analysis. If the water is turbid the substances causing the turbidity may require to be inves- tigated by both chemical and microscopical methods. The total amount of the sediment may be determined by evaporating a given quantity of the water after it has thoroughly sedimented, drying the residue and weigh- ing, when its weight deducted from that obtained by a similar experiment performed on the unsedimented water gives that of the sediment present. If the experiments already described in this article as performed on the nat- ural or unsedimented water are repeated on the thor- oughly filtered or sedimented specimen, a comparison of the results will manifestly discover the special inorganic or organic characters of the sediment. But a formal ex- amination of this kind is seldom necessary, as the mi- croscope usually suffices to determine the quality of the sedimented matters. The microscopic appearances are extremely complex when examined in detail, but each sediment presents certain characteristics which may be seen at a glance with ordinary powders, and on which the quality of the water may frequently be predicated. The matters are mineral, organic, and vitalized. The mineral consist of: 1. Silica, which occurs in angular fragments, unaf- fected by acids. When these are the characteristics of the microscope-field in a water which is comparatively clear, that water is probably pure. When the water is densely turbid with such particles it may be, on the con- trary, very impure; but, even if so, the rapidity with which the particles are precipitated, and their influence in removing other suspended matters, render the water less objectionable than one turbid from other causes. 2. Clay occurring in particles just visible in the field ; when slightly out of focus these particles may appear as minute spherules ; when aggregated, as by an accidental touch on the glass cover, they may assume an obscurely organized appearance. They are, like silica, unaffected by reagents. Generally the turbidity of our river-wyaters is due to clay or sand, or a mixture in varied proportions. Particles of finely divided clay take long to subside. Sandy particles sink readily and carry clay and other matters along with them. Clay clogs the pores of a fil- ter and covers its surface with an impermeable layer. Sand is readily removed by filtration, and does not choke the filter. The sanitary bearing of an inorganic turbid- ity depends therefore more on the kind of matter consti- tuting it than upon its quantity. A small quantity of clay suspended in a water detracts more from its value as a water-supply than a large quantity of sand, provided that in both instances the water contains so much inor- ganic matter that purification by filtration or sedimenta- tion must be effected before it may be used. 3. Lime carbonate, in angular fragments, which are readily discriminated by their effervescence when a trace of acid is insinuated beneath the glass cover of the mi- croscope-slide. In such cases the w'ater is probably hard. 4. Carbonaceous particles, which may be regarded as inorganic, since combustion has dissolved their connec- tion with the organism. They may be present in large quantity in pure cistern-water, which, in consequence, would be condemned by the permanganate process, if its results were accepted as final. 5. Accidental inorganic substances, depending usually on some peculiarity of the composition of the shedding surface. The organic matters in suspension are various in char- acter. They are easily discriminated when fresh, but in the progress of disintegration and decay their histologi- cal characteristics become lost, and their origin is of ne- cessity obscured. Their organic derivation may, how- 707 Water. Water. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ever, be generally determined by their difference from the usual forms of inorganic matter and by the activity of the organic life in their neighborhood. Those most frequently occurring are fragments of woody tissue from the roof in cistern-waters, and from the wood-work in well-waters-the pitted tissues showing their derivation from cypress or pine,-straw, starch-cells, pollen grains, as also the cellular tissue, stomata, veinlets, etc., of broken up leaves. Dark-colored masses of woody tissue from the roots of trees, when present in a well-water, lead to the expectation of vegetable impurity in the water. Cotton fibres are often found in the cistern-waters and in many of the wells of the Southern States ; but their prevalence in the atmosphere deprives their presence in the water of any sinister meaning. Wool and linen fibres may also be washed from the roof into cisterns, but when they are found in well-waters inflow from the surface may be suspected. Fragments of human hair and epi- dermic scales suggest a direct surface-leakage of a dan- gerous character, or an equally dangerous carelessness in protecting the water after it has been drawn. Insect remains, such as the legs, antennae, abdominal shell, and wing-scales may be present in cisterns, indicating a cor- responding degree of impurity in the water and afford- ing evidence of inefficient filtration, or of insufficient protection in the case of well-water. The germs of vitality are so generally diffused that, where there is food, development, growth, and reproduc- tion will ensue under ordinary circumstances. Temper- ature retards or accelerates these changes ; but the same temperature which promotes the growth of microscopic organisms induces, in devitalized substances, the devel- opment of the putrefactive changes which transform their albuminoids from wholesome to unwholesome, as regards their action on the human system. The growth of these microscopic organisms may therefore be con- sidered, in many cases, as measuring the harmfulness of a water-supply. Bacteria, on the microscopic field, show a putrefactive tendency in the organic matter of waters. Of the tentacled infusoria, oxytricha, kerona, and euplotes are found in waters which do not give a satisfactory re- sponse to the chemical tests. The flat worms, the an- guillula, and the regularly ciliated paramecia, of which that most commonly met is the oblong compressed para- mecium, with its oblique fold, the elongated amphileptus, and the flask-shaped lacrymaria, with its long neck and ciliated mouth, coincide with waters which would be condemned on chemical grounds. Sluggish amoeboids and the more active protoplasmic masses, such as mo- nas, cyclidium, cercomonas, etc., and a profusion of vor- ticellae in an active or encysted condition, are certainly characteristic of an impure water. The question sometimes arises as to the presence of injurious quantities of certain metals in water. Lead, derived from service pipes or tanks, is usually the sus- pected metal, but it may be copper from boilers. These, when present, may be detected by the method recom- mended by Professor Wanklyn. A small quantity of the water, about one hundred cubic centimetres, is stirred in a white porcelain dish with a glass rod which has been dipped in a solution of ammonium sulphide. If the liquid becomes darkened in color, the effect is due to the formation of a sulphide of iron, lead, or copper. If the color disappears on the addition of a drop of hy- drochloric acid, it is due to iron and is not injurious unless the metal is present in excess ; but if the color persists, it is owing to the presence of lead or copper, either of which ought to condemn the water as a potable supply or for kitchen use. A few words may be said concerning the analytical results obtained, by the processes above mentioned, from water-samples derived from various sources. The characteristics of rain-water which has been col- lected in clean dishes as it falls from the clouds, are dis- tinctly marked. A trace only of solid matter-about 2 parts or less per 100,000-giving an evanescent blacken- ing on ignition, and a slight loss of weight, indicates that the water has not come in contact with the soil ; traces of nitrous and nitric acids, and of chlorine, are also obtained. The rain-water yields, however, so large an amount of free and albuminoid ammonia, that if the source of the water is rendered uncertain by the pres- ence of some solid matters accidentally introduced, the gravest suspicions may be entertained against it; .050 part of free ammonia, and .030 of albuminoid ammonia per 100,000 of the rain-water, are quantities which are frequently found, especially in the first part of a rain- fall ; but if the shower has continued for some hours, the ammonia may be diminished to .030 part free and .020 part albuminoid. The quantity of oxygen required to oxidize the organic and other matters, such as nitrous acid present, is small as compared with the large quan- tity of nitrogen indicated by the albuminoid ammonia ; .2 part of oxygen per 100,000 is generally the result of the permanganate test. Snow-flakes collected and melted give a water which yields as much as .050 part of albuminoid ammonia per 100,000. Rain-water is modified by the character of the roof which sheds it-that from a clean slate roof may not dif- fer materially from the specimens collected in clean dishes; while rotting shingles, foul conductors, and equally foul cisterns may impress their characters upon the analytical results. Thus the solid matter is increased to 5 or 6, and even sometimes to 10 or 12, parts per 100,000 ; but a large part of this is dissipated on ignition, with much blackening and vegetable odors. The free ammonia is generally increased by the solution of such ammoniacal products of combustion as may have settled on the roof, but the organic ammonia is not materially altered unless the water has been stored in the cistern for some time, in which case both the ammonias may be considerably reduced in quantity. Carbon and other matters washed from the roof increase the quantity of permanganate so- lution required to oxidize them ; .3 and .4 part are often the result of the Kubel experiment, and .6 part is occa- sionally found ; a New Orleans public school cistern- water required .8 part. If the storage cistern is a wooden tank, the free and al- buminoid ammonias may continue present in large quan- tities for a long time after the inflow of a fresh rainfall. These, with a large oxygen figure due to carbon washed from the roof, constitute analytical results which would condemn any water save that with this particular history. If the history of the water is unknown, the small amount of the solids and of the chlorine indicates with certainty that the water has not come in contact with mineral mat- ters, and that it is probably a rain-water from a wooden tank. During the hot season putrefactive changes take place in the albuminoids of waters thus stored. The water may even become so tainted that the senses may take cognizance of its impurity. It is therefore especially de- sirable, when -wooden tanks are used, that the impure portions of the rain-shower be rejected by a cut-off, and that the water used for drinking purposes be subjected to filtration. But, as will be seen presently, much may be done to free the water from its saline and organic am- monia during the period of its storage. If the rain-water is contained in a brick cistern, the carbonic acid which it holds in solution enables it to dis- solve a small portion of lime from the lining of the cis- tern. The total solids are therefore increased in quan- tity to 10, 12, or even 16 parts per 100,000 of the water. The presence of the lime is readily demonstrated ; and the absence of chlorine, save in quantities normal to rain- water, shows that the alkaline earth is not derived by sipage from the soil in which the cistern is built. In waters thus stored a remarkable change takes place in a very few hours. Although the rainfall on entering may have contained .050 free ammonia and .030 albuminoid ammonia, the former may disappear completely and the latter be reduced to less than .010 part, constituting, ac- cording to the opinion of most analysts, a record indica- tive of a pure and probably wholesome water. The purification which is experienced by rain-water -when stored in an underground cistern, so notable in contrast with the continued impurity of that contained in wooden tanks, was at first attributed by the writer to conditions, 708 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Water. Water. as of exclusion from light and heat, pertaining to the underground position. But the speedy purification is now known to be owing to a process of nitrification, the earthy lining of the cistern appearing to furnish the germs of the organic ferment. This knowledge explains certain anomalous results which were puzzling to the writer when dealing with the tank-waters of New Or- leans, La. Of two cisterns, one of which was new or newly cleaned, and the other many years old and per- haps never cleaned, the latter in most instances furnished the purer water. Many such cases may be found in his report in the " Annual Report of the National Board of Health" for 1880. Nitrification was effected in the old cisterns by germs in the sediment which had gradually accumulated as the result of roof-washing. But if the shedding surface was very foul and the sediment largely charged with organic matter, the water by prolonged digestion, especially at summer temperatures, became contaminated by the sediment rather than purified by the organisms which it contained. Hence the old and uncleaned cistern did not in every instance furnish a purer water than the new or recently cleaned cistern. The lesson taught by these facts is the introduction of the nitrification ferment by a cleaner and surer medium than the accumulated sediment. If a layer of sand or gravel be placed in the bottom of a clean wooden tank, nitrifica- tion will progress in its contained water as certainly as in that of the underground brick cistern. And if the sedi- ment in a tank which yields a comparatively pure water be removed and replaced by sand or gravel, the purifica- tion of the water will be more rapidly and thoroughly effected. Rain-water shed from the surface of the ground and collected in low-lying situations with an impervious subsoil layer constituting swamps, ditches, or ponds, gives an increase in the total solids over that proper to cistern-water, even when the lining of the cistern has been attacked. The chlorine is usually augmented to .5, 1.0. or more parts per 100,000 of the water. Such waters may become impure by passing over an unclean surface ; but even if uncontaminated in their progress to the lower level, their subsequent stagnation in or on the highly organic surface soil affords opportunity for the solution of decaying vegetable matter, and they be- come impure, as their volume is small compared with the mass of organic matter which underlies them. The conditions in these instances appear similar to those in a cistern with a low water-level and a large and foul or- ganic sediment. In fact, the analyst may be in some cases at a loss to determine whether he is dealing with a swamp-water or with a foul cistern-water. The influ- ence of nitrification is lost in the continued absorption of ammonia and solution of albuminoids from decom- posing tissues, so that the water yields to the Wanklyn process high figures of free and albuminoid ammonia ; as much as .050 of the former and from .040 to .090 of the latter. The swamp-water of New Orleans yielded .050 free and .090 albuminoid ammonia, and its organic matter required as much as 1.345 part of oxygen from permanganate for its oxidation Foul pond-waters are sometimes used as public sup- plies, although they manifestly should not be so used. The water of Easton's pond constitutes, for exam- ple, the city supply of Newport, R. I. It was repeat- edly examined by the writer in connection with a sani- tary survey of the city, and its organic -constitution, as developed by the analysis, did not differ from that of swamp-water. On one occasion it yielded as much as .105 part of albuminoid ammonia per 100,000, and re- quired .840 part of oxygen from permanganate. It might be supposed that, if the use of such a water was specially dangerous, the health reports of the city of Newport would bear testimony of the fact; but, as Bow- ditch says in his report on Summer Resorts; "It is questionable, however, whether the health of the city is known to anyone; with the exception of a few of the citizens it is undoubtedly so, and it would be entirely safe to assert that neither the local board of health nor their officer know at any time the actual health of the community or anything approaching it, while the records show nothing." When necessity requires the use of these impure surface-waters, they should be puri- fied by systematic filtration, for although the quantity or quality of the organic matter may not suffice to cause a notable endemic of diarrhoeal disease, and although the germs of specific disease may not be present, the ten- dency to the former, and the probability of the presence of the latter, must be acknowledged to be greater in a supply which has much organic impurity than in one which has little or none. The microscopic characters of such waters are usually distinctive, consisting of bacteria in the zooglea form, amoebae and other sluggish proto- plasmic masses, and a profusion of active and encysted vorticels. Lake-waters, resting on bed-rock, and having their volume incomparably greater than the small marginal zone of organic decay, are usually pure. They are anal- ogous in organic constitution to rain-water in a clean and sound underground cistern. After a heavy rainfall on the water-shed the free and albuminoid ammonia may be slightly increased for a few hours, but the active progress of nitrification soon effects a return to the nor- mal constitution. Naturally, the total solids show a slight increase over those of cistern-water, and the chlo- rine participates in this increase. If the level of the lake is preserved less by direct outflow than by surface evap- oration, the consequent concentration may give a marked increase to the various mineral matters, an exaggerated instance of which may be seen in the Great Salt Lake of Utah Territory. The total solids in river-waters range from 10 to 25 or 30 parts in the 100,000. With a small amount of dis- solved solids the water is usually soft; with a larger amount there may be a certain degree of hardness from lime-salts. Chlorine is present, but it is seldom in ex- cess of 1 part in the 100,000. A trace of nitrites may be present; nitrates are also found as a result of the trans- formation of free ammonia and the albuminoids ; but if they exceed 0.5 part, an unusual amount of organic mat- ter has been washed into the stream. The free ammonia varies from .001 to .020, and the albuminoid ammonia from .010 to .025 ; while the oxygen from permanganate required to oxidize the organic matter ranges from .1 to .4 part. River-water is so liable to change in its quality from temporary disturbing causes, that its general charac- ter cannot be determined from a single examination. If a heavy rainfall has increased the volume of the stream just before the sample was collected, the free and albu- minoid ammonias may be as high as the maximum quan- tities above mentioned. On the other hand, if no rain has fallen for some time before the collection of the speci- men, the free ammonia and albuminoids may be present only in comparatively small quantities. Moreover, there are seasonal changes in the quality of river-water. Heavy rains and snow-meltings carry into the stream the sewage of the atmosphere. The former, especially, erode the surface-soil and diffuse its organic constituents in the running water, while the increased flow prevents the deposition of suspended matters and the consequent purification which occurs under other conditions. On account of these normal variations in quality, the water of one stream may not be compared in its analytical re- sults with that of another. The mean annual quality of each must be known. This varying constitution of a river-water renders it difficult to detect sewage in it by chemical means, unless the contamination is very gross indeed-in which case analysis will prove nothing that may not be determined by an inspection of the water-shed. Even when a large inflow of sewage is known to take place at a given point, the analysis of samples collected above this point, and a few miles below it, may not show any marked differ- ences in organic quality. The presence of the sewage becomes marked only by a slight increase in the quantity of nitric acid, and a corresponding increase in the quan- tity of the chlorides. The quantity of dissolved oxygen present in a water has been suggested as a measure of organic impurity. 709 Water. Water. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Professor Leeds says: "Pure natural water, such, for instance, as that of the Passaic in the upland hill coun- try of New Jersey, contains in solution the maximum amount of oxygen which water can dissolve at natural temperatures and under ordinary atmospheric pressure. This amount is not far from 6.5 c.c. of oxygen in a litre. On coming into contact with decomposing organic mat- ter, a portion of this dissolved oxygen is used up in pro- cesses of oxidation. The amount of oxygen held in solu- tion becomes, therefore, an index of the degree to which the water is contaminated by decomposable organic sub- stances." It is true that a large quantity of oxygen in a water is inconsistent with the presence of a large quan- tity of organic matter, since the latter, in its decomposi- tion, forms transition products which are susceptible of oxidation by the dissolved oxygen ; but as the oxidation of organic matter does not progress quickly, the presence of oxygen in a water may mean either that there is no accompanying organic matter, or that the two have not been associated long enough for the oxidation to be com- pleted. If Professor Leeds' analyses are compared with some of those published by Professor Mallet in the "An- nual Report of the National Board of Health " for 1882, it will be seen, for instance, that the stagnant water of the old Basin Canal at New Orleans, La., containing as it did 5.2 c.c. of dissolved oxygen, even after the many days which elapsed between its collection and analysis, does not differ much in this respect from the Passaic River supply ; and yet it yielded 1.0 part of free, and .83 part of albuminoid ammonia per million, and no one would think of using it as a potable supply. In fact, as already explained, the self-purification of water is not dependent on a chemical oxidation, but on a vital pro- cess, some of the products of which are susceptible of oxidation. The dissolved solids in well- or spring-water may be so large as to cast doubt on the wholesomeness of the sup- ply. But, even when these are not present in such ex- cess as to interfere with potability by the saline character or hardness which they give to the water, they usually contain a much larger proportion of chlorides than the solid residues of pond- or river-waters. Nevertheless, this increase in the quantity of the chlorides need not be viewed with suspicion, unless the water of the well under examination contains more than is found in the organically pure well-waters of the district. When the excess is due to local causes, the character of these and their bearing on the quality of the water must be studied. Similarly, in the case of nitrates, their pres- ence in larger quantity than in the unquestionably pure waters of the same section calls for a demonstration of the absence of polluting sources from the area of drain- age. Such sources are usually privies, sinks, cesspools, leaky house-drains, stables, pigsties, manured lands, grave-yards, and the contaminated condition of the soil which results from the accumulated filth of many years of occupation. The organic matters from these reach the well by inflow from the surface, by subterranean chan- nels which may have been formed in the soil, or by a fail- ure on the part of the soil to effect purification during the percolation of the water into the well, such failure oc- curring when the soil has become permeated by impurity. Subterranean communications between a well and a pol- luting source in its vicinity may sometimes be detected by pouring on or into the latter a solution of some chem- ical foreign to the constitution of the well-water, and testing at intervals for its appearance in the well. The communication which occasioned the typhoid poisoning of the Lausen Spring (see infra, page 718) was thus de- tected by means of common salt; and in the case pub- lished by Dr. Janeway, of New York (infra, page 719), chloride of lithium was employed to demonstrate the connection between the drain and the well-water. If the contaminating source is near, the nitrates may not be in excess, but the results of the distillations from alkaline permanganate will indicate its influence on the quality of the water. The organic matter may be of a harmless quality, but it is not so in all cases ; and prudence dic- tates the disuse of the water which contains it. The danger arises from the fact that organic matter reaches the water by some channel; for, where harmless organic matter enters, harmful organic matter, if placed in the area of drainage, will also enter. If the polluting source is distant, and especially if the soil in the drainage area is not surcharged with organic matter, the absence of free and albuminoid ammonia may indicate a water or- ganically pure. A water of this kind is generally whole- some, but it is not so always. Typhoid fever may be disseminated by well-waters which contain only traces of free ammonia and the albuminoids, but in these instances the nitrates and chlorides are usually in excess. If a well-water is contaminated by undecomposed sewage, its presence may be determined by the peculiar manner in which urea evolves its nitrogen as ammonia when treated by the Wanklyn process. The well-waters of cities usually contain large quanti- ties of nitrates and chlorides, and in many instances the coexistence of organic matter indicates that these salts are of recent formation, and the well correspondingly dangerous ; not perhaps dangerous from the sewage or other foul matters which enter them, for ordinary or non-specific matter is not necessarily dangerous ; but at all times threatening the consumers with an epidemic of typhoid fever or cholera, should the sewage which en- ters the wells become infected with the poison of either of these diseases-for a well which contains nitrates may admit the specific poison in full potency, although other and ordinary organic matters have been destroyed in transit. When the analyst has completed his w'ork, he is able to state that the examined water does or does not con- tain a certain quantity of the elements of organic matter. He is able also to state whether the water at one time contained more than this quantity ; and sometimes he may indicate that this increased quantity had a recent or remote existence. He may be able to say that the or- ganic matter was of an animal or vegetable nature, and fresh or decomposing in condition. He may even de- termine the presence and the approximate quantity of sewage matters in the water. But the important ques- tion-Is the water wholesome or unwholesome ?-cannot receive a positive answer from the records of the analy- sis. The nitrogen which enters into the composition of the albuminoid ammonia, distilled from a water which the analyst wrould characterize as foul, unfit for use, or dangerous, may come from an organic matter which is perfectly harmless, or from one which is a deadly poi- son. The extensive investigations into the methods of water analysis undertaken by Professor Mallet for the National Board of Health, and published in the Report of that Board for the year 1882, had for one object the determination of the value of the processes, as furnishing indications of the wholesomeness or unwholesomeness of a water. From a careful study of the analytical reports on a number of samples, the full history of which were known to him, although unknown to the analysts who investigated their character by the various methods, Professor Mallet concluded that, "It is not possible to decide absolutely upon the wholesomeness or unwhole- someness of a drinking-water by the mere use of any of the processes examined for the estimation of organic matter or its constituents." But, as has been advanced in these pages as the result of an extensive experience in water analysis, and its bearing on the question of whole- soineness, a study of the analytical record, combined with a careful inquiry into the source and surroundings of the water, will frequently enable an opinion to be given which will have value as indicating the probabil- ity of dangerous qualities. In the future, culture experi- ments and the microscope may be used for the detection of the living particles which give a morbific quality to water, but until a greater advance has been made in this direction than at present, the chemical processes above outlined afford, in connection with a close inquiry into the natural history of the water, the only trustworthy data for the formation of an opinion as to the potable quality of any given sample. 710 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Water. Water. Sanitary Aspects.-Water is second only to air in its importance in the animal economy. The necessity for continued breathing is felt at the end of a few seconds, but the system does not manifest so imperatively its need of fresh supplies of water, for it contains in its own liquids a store or reservoir whence loss takes place, slowly or rapidly, according to the conditions existing during the performance of vital actions ; and it is only when this store has been reduced to a level inconsistent with the proper continuance of these vital operations that nature expresses her requirements in a marked man- ner. All living tissues contain water. They are evolved, under vital laws, from water containing their proximate principles in solution, as crystals are developed and grow under physical laws in strong solutions of their inorganic constituents. In the stomach water effects the solution of fresh pabulum, which it carries into the blood-current, circulates, and deposits at the indication of the organic necessity. It removes worn-out material, and in effect- ing its discharge by the lungs or skin, so regulates the temperature that the chemico-vital processes of the ani- mal laboratory are carried on continuously with equable and healthful force. Water exercises a sanitary influence as a climatic factor, by its geographical distribution and the quantity present as vapor in the atmosphere ; it has a potent influence on the human race by its presence in soils, causing disease as well when the temperature is low as when it is high ; it is an essential in the sanitary police of individuals, families, and communities ; but it is only as a supply for the physiological necessities of the human organism that we propose now to consider it. Natural waters have been variously classified, for con- venience in discussion, by their source, into rain-, snow-, ice-, river-, lake-, spring-, well-, sea-water, etc.; by their prominent inorganic impurities, into saline, chalybeate, sulphurous, calcareous, magnesian, etc. ; by their abster- gent qualities, into hard and soft. For sanitary pur- poses no system of classification appears to be needful or of value, for we can rarely generalize when a water- supply is in question, or predicate of one from the known qualities of another. Every specimen must be analyzed, its history carefully examined, and an opinion formed upon the results independent of its source from wyell, river, or lake, or of its hardness, softness, or mineral characteristics. But there is a marked difference in the results of the analysis of certain naturally pure waters, and to give expression to this difference, which will be explained hereafter, waters may be divided into surface waters and percolated waters. These classes are fre- quently found in natural supplies to be mixed one with the other. Rain-water stored in sound cisterns may be taken as an illustrative specimen of the one, deep well- water of the other, while river-water consists of varying proportions of both. Rain-water is generally regarded as a pure water. It contains but minute traces of the mineral salts which are found in well-w'aters. The solid residue left on its evapo- ration is small as compared with that of the average well- water ; but it cannot on that account be considered as cor- respondingly pure, for it contains other matters which are characterized by chemical reactions as marked after their kind as the mineral films and crusts, or crystalline residues, which can be seen, handled, and w'eighed. It is by means of the rainfall that the atmosphere is pu- rified after long periods of drought. The detritus-min- eral, vegetable, and animal-of the earth is swept up into the air, where it becomes diffused, and may accumulate so as to dim the outlines of distant views. If in the air, there are miasmatic exhalations and volatile poisons which are unsusceptible of destructive oxidation by at- mospheric influences, spores of bacilli or fungi capable of instituting a fermentative action in organic substances under congenial conditions ; these, although undiscover- able, or as yet undiscovered by the microscope, will be washed down by the falling rain as certainly as the pollen and starch grains, carbon particles, fibres, filaments, and mineral dust which may always be detected in the sedi- ment of a rain-water. In times of epidemic prevalence of disease, as of cholera or yellow fever, it is possible that the rain-washed impurity from the air may contain the essence of the prevailing disease. When the exhala- tions from extensive malarious tracts rise into colder strata of the atmosphere, it is probable that the disease cause is carried thence with them, where it is condensed and falls as a constituent of the rain. When, during the warm days of summer, the atmosphere stagnates in the streets of a city and becomes so saturated with the foul issues from sewer ventilation, half-dried gutters, unre- moved garbage, and a generally impure soil, that a putre- factive tendency is established, it is probable that the falling showier, in purifying the atmosphere, becomes it- self exceedingly impure and the source of subsequent diarrhoeal, choleraic, dysenteric, or typhoid troubles, if used as a drinking-water. The rain is the sewage of the atmosphere, and it is hardly to be supposed that spores, germs, bacilli, ferments, poisons, or other deleterious or- ganic substances which have resisted the atmospheric oxidizing agencies, will become destroyed or rendered inert by their transference from an aerial to an aqueous medium. The ammonia which is evolved during the putrefactive process escapes into the air and is diffused therein ; the bacteria, the cause of this putrefactive change in organic matter, also pervade the atmosphere. The presence of the one may be shown by chemical means, that of the other by culture experiments. But the presence of both may be in like manner demonstrated in the rain which .has washed them down from the atmosphere. Since these bacteria and the products which accompany them as exhalations from fermenting organic matters may be found in the rain, it seems within the limits of probabil- ity that a malarial germ or microphyte, or a product of its growth during the fermentative change in organic matter which is connected w'ith paroxysmal fevers, may be exhaled into the atmosphere, and be found thereafter in the rain or snow ; or that a choleraic germ may in like manner be present in the rain during the epidemic prev- alence of the disease. Moreover, rain-water is liable to be contaminated by impurities on the collecting surface. The cleanest of roofs become covered with dust in dry seasons, and this dust, although largely mineral in character, contains a percentage of organic matter which requires only moist- ure for the inception of fermentative change and the de- velopment and growth of organic forms. The germ, essence, or poison of specific disease, which may be air- borne, must thus, of necessity, be also susceptible of transmission to the system by means of a rain-water sup- ply ; for it may be either carried down by the falling rain, or be washed into the reservoir from the collecting surface on which it may have been condensed or de- posited. Nevertheless, rain-water, as will be shown hereafter, is one of the purest sources of water-supply. By re- jecting all short summer storms and the first part of the fall of continued rains, thus excluding from the reser- voir the atmospheric impurities and the washings from the water-shed, a w'ater may be obtained which, although containing traces of ammonia and of organic matter, must, from its natural history, be considered as a per- fectly wholesome supply. When the rainfall reaches the ground it is disposed of in one or other of two wrays. It runs off by surface channels or it penetrates. Its disposition is determined by the rapidity of the fall, the superficial characteristics of the receiving surface, its porosity, and the permeabil- ity or impermeability and dip of the underlying strata. That which runs off by surface channels into ponds, lakes, or river-bottoms, is practically a rain-water which has become somewhat changed in its character by its contact with the ground forming the water-shed. It has lost some of its impurities which it washed from the atmosphere, but it has gathered more in its course over the surface; and the alteration in its quality depends upon the nature of these fresh acquisitions. Running over the rocky ground of an unpeopled country, it ac- 711 Water. Water. REFERENCE HANDBOOK- OF THE MEDICAL SCIENCES. quires only a few grains of mineral matter per gallon ; sweeping over the foul streets of a city, it may become converted into veritable sewage. The rainfall which penetrates the surface soil perco- lates until it joins some body of subsoil or subterranean water. This may be immediately below the surface, as when the ground-water is upheld by an impervious layer underlying a shallow stratum of superficial soil. In river bottoms the subsoil water is usually found close to the surface, upheld in this position by the bed-rock. In some situations, as in the mesas of Arizona and New Mexico, the impervious layer is at such a depth under porous sand and gravel that there is practically no subsoil wa- ter. In other localities, as where the rainfall penetrates the uplands of a river-valley, the water, on reaching the impervious stratum, may have to percolate along its slope for a long distance before it reaches the general body of subsoil water in the river-bottom. In its passage along this slope it may return to the surface as a spring at some point where a rift or erosion of the surface-soil has exposed the bed-rock of the water-shed. Where the rainfall is absorbed on ground which forms the outcrop of a porous stratum underlying an impervious layer, it may have to percolate for great dis- tances before it reaches the subterranean basin where its level is temporarily found. Here it may be tapped by deep wells, or it may issue by natural crevices in the form of springs. The water which percolates the soil becomes altered in character by the penetration, and the extent of the alteration depends on the solubility of the mineral matter through which it passes and its freedom from, or saturation with, organic substances in a decom- posing state. If the distance traversed is great the inor- ganic constituents of the water may be increased, but the organic will probably be diminished ; for the chances of encountering soluble mineral matters are augmented and time is afforded for the progress of changes which trans- form organic matter into inorganic salts. The mineral matters which a percolated water takes up do not usually come up for consideration in questions as to wholesome- ness or usefulness as a domestic supply. When they are large enough to be unwholesome the taste of the water generally interferes with its use as a potable supply, and its hardness with its use for domestic and economic purposes. When they are not in sufficient amount to be perceptible to the taste, they are usually neither un- wholesome nor injurious in other ways. Organic matter dissolved in water, such as that carried down in the rain- fall and that gathered by contact with an impure re- ceiving surface, becomes transformed into ammonia and nitric acid during its percolation. This was formerly considered to be an oxidation of the organic nitrogen by the air in the pores of soil. The explanations given were theoretical and obscure so long as chemical laws only were conceived to be involved in the process. It is now well known that the retrograde metamorphosis of organic matter which fits it for absorption by living vegetation is due to the action of micro-organisms. Bacteria are recognized as the agents which reduce the organic nitrogen to the ammoniacal condition, and the experiments of Schloesing, Warington, and many others following them, have shown that the formation of nitrates from this ammonia is likewise due to actions of a similar character, although the living ferment has not been identified. The influence of percolation through the soil has thus a purifying tendency. As an offset to the comparatively harmless mineral additions, the subtile organic matter and the complex and unstable substances formed during its decomposition are transformed into innocent inor- ganic salts. Even some of the germs which are washed from the air by the falling rain or collected from an im- pure surface may be removed by this natural process of filtration, if we assume the essence of malarial diseases to reside in a minute organism ; for while such diseases have been frequently referred to the use of surface-waters, no instance has been recorded which throws suspicion on percolated waters. On the contrary, the testimony is strong as to the efficiency of filtration in removing the malarial germ ; for the purer water-supply which, in all countries, has succeeded the use of surface-collections, and which has been coincident with the diminished prev- alence of malarial diseases, has been in the first instance derived from wells and springs ; in other words, a per- colated water. But this favorable change, exercised by percolation in the case of the malarial germ, is, unfortu- nately, exceptional. The experiments of Pumpelly and Smythe for the National Board of Health, and those more recently recorded by P. F. Frankland (Van Nostrand's Engineering Magazine, xxxv., p. 315, 1886), warrant the assertion that bacteria are not completely removed from water by any process of filtration. The history of cer- tain outbreaks of typhoid fever and cholera give full assurance that percolation does not purify water from the essence of these diseases. So it is probably with the causes of other specific diseases, as scarlet fever, diphthe- ria, small-pox, yellow fever, etc., which may be washed from a contaminated atmosphere. But it is not so much from the air as after its contact with the soil that rain-water becomes impregnated with specific-disease poisons. The germs of typhoid fever and cholera find their way to the soil with the excretions of individuals suffering from these diseases, and are taken up by and accompany the percolating water. The dead organic matter which may be dissolved at the same time may afterward disappear by nitrification ; but there is no assurance that any modifying influence is exerted on the living matter. The purity of water depends on the purity of the sub- stances with which it comes in contact. Rain-water shed from a well-washed slate roof into a clean cistern is a pure supply, but collected in a tank, ditch, pond, or lake, it will be pure or impure according to the condition of the water-shed and the receiving basin. Subsoil water may be rain-water purified by filtration, as in springs or wells in a clean sand, or it may be so altered by the ad- dition of organic matter from a foul soil as to be unfit for use, as in the shallow wells of most localities which have been occupied for some time. Subterranean springs or deep well-waters are usually organically pure, and wholesome if not excessively charged with mineral salts, but even these have occasionally been the source of epi- demic diseases. River-waters have their quality deter- mined by the characters of the water-shed and soil-drain- age, and especially by the presence or absence of masses of population on their banks. The effects of impure water vary according to the im- purity. Where the mineral matter does not exceed 30 parts per 100,000 (17.5 grains per U. S. gallon, or 21 grains per imperial gallon), and does not give a taste to the water, it may be accepted as wholesome without inquiry into the special constitution of the inorganic salts. It has been suggested that mineral salts in the drinking- water may supply certain wants in the economy, as, for instance, lime for the bones of the growing child ; but as every article of food contains its percentage of such matters, it would seem that ample provision has been made by nature without requiring their introduction by means of the water-supply. Moreover, as water is, so far as we know, intended for the solution of fresh nutri- tive materials and the removal of the products of tissue- change, its freedom from dissolved solids would seem desirable. Where the mineral salts are in excess of 30 parts per 100,000 of the water, yet do not give a taste to it, some doubt as to its qualities may be entertained, for it is well known that certain waters induce relaxation of the bowels or affect the kidneys through the agency of their mineral constituents. These doubts are usually settled, not by chemical analyses, but by the test of experience. The influence, if any, of the long-continued use of waters containing small quantities of earthy or other salts has not been determined. Urinary calculi have been attributed to the use of lime-waters, but on insufficient evidence. The materials of which these are composed are furnished by many articles of diet, and they may, of course, be formed, if the predisposition is present, irrespective of the quality of the water-supply. Many 712 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Water. Water. physicians in parts of the country where urinary cal- culus is of frequent occurrence do not consider the water as concerned in its production. Goitre has been gener- ally regarded as due to mineral impurity in water, but the causation of the disease has not been definitely set- tled. Dr. Letheby instituted a comparison between the death-rate of a number of cities and the hardness of their water-supplies, the result showing that a higher death-rate corresponded with a soft water ; but it is evi- dent that no deduction is allowable from such data, since the death-rate of a city is influenced by so many factors, many of them of vastly more importance than the hard- ness or softness of the water-supply. If the water contains more than 100 parts of salts in the 100,000 it is evidently unsuited for a potable supply. The sense of taste objects to many lime, magnesian, and alka- line waters even before this limit is reached. Iron in comparatively minute quantities may be recognized, but when it is so the water containing it is thereby removed from the potable to the list of mineral waters. As water is frequently distributed by leaden pipes and sometimes stored in lead-lined cisterns, the possibility of the solution of poisonous quantities of the metal must be held in view. Such instances are of rare occurrence ; but it is possible that noxious effects from lead may have been overlooked in some instances and attributed to other causes. The symptoms are violent neuralgic pains in the abdomen simulating colic, but oftentimes affect- ing also the limbs and trunk, with constipation and grad- ual loss of strength. Rain and other soft and aerated waters attack lead with facility. It is usually stated that waters containing mineral salts do not dissolve this metal ; but if a piece of clean lead be placed in a water- sample containing mineral salts the metal will probably be acted upon and the water tainted. In accordance with the results of such an experiment the use of leaden pipes would have to be condemned in connection with that water. In practice, however, lead may be used for the distribution of many waters which are thus shown to dissolve the metal ; for where the mineral salts are present their reaction with the lead deposits on its sur- face an insoluble coating which is an efficient protection against the future contamination of the water. Where lead is used for service-pipes the water which has stood in the pipes during the night should be run to waste before drawing a supply for use. The contact with the metal of the service-pipes during daily use is so slight that lead is seldom found in such quantities as to be harmful. But the use of lead for cisterns is of doubtful propriety. Where metal is used iron should be employed, protected, as Professor Nichols recommends, by a coat- ing of asphalt paint or black varnish. Zinc is also acted upon by most waters, and may be detected in those which have been stored in galvanized- iron tanks. The corrosion is especially active if the coat- ing is imperfect. Dr. Downes, of Chelmsford, England, who studied this subject, remarked with truth that if the zinc were seriously injurious we should have more cases of poisoning on record, for a great number of people must be in the habit of drinking water more or less con- taminated with the metal. Dr. Boardman, of Boston, came to the conclusion, as the result of his own experi- ments and of an examination of the literature of the sub- ject, that if all the zinc found in water existed in the form of chloride, which is known to be the most actively poisonous of the zinc salts, the amount would be insuffi- cient to endanger health. W. R. Nichols and L. K. Russell made quantitative determinations of the zinc washed from galvanized-iron pipes by the action of Boston water. A lengt